Effect of Neuraxial Anaesthesia on Left Ventricular Diastolic Function Assessed by Transthoracic Echocardiography

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Vol 2 | Issue 2 | July-December 2021 | Page 131-136 | Maithriye Kavishree, Srinath Damodaran, Sharanu Patil, Kumar Belani, Muralidhar Kanchi

DOI: 10.13107/ijra.2021.v02i02.041

Authors: Maithriye Kavishree [1], Srinath Damodaran [1], Sharanu Patil [2], Kumar Belani [3], Muralidhar Kanchi [1]

[1] Department of Cardiac Anaesthesia, Narayana Institute of Cardiac Sciences, Narayana Health City, Bangalore, Karnataka, India.
[2] Department of Anaesthesia and Intensive care, Sparsh Hospital, Bangalore, Karnataka, India.
[3] Department of Cardiac Anaesthesia, Masonic Children’s Hospital, University of Minnesota, Minneapolis, United States of America.

Address of Correspondence
Dr. Muralidhar Kanchi
Academic Director, Senior Consultant & Professor, Department of Cardiac Anaesthesia, Narayana Institute of Cardiac Sciences, Narayana Health City, Bangalore, Karnataka, India.
E-mail: muralidhar.kanchi.dr@narayanhealth.org

Abstract

Purpose: To evaluate the effect of neuraxial anaesthesia on left ventricular (LV) diastolic function in clinical setting using transthoracic echocardiography (TTE).
Methods: This prospective observational study was performed in 50 adult patients undergoing elective orthopaedic surgical procedures under neuraxial anaesthesia for lower limb surgery. TTE was performed before, 20, 40 and 60 minutes after neuraxial anaesthesia. Pulsed wave Doppler of the transmitral flow (TMF), pulmonary venous flow (PVF), deceleration time (DT) and propagation velocity (Vp) were measured. Septal and lateral wall mitral annular velocities (E’, A’) were assessed by tissue Doppler imaging (TDI). The maximum diameter of left atrium (LA) and right atrium (RA), LA volume index, left ventricular (LV) and right ventricular (RV) end-diastolic area (EDA), end-systolic area (ESA), fractional area change (FAC),LV end-diastolic volume (EDV), end-systolic volume (ESV), were measured from apical 4-chamber view (A4CV) view.
Results: There were 50 patients in the cohort of whom 48 had normal diastolic function preoperatively. Following neuraxial anaesthesia, mean arterial pressure decreased (96.61.52 to 83.70.3, p <0.001) while heart rate remained unchanged (84.416.6 to 85.315.0, p =0.436). The dimensions and volumes of cardiac chambers, LV FAC and RV FAC transmitral pulse wave Doppler, DT, Vp, PVF and mitral annular TDI did not vary after neuraxial anaesthesia (p>0.05).
Conclusion: In patients with normal diastolic function, neuraxial anaesthesia does not alter diastolic function indices and grading. “It is recommended that the study be performed in patients with documented diastolic dysfunction to demonstrate beneficial or detrimental effects of central neuraxial blockade, if any.”
Keywords: Spinal anaesthesia, Neuraxial anaesthesia, Transthoracic echocardiography, Diastolic function, Left ventricle

References

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How to Cite this Article: Kavishree M, Damodaran S, Patil S, Belani K, Kanchi M | Effect of Neuraxial Anaesthesia On Left Ventricular Diastolic Function Assessed By Transthoracic Echocardiography | July-December 2021; 2(2): 131-136.

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Difficult subarachnoid anaesthesia Prediction and Performance

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Vol 2 | Issue 2 | July-December 2021 | Page 92-99 | André Van Zundert

DOI: 10.13107/ijra.2021.v02i02.034

Authors: André Van Zundert [1, 2]

[1] Department of Anaesthesia, The University of Queensland, Faculty of Medicine, Brisbane, Queensland, Australia.
[2] Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia.

Address of Correspondence
Professor Dr. André Van Zundert,
Professor & Chair Anaesthesiology, The University of Queensland, Faculty of Medicine,
Brisbane, Queensland. Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia.
E-mail: vanzundertandre@gmail.com

Introduction

Spinal anaesthesia (SA) has enjoyed a long history of success, celebrating soon its 125th anniversary. Puncturing the dura mater is considered a simple procedure, followed by a subarachnoid injection of a local anaesthetic (LA) agent into the cerebrospinal fluid (CSF). Even when the technique is performed perfectly, there is no guarantee that the block sits perfectly. Failure is not uncommon and encompasses a range from total absence of any neuraxial blockade, a partial block (insufficient height, quality or duration) or a patchy block. Table 1 lists a large number of potential causative factors that may result in a failed spinal anaesthetic, providing suggestions of solutions. Analysing each distinct phase of the procedure, i.e., spinal puncture, injection of local anaesthetic solution, spread of the local anaesthetic solution through the cerebrospinal fluid, action of the drug on subarachnoid neural tissue and patient management, are the keys to success at each stage. Mechanisms of failure of spinal anaesthesia include insufficient preparation and check of equipment and drugs, suboptimal positioning of the patient, unsuccessful puncture due to inadequate training or experience and inadequate use of needles and local anaesthetic solution.1-5 Besides operator, preparation, technique-dependent and patient-related factors (anatomical variations), there are also organisational factors (lack of block room, lack of adequate monitoring and trained personnel, insufficient time between block and onset of surgery, subsequent management following block). The use of the correct local anaesthetic (dose, volume, concentration) injected at the correct lumbar interspace is of paramount importance to produce an adequate spinal block for the right surgical intervention.
Nevertheless, failures may still occur. Therefore, the anaesthetist should always have a contingency plan for a failed spinal block. Indeed, patients expect reliable surgical anaesthesia when undergoing an operation under regional anaesthesia. If the block fails, we need to be ready to offer a solution, using rescue techniques. The alternatives are either to repeat the spinal anaesthesia or to convert to a general anaesthetic.
Failed spinal anaesthesia has roughly three reasons: a) the local anaesthetic solution does not reach the subarachnoid space; b) the drug has been injected at the right location, but the block is not what is expected; and c) the local anaesthetic solution works well, but the dosage chosen is not correct or results in unilateral or patchy blocks as the resulting block is deficient in quantity, quality or duration.

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3. Fettes PDW, Jansson J-R, Wildsmith JAW. Failed spinal anaesthesia: mechanisms, management, and prevention, Br J Anaesth 2009;102:739–748, https://doi.org/10.1093/bja/aep096
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How to Cite this Article: Van Zundert A | Difficult Subarachnoid Anaesthesia Prediction and Performance | International Journal of Regional Anaesthesia | July-December 2021; 2(2): 92-99.

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Regional Anaesthesia in Enhanced Recovery After Surgery Pathways – A Quintessential Component

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Vol 2 | Issue 2 | July-December 2021 | Page 87-91 | Abhijit S. Nair, Sandeep Diwan

DOI: 10.13107/ijra.2021.v02i02.033

Authors: Abhijit S. Nair [1], Sandeep Diwan [2]

[1] Department of Anaesthesia, Ibra Hospital, Ministry of Health-Oman, Ibra, Sultanate of Oman.
[2] Department of Anaesthesia, Sancheti Hospital, Pune, Maharashtra, India.

Address of Correspondence
Dr. Abhijit S. Nair, Department of Anaesthesia, Ibra Hospital, Ministry of Health-Oman, Ibra-414, Sultanate of Oman.
E-mail: abhijitnair95@gmail.com

Introduction

Enhanced recovery after surgery (ERAS) is a multimodal, perioperative care pathway designed to achieve early recovery for patients undergoing major surgery. [1] Initially described by Henry Kehlet in 1995 for colonic surgeries, the enhanced recovery pathways have now evolved and are now validated for more than 30 different types of surgery which include but are not limited to emergency laparotomy, neonatal surgeries, and lower segment cesarean sections. [2] Not only is the patient benefited from this by having an enhanced recovery and early discharge from the hospital, the cost of treatment is reduced and also leads to more turnover of patients thereby reducing the waiting list of patients scheduled for various surgeries. [3]

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How to Cite this Article: Nair AS, Diwan S | Regional Anaesthesia in Enhanced Recovery After Surgery Pathways – A Quintessential Component | International Journal of Regional Anaesthesia | July-December 2021; 2(2): 87-91.

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Ultrasound and Modern Regional Anaesthesia

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Vol 2 | Issue 2 | July-December 2021 | Page 100-101  | T.V.S.Gopal

DOI: 10.13107/ijra.2021.v02i02.035

Authors: T.V.S. Gopal [1, 2, 3]

[1] Managing Director, Axon Anaesthesia Associates, Hyderabad, Telangana, India.
[2] Clinical Director, Anaesthesiology, General O.T.& C.O.P.Complex, Care Hospitals, Hyderabad, Telangana, India.
[3] Chairperson, Past Academic Director & President AORA India.

Address of Correspondence
Dr. T.V.S Gopal,
Managing Director, Axon Anaesthesia Associates, Hyderabad, Telangana, India.
Clinical Director, Anaesthesiology, General O.T.& C.O.P.Complex, Care Hospitals, Hyderabad, Telangana, India.
E-mail: tvsgopal@gmail.com

Editorial

Lazzaro Spallanzani, an 18th century Italian biologist, is credited with the discovery of ultrasound, which he coined ‘echolocation’. [1] Little may he have realized then that his revelation would transform into an all pervading technology in modern science. Though La Grange and colleagues, in 1978, were the first to employ ultrasonic blood flow detector to locate insertion point for the supraclavicular brachial plexus block, ultrasound guidance in real time motion was first utilized by S. Kapral et al for the same block in a series of forty patients in 1994, thus, heralding a fresh epoch in regional anaesthesia. [2, 3] As is often the case with the introduction of new technologies, ultrasound guidance was also met with cynicism and disdainful resistance. However, not much later, ultrasound guidance was being hailed as the ‘gold standard’ for regional anaesthesia, and it was proclaimed that the search for the elusive ‘holy grail’ had ended. [4]
Among the first nerve/plexus blocks to find wider acceptance with the adoption of ultrasound guidance was the supraclavicular brachial plexus block. The fear of arterial puncture and accidental pneumothorax magically seemed to vanish into thin air. Correlation between clinical and sono-anatomy led to a better understanding of interscalene, infraclavicular and axillary approaches to the brachial plexus. [5] Lower limb blocks began to witness a renaissance due to the widespread prescription of antiplatelet drugs as part of preventive cardiology. Though deeper to the skin in comparison to the upper limb, ultrasound guidance improved identification of neural structures.
It was reported in literature that ultrasound improves patient comfort, block acceptance, onset of block, quality of block, permits the injection of lower local anaesthetic volumes, and thereby, the potential for LAST, and reduces the incidence of certain complications that may be attributed to the block procedure. [6] However, given the resolution of current portable ultrasound machines, and the huge numbers required to reflect a statistical difference in favour of ultrasound, the rate of neurological complications seems to be comparable to other guidance techniques. Such are the rigours of evidence-based medicine!!
Familiarity with ultrasound offered precision with blocks of the brachial plexus, for eg., intertruncal blockade, combination of superior truncal and cervical plexus block (SCUT), costoclavicular approach to the infraclavicular plexus, and identification of inadvertent targets “in the path”, namely, the long thoracic and dorsal scapular nerves. [7, 8] Not surprisingly, ultrasound guidance was utilized for deeper blocks such as lumbar and sacral plexus, giving impetus to the term, “dual guidance” technique. A “window of opportunity” led to description of neuraxial sonoanatomy and the various benefits of ultrasound assistance for neuraxial blocks were widely appreciated. [9] Nearly seven decades after Mario Dogliotti invented the loss of resistance technique for identification of the epidural space, another guidance tool was incorporated. Newer approaches to older blocks were introduced, such as the suprainguinal fascia iliaca plane block. Differential blocks limited to sensory desensitization alone came into vogue, viz. PENG (Pericapsular Nerve Group), iliopsoas plane block & the i-PACK. [10, 11]
Perhaps, the most significant shift in regional anaesthesia was the introduction of interfascial plane blocks that abandoned the “search” for neural structures by beckoning regional anaesthesia enthusiasts to deposit large volumes of local anaesthetic solutions into fascial planes. What began with the ultrasound guided TAP block in 2007, rapidly found application in a variety of truncal fascial planes. The interfascial plane block added a new dimension to the multimodal analgesia regime. Simplicity of performance and safety was the overriding factor that appealed to anaesthesiologists. With some blocks, the drug was confined to the point of injection. With several others, the propensity of aponeurotic fascia to communicate with other fascial planes facilitated the theoretical spread of drug to sites far removed from the point of injection. Though conjecture exists with respect to the mechanism of action of blocks such as the QLB, future studies should put an end to controversies. [12]
The erector spinae block, first published by Forero et al, in 2016, set the world of regional anaesthesia literally on fire. [13] In the past five years, several publications, mostly case reports and limited case series, eulogizing the virtues of, the potential for, the clinical applications for, and the possible mechanism of action of this popular block, have emerged in scientific literature. [14] Currently, this ESP block, due to a lack of credible evidence on the mechanism of action, has the naysayers clamouring for this block to be rested in peace. [15] Given that the ESP has been in existence for less than five years, it is sincerely hoped that concrete studies may demystify this esoteric block.
In addition to regional anaesthesia, the appeal of modern, portable ultrasound places the FOCUS firmly on POCUS or Point Of Care Ultrasound. Today, regional anaesthesiologists are comfortable with fancy acronyms like FATE, FEEL, FAST etc. The integration of Artifical Intelligence to ultrasound technology imparts further precision. High resolution ultrasound as a diagnostic and therapeutic tool with multiple applications for clinicians is here to stay. The chorus for fusion of ultrasound into clinical practice is based on the edifice of evidence, ubiquity and durability, and NOT on the caprice of an elite core of die-hard proponents. The sooner anaesthesiologists jump on the bandwagon and hitch a ride, the better.
It is my sacred duty, as Chairperson of AORA INDIA, to place on record my appreciation to the editorial board of the International Journal of Regional Anaesthesia for embarking on this challenging journey of enlightening readers with advances in the exciting field of regional anaesthesia. In years to come, this online, peer reviewed journal will hopefully have made entry into the pantheon of impactful regional anaesthesia journals worldwide. Indeed, as the famous quote goes, “the purpose of education is to turn mirrors into windows”.

T.V.S.Gopal
Chairperson, Past Academic Director & President
AORA INDIA

References

1. Kaproth-Joslin KA, Nicola R, Dogra VS. The History of US: From Bats and Boats to the Bedside and Beyond: RSNA Centennial Article. Radiographics. 2015; 35:960-70.
2. la Grange P, Foster PA, Pretorius LK. Application of the Doppler ultrasound bloodflow detector in supraclavicular brachial plexus block. Br J Anaesth. 1978; 50:965-7.
3.Kapral S, Krafft P, Eibenberger K, Fitzgerald R, Gosch M, Weinstabl C. Ultrasound-guided supraclavicular approach for regional anesthesia of the brachial plexus. Anesth Analg. 1994; 78:507-13.
4.Horlocker TT, Wedel DJ. Ultrasound-guided regional anesthesia: in search of the holy grail. Anesth Analg 2007; 104:1009–11.
5.Sites BD, Spence BC, Gallagher J, Beach ML, Antonakakis JG, Sites VR, Hartman GS. Regional anesthesia meets ultrasound: a specialty in transition. Acta Anaesthesiol Scand. 2008; 52:456-66.
6.Neal JM. Ultrasound-Guided Regional Anesthesia and Patient Safety: Update of an Evidence-Based Analysis. Reg Anesth Pain Med. 2016; 41:195-204.
7.Karmakar MK, Pakpirom J, Songthamwat B, Areeruk P. High definition ultrasound imaging of the individual elements of the brachial plexus above the clavicle. Reg Anesth Pain Med. 2020; 45:344-50.
8.Hanson NA, Auyong DB. Systematic ultrasound identification of the dorsal scapular and long thoracic nerves during interscalene block. Reg Anesth Pain Med. 2013; 38:54-7.
9.Kalagara, H., Nair, H., Kolli, S. et al. Ultrasound Imaging of the Spine for Central Neuraxial Blockade: a Technical Description and Evidence Update. Curr Anesthesiol Rep.2021; 11: 326–39.
10. Bugada D, Bellini V, Lorini LF, Mariano ER. Update on Selective Regional Analgesia for Hip Surgery Patients. Anesthesiol Clin. 2018; 36:403-15..
11.Tran J, Giron Arango L, Peng P, Sinha SK, Agur A, Chan V. Evaluation of the iPACK block injectate spread: a cadaveric study. Reg Anesth Pain Med. 2019: rapm-2018-100355.
12. Gopal TVS, Maniar A, Chakraborty A, Kulkarni R. Abdominal Wall Blocks in Abdominal Surgery: An Update. International Journal of Regional Anaesthesia. January-June 2021; 2: 47-53.
13. Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The Erector Spinae Plane Block: A Novel Analgesic Technique in Thoracic Neuropathic Pain. Reg Anesth Pain Med. 2016; 41:621-7.
14. Chin KJ, Versyck B, Elsharkawy H, Rojas Gomez MF, Sala-Blanch X, Reina MA. Anatomical basis of fascial plane blocks. Reg Anesth Pain Med. 2021; 46:581-99.
15. Lonnqvist PA, Karmakar MK, Richardson J, Moriggl B. Daring discourse: should the ESP block be renamed RIP II block? Reg Anesth Pain Med. 2021; 46:57-60.

How to Cite this Article: Gopal TVS | Ultrasound and Modern Regional Anaesthesia | International Journal of Regional Anaesthesia | July-December 2021; 2(2): 100-101.

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IJRA Cover Page January-June 2021 Vol 2 Issue 1

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Acknowledgment: Cover Page Photos.

Dr. Ramkumar Mirle, Dr. Sajana Mukundan & M S Ramaiah Advanced Learning Centre, Bangalore, Karnataka, India. (LHS Figure)
Dr. Surajit Giri & Ms. Shreya Nandini Giri (Class IX, Delhi Public School, Nazira, Sivsagar, Assam.) (Middle Figure)
Dr. Shivaprakash S, Dr. Sandeep Diwan & Department of Anatomy, JSSMC, Mysore, Karnataka, India. (RHS Figure)

 

 

AORA4U– A Regional Anaesthesia App for AORA Members

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Vol 2 | Issue 1 | January-June 2021 | Page 78-79 | Murlidhar Thondebhavi S, Hetalkumar Vadera

Authors: Murlidhar Thondebhavi S [1], Hetalkumar Vadera [2]

[1] Department of Anaesthesia, Apollo Hospital, Bengaluru, Karnataka, India.
[2] Department of Anaesthesia, Sterling Hospital, Rajkot, Gujarat, India.

Address of Correspondence
Dr. Murlidhar Thondebhavi S,
Consultant, Anaesthesia and Pain Management, Apollo Hospitals, Bengaluru, Karnataka, Inda.
E-mail: murlidharts@gmail.com

The smartphone in our pocket is a tool with many roles to play in our lives. It has replaced the humble PC for many of our day-to-day needs. The regional anaesthesia (RA) expert needed an app to record the logs, follow-up patients, enhance the knowledge and aid in audit/research activities. AORA embarked on a mission to develop an app for the above purposes in 2017. The app was developed in six months and was launched officially during the annual scientific meeting of AORA in Indore in September 2017. The app is available for all AORA members to use without any added expense. It is available on both the Android and iOS platforms. We have released an updated version based on the feedback from users in the course of last three years and will be releasing another updated version in the coming month.

What can AORA4U do for you?
AORAU is primarily a resource/logbook app developed specifically for RA.
In our country significant proportion of the surgical cases are done in small nursing homes by freelance anaesthetists. They do many cases under RA. This app can help freelance anaesthetists and anaesthetists working in private institutes to maintain their log book and publish data. Ready reference videos on in the app can aid is continuous refinement of knowledge.

It has the following features:
1. Logbook: This is designed keeping in mind the various parameters needed to be captured for RA procedures. It has a user-friendly interface (Fig 1, 2, 3) to capture all details. The closure of a procedure is done after noting the occurrence of any complications or catheter related issues (Fig 4). A useful cloning function is provided to minimise data entry and hence save time for commonly performed operations/procedures (Fig 5). The data of the logbook will be stored locally on your phone and backed up on a secure server. There is no patient identifiable data that is captured in the process.

How to Cite this Article: Murlidhar TS, Vadera H | AORA4U– A Regional Anaesthesia App for AORA Members | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 78-79.

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Abstract

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Vol 2 | Issue 1 | January-June 2021 | Page 80-85 | Sandeep M. Diwan

Authors: Sandeep M. Diwan [1]

[1] Department of Anaesthesia, Sancheti Hospital, Pune, Maharashtra, India.

Address of Correspondence
Dr. Sandeep M. Diwan,
Department of Anaesthesia, Sancheti Hospital, Pune, Maharashtra, India.
E-mail: editor.regional.anaesthesia@gmail.com

I as the academic director congratulate each one of the participants who have taken umpteen efforts to produce these highly academic oriented research materials. I hope this trend will be in each of you as you progress through these troubled times to end up with very bright future.
I must thank the abstract committee who understandably had a mammoth task to scrutinize and bring out the best of the abstracts and finally select the those who really deserved the best.
I thanks all the AORIANS who with their participation in AORA 2021 made a trend setter for virtual/physical/hybrid
conferences in future.
My sincere thanks to the Academic Research Group (ARG) chief Dr. Ashok Shaym and team ARG for their efforts in the initiation and sustaining IJRA.

Best Wishes
Sandeep M. Diwan
Academic Director AORA
Editor IJRA

How to Cite this Article: Diwan S | Abstract | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 80-85.

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USG Guided Forearm Nerve Block

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Vol 2 | Issue 1 | January-June 2021 | Page 72-77 | Madhuri Dadke, Sandeep Diwan

Authors: Madhuri Dadke [1], Sandeep Diwan [1]

[1] Department of Anaesthesia, Sancheti Hospital, Pune, Maharashtra, India.

Address of Correspondence
Dr. Sandeep Diwan,
Consultant Anaesthesiologist, Sancheti Hospital, Pune, Maharashtra, India.
E-mail: sdiwan14@gmail.com

Introduction

Forearm blocks (FAB) are implemented to provide anaesthesia for hand surgeries, as a rescue block for failed or patchy proximal brachial plexus block and to provide postoperative analgesia after a regional or a general anaesthetic [1]. The advantage of these distal blocks is preservation of proximal motor function and avoidance of central structures such as the pleura, subclavian or axillary artery and the phrenic nerve. The proximal muscle function is preserved with these blocks, requiring minimal doses of local anaesthetic. These blocks can be implemented in outpatients [2] and with patients on anticoagulants [3]. Distal nerve blocks do not prevent tourniquet pain since the lateral antebrachial cutaneous nerve of forearm (musculocutaneous nerve), the medial cutaneous nerve of the arm, the posterior cutaneous nerve of the arm, and the intercostobrachial nerve that provide cutaneous innervation of the upper arm are not blocked [4]. The above mentioned nerves are blocked in the arm. Blockade of multiple nerves are needed and so involves multiple injections that may cause more patient discomfort.

References

1) Sayeh Hazmenzedeh, David Bravos.Peripheral Nerve Blocks of the Distal Upper Extremity.ASRA 2019
2) Liebmann O, Price D, Mills C, Gardner R, Wang R, Wilson S, et al.Feasibility of forearm ultrasonography guided nerve blocks of the radial, ulnar, and median nerves for hand procedures in the emergency department.Ann Emerg Med 2006,48:558-62.
3) Jose Soberon,Neil Bhatt,Bobby Nossamon,Scott Duncan et al.Distal peripheral nerve blockade for patients undergoing hand surgery: a pilot study.Hand(New York)2015 Jun; 10(2): 197–204.
4) Herman Sehmbi,Caveh Madjdpour,Ushma Jitendra Shah,Ki Jinn Shin.Ultrasound guided distal peripheral nerve block of the upper limb: A technical review.JOACP 2015.Volume 31,issue3,296-307.
5) Jordan M.Brown, Corrie M. Yablon , Yoav Morag, Catherine J. Brandon, Jon A. Jacobson.Ultrasound of the Peripheral Nerves of the Upper Extremity: A Landmark Approach. RadioGraphics 2016; 36:452–463.
6) Chad Robertson,John Saratsiotis.A Review of Compressive Ulnar Neuropathy at the Elbow. Journal of manipulative and physiological therapeutics ,June 2005;28(5):345.
7) Henrich Kele.Ultrasonography of the peripheral nervous system. Perspectives in Medicine 2012.Volume 1, Issues 1–12, September 2012, Pages 417-421
8) Admir Hadzic.Ultrasound-Guided Forearm Blocks. Hadzic’s Nerve Blocks and Anatomy for Ultrasound Guided Regional Anesthesia, 2e.
9) Wachara Wongkerdsook,Sithiporn Agthong,Chavarin Amarase,Pattarapol Yotnuengnit,Thanasil Huanmanop,Vilai Chentanez. Anatomy of the lateral antebrachial cutaneous nerve in relation to the lateral epicondyle and cephalic vein. Clinical Anat. Jan 2011;24(1):56-61.
10) Thomas K, Sajjad H, Bordoni B. Anatomy, Shoulder and Upper Limb, Medial Brachial Cutaneous Nerve. Treasure Island : Feb 14,2021.
11) Starr,Dennis Lee,Peter Stern. Anatomy of the Posterior Antebrachial Cutaneous Nerve, Revisited.Scientific Article Volume 45,Issue4,April 2020.
12) M Lurf et al.Ultrasound guided ulnar nerve catheter placement in the forearm for postoperative pain relief and physiotherapy. Acta Anaesthesiology Scandinavia. Feb 2009;53(2):261-3
13) Sanjeev Bhoi, Amit Chandra, Sagar Galwankar. Ultrasound-guided nerve blocks in the emergency department Journal of emergencies trauma and shock.Jan-Mar 2010. 3(1): 82–88.
14) RA McCahon,NM Bedforth.Peripheral nerve blocks at the elbow and wrist.Critical Care & Pain journal,Volume 7, Issue 2, April 2007, Pages 42–44.
15) Brian M Ilfeld.Continuous .Peripheral Nerve Blocks: An Update of the Published Evidence and Comparison With Novel, Alternative Analgesic Modalities.Anesth Analg ,2017 Jan;124(1):308-335.

How to Cite this Article: Dadke M, Diwan S | USG Guided Forearm Nerve Block | International Journal of Regional Anaesthesia | January- June 2021; 2(1): 72-77.

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Adjuvants in Peripheral Nerve Blocks

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Vol 2 | Issue 1 | January-June 2021 | Page 63-66 | Rudra Deshpande, Harshal Wagh, Satish Kulkarni

Authors: Rudra Deshpande [1], Harshal Wagh [2], Satish Kulkarni [1]

[1] Department of Anaesthesia, Lilavati Hospital & Research Centre, Mumbai, Maharashtra, India.
[2] Department of Anaesthesia, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India.

Address of Correspondence
Dr. Satish Kulkarni,
Consultant, Department of Anaesthesia, Lilavati Hospital & Research Centre, Mumbai, Maharashtra, India.
E-mail: drsatishkulkarni@yahoo.com

Introduction

An increase in the use of peripheral nerve blocks (PNBs) has been noted in recent years. Not only do these blocks provide adequate anaesthesia intraoperatively, but they are also now the cornerstone of perioperative pain management. Superior pain control, a significant decrease in opioid requirements as well as opioid-related side effects, improved patient satisfaction, earlier discharge from hospital and increasing use with the advancement of ultrasound technology have contributed to the increasing use of peripheral nerve blocks [1-4].
Regional anaesthesia techniques including PNBs have also become the need of the hour in recent times of the Covid19 pandemic. As per recent practice recommendations (American Society of Regional Anaesthesia May 2020), Regional anaesthesia is preferred to avoid aerosol-generating procedures associated with General anaesthesia [5].

For postoperative pain management, PNBs are used as a single injection or as a continuous catheter infusion. Single-injection nerve blocks are more commonly done as they are technically easier and quicker. They provide superior analgesia in the immediate postoperative period for various procedures in which the pain intensity is high initially and reduces over significantly over time. Oral analgesics may be effective by then as the effect of PNBs is wearing off gradually over 12 to 24 hours. Rebound pain can however be a significant problem [6]. Continuous catheter techniques are not only technically challenging but require greater monitoring and are prone to secondary block failures due to catheter blockage and displacement [7]. They are labour and resource intensive. Hence the need for adjuvants that will help prolong the duration of PNBs and avoid the placement of continuous catheters has been part of the quest of regional anaesthesiologists. Multiple classes of drugs have been tested as adjuvants in the past. Some have stood the test of time and helped improve the practice of regional anaesthesia while others proved more detrimental. Discussed below are some of the adjuvants that have been successfully used (Table 1).

References

1. Hughes MS, Matava MJ, Wright RW, Brophy RH, Smith MV. Interscalene brachial plexus block for arthroscopic shoulder surgery: a systematic review. J Bone Joint Surg Am. 2013;95(14):1318-24.
2. Liu Q, Chelly JE, Williams JP, Gold MS. Impact of peripheral nerve block with low dose local anesthetics on analgesia and functional outcomes following total knee arthroplasty: a retrospective study. Pain Med. 2015;16(5):998-1006.
3. Lenart MJ, Wong K, Gupta RK, Mercaldo ND, Schildcrout JS, Michaels D, et al. The impact of peripheral nerve techniques on hospital stay following major orthopedic surgery. Pain Med. 2012;13(6):828-34.
4. Chan EY, Fransen M, Parker DA, Assam PN, Chua N. Femoral nerve blocks for acute postoperative pain after knee replacement surgery. Cochrane Database Syst Rev. 2014;2014(5):Cd009941.
5. Uppal V, Sondekoppam RV, Lobo CA, Kolli S, Kalagara HK. Practice recommendations on neuraxial anesthesia and peripheral nerve blocks during the COVID-19 pandemic. ASRA/ESRA COVID-19 Guidance for Regional Anesthesia March. 2020;31.
6. Nobre LV, Cunha GP, Sousa P, Takeda A, Cunha Ferraro LH. [Peripheral nerve block and rebound pain: literature review]. Rev Bras Anestesiol. 2019;69(6):587-93.
7. Ahsan ZS, Carvalho B, Yao J. Incidence of failure of continuous peripheral nerve catheters for postoperative analgesia in upper extremity surgery. J Hand Surg Am. 2014;39(2):324-9.
8. Karaman S, Kocabas S, Uyar M, Hayzaran S, Firat V. The effects of sufentanil or morphine added to hyperbaric bupivacaine in spinal anaesthesia for Caesarean section. Eur J Anaesthesiol. 2006;23(4):285-91.
9. Axelsson K, Johanzon E, Essving P, Weckström J, Ekbäck G. Postoperative extradural analgesia with morphine and ropivacaine. A double-blind comparison between placebo and ropivacaine 10 mg/h or 16 mg/h. Acta Anaesthesiologica Scandinavica. 2005;49(8):1191-9.
10. Flory N, Van-Gessel E, Donald F, Hoffmeyer P, Gamulin Z. Does the addition of morphine to brachial plexus block improve analgesia after shoulder surgery? British Journal of Anaesthesia. 1995;75(1):23-6.
11. Alemanno F, Ghisi D, Fanelli A, Faliva A, Pergolotti B, Bizzarri F, et al. Tramadol and 0.5% levobupivacaine for single-shot interscalene block: effects on postoperative analgesia in patients undergoing shoulder arthroplasty. Minerva Anestesiol. 2012;78(3):291-6.
12. Kesimci E, Izdes S, Gozdemir M, Kanbak O. Tramadol does not prolong the effect of ropivacaine 7.5 mg/ml for axillary brachial plexus block. Acta Anaesthesiologica Scandinavica. 2007;51(6):736-41.
13. Fanelli G, Casati A, Magistris L, Berti M, Albertin A, Scarioni M, et al. Fentanyl does not improve the nerve block characteristics of axillary brachial plexus anaesthesia performed with ropivacaine. Acta Anaesthesiol Scand. 2001;45(5):590-4.
14. Jain N, Khare A, Khandelwal S, Mathur P, Singh M, Mathur V. Buprenorphine as an adjuvant to 0.5&#37; ropivacaine for ultrasound-guided supraclavicular brachial plexus block: A randomized, double-blind, prospective study. Indian Journal of Pain. 2017;31(2):112-8.
15. Tulsyan V, Singh J, Thakur L, Verma V, Minhas A. A comparative study of buprenorphine in two different doses as an adjuvant to levobupivacaine in US-guided lumbar plexus block for postoperative analgesia. Ain-Shams Journal of Anesthesiology. 2021;13(1):7.
16. Virk MS, Arttamangkul S, Birdsong WT, Williams JT. Buprenorphine is a weak partial agonist that inhibits opioid receptor desensitization. J Neurosci. 2009;29(22):7341-8.
17. Schoenmakers KPW, Fenten MGE, Louwerens JW, Scheffer GJ, Stienstra R. The effects of adding epinephrine to ropivacaine for popliteal nerve block on the duration of postoperative analgesia: a randomized controlled trial. BMC Anesthesiology. 2015;15(1):100.
18. Dogru K, Duygulu F, Yildiz K, Kotanoglu MS, Madenoglu H, Boyaci A. Hemodynamic and blockade effects of high/low epinephrine doses during axillary brachial plexus blockade with lidocaine 1.5%: A randomized, double-blinded study. Reg Anesth Pain Med. 2003;28(5):401-5.
19. Schoenmakers KP, Vree TB, Jack NT, van den Bemt B, van Limbeek J, Stienstra R. Pharmacokinetics of 450 mg ropivacaine with and without epinephrine for combined femoral and sciatic nerve block in lower extremity surgery. A pilot study. Br J Clin Pharmacol. 2013;75(5):1321-7.
20. Weber A, Fournier R, Van Gessel E, Riand N, Gamulin Z. Epinephrine does not prolong the analgesia of 20 mL ropivacaine 0.5% or 0.2% in a femoral three-in-one block. Anesth Analg. 2001;93(5):1327-31.
21. Tschopp C, Tramèr MR, Schneider A, Zaarour M, Elia N. Benefit and Harm of Adding Epinephrine to a Local Anesthetic for Neuraxial and Locoregional Anesthesia: A Meta-analysis of Randomized Controlled Trials With Trial Sequential Analyses. Anesth Analg. 2018;127(1):228-39.
22. Pöpping DM, Elia N, Marret E, Wenk M, Tramèr MR. Clonidine as an adjuvant to local anesthetics for peripheral nerve and plexus blocks: a meta-analysis of randomized trials. Anesthesiology. 2009;111(2):406-15.
23. Chakraborty S, Chakrabarti J, Mandal MC, Hazra A, Das S. Effect of clonidine as adjuvant in bupivacaine-induced supraclavicular brachial plexus block: A randomized controlled trial. Indian J Pharmacol. 2010;42(2):74-7.
24. McCartney CJL, Duggan E, Apatu E. Should We Add Clonidine to Local Anesthetic for Peripheral Nerve Blockade? A Qualitative Systematic Review of the Literature. Regional Anesthesia &amp;amp; Pain Medicine. 2007;32(4):330-8.
25. El-Boghdadly K, Brull R, Sehmbi H, Abdallah FW. Perineural Dexmedetomidine Is More Effective Than Clonidine When Added to Local Anesthetic for Supraclavicular Brachial Plexus Block: A Systematic Review and Meta-analysis. Anesth Analg. 2017;124(6):2008-20.
26. Sachdev S, Sharma V, Malawat A, Jethava D, Moin K. Comparison of levobupivacaine alone and levobupivacaine with dexmedetomidine in supraclavicular brachial plexus block: A prospective randomized clinical trial. Indian Journal of Clinical Anaesthesia. 2020;7(1):16-22.
27. Lundblad M, Trifa M, Kaabachi O, Ben Khalifa S, Fekih Hassen A, Engelhardt T, et al. Alpha-2 adrenoceptor agonists as adjuncts to peripheral nerve blocks in children: a meta-analysis. Pediatric Anesthesia. 2016;26(3):232-8.
28. Ray A, Kulkarni S, Kaur K, Paul D, Singh S, Khan S. Comparative study of two different doses of dexmedetomidine as an adjuvant to bupivacaine in the peripheral nerve block. Journal of Marine Medical Society. 2020;22(2):161-5.
29. Xue X, Fan J, Ma X, Liu Y, Han X, Leng Y, et al. Effects of local dexmedetomidine administration on the neurotoxicity of ropivacaine for sciatic nerve block in rats. Mol Med Rep. 2020;22(5):4360-6.
30. Sehmbi H, Brull R, Ceballos KR, Shah UJ, Martin J, Tobias A, et al. Perineural and intravenous dexamethasone and dexmedetomidine: network meta-analysis of adjunctive effects on supraclavicular brachial plexus block. Anaesthesia. 2020. doi: 10.1111/anae.15288. Online ahead of print
31. Albrecht E, Vorobeichik L, Jacot-Guillarmod A, Fournier N, Abdallah FW. Dexamethasone Is Superior to Dexmedetomidine as a Perineural Adjunct for Supraclavicular Brachial Plexus Block: Systematic Review and Indirect Meta-analysis. Anesth Analg. 2019;128(3):543-54.
32. Choi S, Rodseth R, McCartney CJ. Effects of dexamethasone as a local anaesthetic adjuvant for brachial plexus block: a systematic review and meta-analysis of randomized trials. Br J Anaesth. 2014;112(3):427-39.
33. Pehora C, Pearson AM, Kaushal A, Crawford MW, Johnston B. Dexamethasone as an adjuvant to peripheral nerve block. Cochrane Database Syst Rev. 2017;11(11):Cd011770.
34. Marhofer P, Columb M, Hopkins PM, Greher M, Marhofer D, Bienzle M, et al. Dexamethasone as an adjuvant for peripheral nerve blockade: a randomised, triple-blinded crossover study in volunteers. Br J Anaesth. 2019;122(4):525-31.
35. Golwala M, Swadia V, Dhimar AA, Sridhar N. Pain relief by dexamethasone as an adjuvant to local anaesthetics in supraclavicular brachial plexus block. J Anaesth Clin Pharmacol. 2009;25(3):285-8.
36. Liu J, Richman KA, Grodofsky SR, Bhatt S, Huffman GR, Kelly IV JD, et al. Is there a dose response of dexamethasone as adjuvant for supraclavicular brachial plexus nerve block? A prospective randomized double-blinded clinical study. Journal of clinical anesthesia. 2015;27(3):237-42.
37. Williams BA, Hough KA, Tsui BY, Ibinson JW, Gold MS, Gebhart G. Neurotoxicity of adjuvants used in perineural anesthesia and analgesia in comparison with ropivacaine. Regional Anesthesia & Pain Medicine. 2011;36(3):225-30–30.
38. Attardi B, Takimoto K, Gealy R, Severns C, Levitan E. Glucocorticoid induced up-regulation of a pituitary K+ channel mRNA in vitro and in vivo. Receptors & channels. 1993;1(4):287-93.
39. Chong MA, Berbenetz NM, Lin C, Singh S. Perineural versus intravenous dexamethasone as an adjuvant for peripheral nerve blocks: a systematic review and meta-analysis. Regional Anesthesia & Pain Medicine. 2017;42(3):319-26.
40. Zhao W-L, Ou X-F, Liu J, Zhang W-S. Perineural versus intravenous dexamethasone as an adjuvant in regional anesthesia: a systematic review and meta-analysis. Journal of Pain Research. 2017;10:1529-43.
41. Desmet M, Braems H, Reynvoet M, Plasschaert S, Van Cauwelaert J, Pottel H, et al. IV and perineural dexamethasone are equivalent in increasing the analgesic duration of a single-shot interscalene block with ropivacaine for shoulder surgery: a prospective, randomized, placebo-controlled study. British journal of anaesthesia. 2013;111(3):445-52.
42. Zorrilla-Vaca A, Li J. Dexamethasone Injected Perineurally is More Effective than Administered Intravenously for Peripheral Nerve Blocks. The Clinical journal of pain. 2018;34(3):276-84.
43. Tien M, Gan T, Dhakal I, White W, Olufolabi A, Fink R, et al. The effect of anti‐emetic doses of dexamethasone on postoperative blood glucose levels in non‐diabetic and diabetic patients: a prospective randomised controlled study. Anaesthesia. 2016;71(9):1037-43.
44. Kassem H, Urits I, Viswanath O, Kaye AD, Eskander JP. Use of Dexmedetomidine With Dexamethasone for Extended Pain Relief in Adductor Canal/Popliteal Nerve Block During Achilles Tendon Repair. Cureus. 2020;12(12):e11917-e.
45. Zusman RP, Urits I, Kaye AD, Viswanath O, Eskander J. Synergistic Effect of Perineural Dexamethasone and Dexmedetomidine (Dex-Dex) in Extending the Analgesic Duration of Pectoral Type I and II Blocks. Cureus. 2020;12(9):e10703-e.
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How to Cite this Article: Deshpande R, Wagh H, Kulkarni S | Adjuvants in Peripheral Nerve Blocks | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 63-66.

 

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