The Fate of Lumbar Epidural Catheters in the Postoperative Period- A Retrospective Single-center Audit

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Vol 4 | Issue 2 | July-December 2023 | Page 14-17 | Sandeep Diwan, Himaunshu Dongre, Parag Sancheti

DOI: https://doi.org/10.13107/ijra.2023.v04i02.077

Submitted: 26-06-2023; Reviewed: 18-07-2023; Accepted: 23-10-2023; Published: 10-12-2023

Authors: Sandeep Diwan [1], Himaunshu Dongre [1], Parag Sancheti [2]

 

[1] Department of Anesthesiology, Sancheti Hospital, Pune, Maharashtra, India.
[2] Department of Orthopaedics, Sancheti Hospital, Pune, Maharashtra, India.

Address of Correspondence
Dr. Himaunshu Dongre,
Department of Anesthesiology, Sancheti Hospital, Pune, Maharashtra State, India.
E-mail: himaunshu.dongre@gmail.com

Abstract

This paper describes a retrospective audit of fate of epidural catheters in post operative period in adults and elderly patients (more than 65 years) receiving epidural infusion analgesia (EIA) in a single institute. Epidural catheters can either migrate inwards (inward migration of epidural catheter or IMEC) otherwise, outwards (outward migration of epidural catheter or OMEC). The OMEC can lead to failure of epidural analgesia and loss of infusate. The primary aim was to evaluate the incidence of OMEC. The secondary aim was, disconnections, kinking, knotting and breakage of catheter. The primary and secondary aim together were considered as fate of epidural catheter. Our study demonstrates the OMEC occurred at 1.12%, disconnection at 7.32%, kink and knot at 1.12% and 0.016% respectively A good communication at all levels (anesthesiologist-handlers at each level-nursing staff), in event of raised incidence (inform the QHC and concerned anesthesiologist) is mandatory to avoid mishandling of epidural assembly. After identifying some of the causes including the dressing material and fixation methods, changes were implemented which will be audited in the subsequent study.
Keywords: Epidural catheter migration, Audit, Observational Study

References

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How to Cite this Article:  Diwan S, Dongre H, Sancheti P | The Fate of Lumbar Epidural Catheters in the Postoperative Period- A Retrospective Single-center Audit | International Journal of Regional Anaesthesia | July-December 2023; 4(2): 14-17 | DOI: https://doi.org/10.13107/ijra.2023.v04i02.077

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Pendant Positioning Vs Traditional Sitting for Successful Spinal Punctures in Elderly

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Vol 4 | Issue 2 | July-December 2023 | Page 9-13 | Tamasi Dawn, Yatindra Kumar Batra, Sunny Rupal, Komal Jit Kaur, Tanvir Samra

DOI: https://doi.org/10.13107/ijra.2023.v04i02.076

Submitted: 10-08-2023; Reviewed: 06-09-2023; Accepted: 24-10-2023; Published: 10-12-2023

Authors: Tamasi Dawn [1], Yatindra Kumar Batra [1], Sunny Rupal [1], Komal Jit Kaur [1], Tanvir Samra [2]

[1] Department of Anaethesiology Max superspeciality Hospital, Mohali, Punjab, India.
[2] Department of Anaesthesia PGIMER, Chandigarh, India.

Address of Correspondence
Dr. Tanvir Samra,
Associate Professor Department of Anaesthesia PGIMER, Chandigarh, India.
E-mail: drtanvirsamra@yahoo.co.in

Abstract

Background- The ability of the pendant position in increasing the intervertebral spaces translating in an increase in the 1st attempt spinal puncture success rate has been reported in pregnant females undergoing cesarean section. However, the same has not been done for the elderly patients in which age-related degenerative anatomical changes, decreased lordosis, disseminated sclerosis, and extensive osteophytosis is known to reduce the intervertebral space.
Materials and Methods- A prospective randomized controlled study was conducted in patients aged 60-80 years undergoing urological surgeries after approvalfrom the Institutional Ethics Committee and written informed consent from the patients. Primary aim was to compare the number of bone contacts during administration of subarachnoid block with the patient in either pendant (Group A) or traditional (Group B) position. Secondary aims were to compare the proportion of successful spinal needle placements, ease of palpation of spinous processes, patient’s comfort, number of spaces used, time to perform spinal puncture, time to reach grade III (as per modified bromage score) motor blockade, time to reach T10 sensory level and rate of complications in both the groups.
Results- Demographic data was comparable and there was no statistical difference in number of bone contacts, ease of administration, success of spinal needle placements, performance times of subarachnoid block and duration of spinal anaesthesia in both the groups. Complication rates were comparable.
Conclusion- Pendant positioning does not confer any advantage over the traditional sitting position in success rates and performance characteristics of subarachnoid block in elderly (60-80 years) patients scheduled for urological surgeries.
Keywords: Pendant position, Spinal-bone contact, Spinal Needle Puncture, Lumbar puncture, Spinal anesthesia, Aged

References

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7. Pryambodho P, Mahdi Nugroho A, Januarrifianto D. Comparison Between Pendant Position and Traditional Sitting Position for Successful Spinal Puncture in Spinal Anesthesia for Cesarean Section. Anesth Pain Med. 2017;7:e14300.
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12. Chohedri A, RaeesiEstabragh R, Eghbal MH, Sahmeddini MA, Eftekharian H, Shahabifar R. Comparing the Duration of Spinal Anesthesia Induced With Bupivacaine and a Bupivacaince- Lidocaine Combination in Trans-Urethral Resection of the Prostate (TURP). Anesth Pain Med 2015;5: e25675.
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14. Tessler MJ, Kardash K, Wahba RM, Kleiman SJ, Trihas ST, Rossignol M. The performance of spinal anesthesia is marginally more difficult in the elderly. Reg Anesth Pain Med. 1999; 24:126-30.
15. Chin KJ, Karmakar MK, Peng P. Ultrasonography of the adult thoracic and lumbar spine for central neuraxial blockade. Anesthesiology. 2011;114:1459–85.
16. Butterworth JF, Mackey DC, Wasnick JD. Anesthesia for genitourinary surgery. In: Butterworth JF, Mackey DC, Wasnick JD, editors. Morgan and Mikhail’s Clinical Anesthesiology. US: McGraw-Hill Education; 2013. pp. 671–90.
17. Fisher KS, Arnholt AT, Douglas ME, Vandiver SL, Nguyen DH. A randomized trial of the traditional sitting position versus the hamstring stretch position for labor epidural needle placement. AnesthAnalg. 2009;109:532–4

How to Cite this Article:  Dawn T, Batra YK, Rupal S, Kaur KJ, Samra T | Pendant Positioning Vs Traditional Sitting for Successful Spinal Punctures in Elderly | International Journal of Regional Anaesthesia | July- December 2023; 4(2): 9-13 | DOI: https://doi.org/10.13107/ijra.2023.v04i02.076

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Thoracic Wall Blocks for Thoracic Surgery

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Vol 4 | Issue 2 | July-December 2023 | Page 01-08 | Neha Pangasa, Anjolie Chhabra

DOI: https://doi.org/10.13107/ijra.2023.v04i02.075

Submitted: 08-07-2023; Reviewed: 01-09-2023; Accepted: 09-10-2023; Published: 10-12-2023

Authors: Neha Pangasa [1], Anjolie Chhabra [1]

[1] Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Address of Correspondence
Dr. Neha Pangasa
Assistant Professor, Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.
Email- nehapangasa@gmail.com

Abstract

Thoracic epidural, paravertebral block and intercostal nerve block were the conventional methods of providing analgesia for thoracic surgery, about a decade ago. In the modern era with the advent of ultrasound guided regional anesthesia, the fascial plane blocks came as a boon to anesthesiologists. These blocks are safer, as the needle tip remains distant from the pleura and they are technically easier to perform. We have described in brief the various techniques for thoracic wall analgesia with special emphasis to fascial plane blocks, along with the current evidence for each block.
Keywords: Thoracic wall blocks, Fascial plane blocks, Local anaesthetic

References

1. Chin KJ, Pawa A, Forero M, Adhikary S. Ultrasound-guided fascial plane blocks of the thorax: pectoral I and II, serratus anterior plane, and erector spinae plane blocks. Advances in Anesthesia 2019; 37: 187–205.
2. Nair S, Gallagher H, Conlon N. Paravertebral blocks and novel alternatives. BJA Education 2020, 20(5): 158-65.
3. Karmakar MK. Thoracic Paravertebral Block. Anesthesiology 2001; 95:771– 80.
4. Yeung JHY, Gates S, Naidu BV, Leuwer M, Gao Smith F. Paravertebral block versus thoracic epidural for patients undergoing thoracotomy. Cochrane Database of Systematic Reviews 2011; 5. Art. No.: CD009121.
5. Lönnqvist PA, MacKenzie J, Soni AK, Conacher ID. Paravertebral blockade: failure rate and complications. Anaesthesia. 1995 Sep;50(9):813-5.
6. Chhabra A, Chowdhury AR, Prabhakar H, Subramaniam R, Arora MK, Srivastava A, Kalaivani M. Paravertebral anaesthesia with or without sedation versus general anaesthesia for women undergoing breast cancer surgery. Cochrane Database of Systematic Reviews. 2021(2).
7. Chin KJ, Versyck B, Pawa A. Ultrasound-guided fascial plane blocks of the chest wall: a state of the art review. Anaesthesia 2021, 76: 110–26.
8. Elsharkawy H, Pawa A, Mariano ER. Interfascial plane blocks: back to basics. Reg Anesth Pain Med 2018; 43: 341–6.
9. Blanco R. The ‘pecs block’: a novel technique for providing analgesia after breast surgery. Anaesthesia 2011; 66: 847–8.
10. Blanco R, Fajardo M, Parras MT. Ultrasound description of Pecs II (modified Pecs I): a novel approach to breast surgery. Revista Espanola De Anestesiologia Y Reanimacion 2012; 59: 470–5.
11. Blanco R, Parras T, McDonnell JG, Prats-Galino A. Serratus plane block: a novel ultrasound-guided thoracic wall nerve block. Anaesthesia 2013; 68: 1107–13.
12. Johnston DF, Black ND, O’Halloran R, Turbitt LR, Taylor SJ. Cadaveric findings of the effect of rib fractures on spread of serratus plane injections. Canadian Journal of Anesthesia 2019; 66: 738–9.
13. Chin KJ ,Kariem ,Boghdadly KE. Mechanisms of action of the erector spinae plane (ESP) block: a narrative review. Can J Anesth 2021; 68:387–408.
14. Moustafa MA, Alabd AS, Ahmed AM, Deghidy EA. Erector spinae versus paravertebral plane blocks in modified radical mastectomy: Randomised comparative study of the technique success rate among novice anaesthesiologists. Indian J Anaesth 2020;64:49-54.
15. Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain. Regional Anesthesia & Pain Medicine. 2016 Sep 1;41(5):621-7.
16. Yang H.M ,Choi Y.J, Kwon HJ, J. O, Cho T.H, Kim S.H. Comparison of injectate spread and nerve involvement between retrolaminar and erector spinae plane blocks in the thoracic region: a cadaveric study. Anaesthesia 2018, 73, 1244–50.
17. Ivanusic J, Konishi Y, Barrington M.J. A Cadaveric Study Investigating the Mechanism of Action of Erector Spinae Blockade. Reg Anesth Pain Med 2018;43: 567–71.
18. Huang W, Wang W , Xie W , Chen Z , Liu Y. Erector spinae plane block for postoperative analgesia in breast and thoracic surgery: A systematic review and meta-analysis. J. Clin Anesth 2020; 66: 109900.
19. Adhikary SD, Liu WM, Fuller E, Cruz-Eng H, Chin KJ. The effect of erector spinae plane block on respiratory and analgesic outcomes in multiple rib fractures: a retrospective cohort study. Anaesthesia 2019; 74: 585–93.
20. Jüttner T, Werdehausen R, Hermanns H , Enrico Monaca E, Oliver D, Pannen B.H et al. The paravertebral lamina technique: a new regional anesthesia approach for breast surgery. J Clin. Anesth. 2011; 23, 443–50.
21. Murouchi T, Yamakage M. Retrolaminar block: analgesic efficacy and safety evaluation. J Anesth 2016;30(6):1003-07.
22. Wang Q, Wei S, Li S, Yu J, Zhang G, Ni C et al. Comparison of the analgesic effect of ultrasound-guided paravertebral block and ultrasound-guided retrolaminar block in Uniportal video-assisted Thoracoscopic surgery: a prospective, randomized study. BMC Cancer 2021; 21:1229.
23. Costache I, Neumann LD, Ramnanan C.J, Goodwin S.L, Pawa A, Abdallah F.W et al. The mid-point transverse process to pleura (MTP) block: a new end-point for thoracic paravertebral block. Anesthesia 2017; 72(10): 1230-36.
24. Chen XU, Yang J, Xia M, Wu H, Wang S, Zhang W. Postoperative Analgesia After Uniportal Video-Assisted Thoracoscopic Surgery: A Randomized Controlled Trial. J.Cardiothorac.Vasc. Anesth.2022; 36 : 2432-38.
25. Shibata Y, Kampitak W, Tansatit T. The Novel Costotransverse Foramen Block Technique: Distribution Characteristics of Injectate Compared with Erector Spinae Plane Block. Pain Physician. 2020 Jun;23(3):E305-E314. PMID: 32517407.
26. Nanda S, Bhoi D, Pangasa N, Jain D. Multiple injection costotransverse block for chronic pain in a patient with granulomatous mastitis. Indian J Anaesth 2021;65:772-4.
27. Chin KJ. Thoracic wall blocks: From paravertebral to retrolaminar to serratus to erector spinae and back again-A review of evidence. Best Pract.Res. Clin. Anaesthesiol 2019;33: 67-77 .
28. Pascarella, G.; Costa, F.; Nonnis, G.; Strumia, A.; Sarubbi, D.; Schiavoni, L.; Di Pumpo, A.; Mortini, L.; Grande, S.; Attanasio, A.; et al. Ultrasound Guided Parasternal Block for Perioperative Analgesia in Cardiac Surgery: A Prospective Study. J. Clin. Med. 2023, 12, 2060.
29. Diwan S, Nair A. Ultrasound‐guided bilateral parasternal block: A boon for managing pain after sternal fracture/ dislocation. Saudi J Anaesth 2020;14:224‐7.
30. Versyck B, Geffen GJV , Chin KJ. Analgesic efficacy of the Pecs II block: a systematic review and meta-analysis. Anaesthesia 2019; 74: 663–73.
31. Hussain N, Brull R, McCartney CJL, et al. Pectoralis-II myofascial block and analgesia in breast cancer surgery: a systematic review and meta-analysis. Anesthesiology 2019; 131: 630–48.
32. Liu XC, Song TT, Xu HY, Chen XJ, Yin PF, Zhang JJ. The serratus anterior plane block for analgesia after thoracic surgery: A meta- analysis of randomized controlled trails. Medicine 2020;99:21(e20286).
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How to Cite this Article: Pangasa N, Chhabra A | Thoracic Wall Blocks for Thoracic Surgery | International Journal of Regional Anaesthesia | July-December 2023; 4(2): 01-08 | DOI: https://doi.org/10.13107/ijra.2023.v04i02.075

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Supra-inguinal Fascia Iliaca Block and the Obturator Nerve Obsession

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Vol 4 | Issue 2 | July-December 2023 | Page 27-28 | Sandeep Diwan, Georg Feigl, Shivaprakash S

DOI: https://doi.org/10.13107/ijra.2023.v04i02.080

Authors: Sandeep Diwan [1], Georg Feigl [2], Shivaprakash S [3]

[1] Department of Anaesthesia, Sancheti Institute of Orthopaedic and Rehabilitation, Pune, Maharashtra, India.
[2] Department of Anatomy and Clinical Morphology, Witten / Herdecke University, Witten, Germany.
[3] Department of Anatomy, JSS Medical College, JSS Academy of Higher Education and Research, Mysore, Karnataka State, India..

Address of Correspondence
Dr. Sandeep Diwan,
Department of Anaesthesia, Sancheti Institute of Orthopaedic and Rehabilitation, Pune, Maharashtra, India.
E-mail: sdiwan14@gmail.com

To the Editor,

Anatomic block efficacy of lumbar plexus elements is based upon the involvement of the obturator nerve. However, despite the anatomic location of the obturator nerve and improbable translocation of local anesthetic beyond the confinement of the fascia iliacus plane [1], investigators struggle to study extensively, exhaustively, and try to explicitly describe the means and mechanism to block the obturator nerve [2].
Our anatomical dissections reveal three important dissimilar fascial planes (figure 1a). The quadratus lumborum, the fascia iliaca, and the circum-psoas planes are isolated from each other with tight fascial attachments [Figure 1b], impeding the dissemination of local anaesthetic agents unless inadvertently perforating the fascia. Further exploration revealed the femoral, lateral femoral cutaneous, obturator nerves and the lumbosacral trunk emerge from the lateral and medial of the psoas muscle respectively, and exits the psoas fascia (figure 1a,1b, and 1c) to take their respective course. The obturator nerve might further arise in a separate muscular fold (Figure 1c).
However, if the obturator nerve needs to be blocked, two we recommend two alternatives; We presume that with injections deep to the psoas sheath, the plausibility of involvement of all the nerves of the lumbar plexus (lateral femoral cutaneous nerve, femoral nerve, and ON) exists, as reported in a case series [3] and the obturator nerve needs to be blocked separately after a supra-inguinal fascia iliaca block.

References

1. Bendtsen TF, Pedersen EM, Moriggl B, et al. Anatomical considerations for obturator nerve block with fascia iliaca compartment block. Reg Anesth Pain Med. 2021; 46:806-12.
2. Swenson JD, Davis JJ, Stream JO, Crim JR, Burks RT, Greis PE. Local anesthetic injection deep to the fascia iliaca at the level of the inguinal ligament: the pattern of distribution and effects on the obturator nerve. J Clin Anesth. 2015; 27:652-7.
3. Diwan S, Nair A, Gawai N, Shah D, Sancheti P. Circumpsoas block – an anterior myofascial plane block for lumbar plexus elements: case report. Braz J Anesthesiol. 2021: S0104-0014(21)00180-9.

How to Cite this Article:   Diwan S, Feigl G, S Shivaprakash | Supra-inguinal Fascia Iliaca Block and the Obturator Nerve Obsession | International Journal of Regional Anaesthesia | July-December 2023; 4(2): 27-28 | DOI: https://doi.org/10.13107/ijra.2023.v04i02.080

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Making Regional Anaesthesia Safe

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Vol 4 | Issue 2 | July-December 2023 | Page 21-26 | Ashish A. Bartakke

DOI: https://doi.org/10.13107/ijra.2023.v04i02.079

Submitted: 12-11-2023; Reviewed: 18-11-2023; Accepted: 25-11-2023; Published: 10-12-2023

Authors: Ashish A. Bartakke [1]

[1] Department of Anaesthesiology and Perioperative Medicine, Hospital Valle de los Pedroches, Pozoblanco, Andalucia, Spain.

Address of Correspondence
Dr. Ashish A. Bartakke,
Senior Faculty Consultant, Department of Anaesthesiology and Perioperative Medicine, Hospital Valle de los Pedroches, Pozoblanco, Andalucia, Spain.
E-mail: ashishbartakke@gmail.com

Abstract

The complexity of current practice in anaesthesiology and perioperative medicine has resulted in employing complex regional anaesthesia techniques to improve patient outcomes in terms of better postoperative pain control and thus facilitate early mobilization and recuperation of patients. However, ensuring patient safety while performing these complex procedures is of paramount importance and all efforts need to be undertaken to minimise the possibility of harm to the patient. Quality improvement and patient safety go hand in hand. Ensuring safe practices in regional anaesthesia is not just an individual task but a collective responsibility of the perioperative team. It thus involves both technical skills as well as non-technical skills and human factors.
This article provides a brief discussion of the various measures involving technical and non-technical factors to improve patient safety in modern day regional anaesthesia practice.
Keywords: Regional Anaesthesia, Patient safety, Non-technical skills, Human factors

References

1. Mellin-Olsen J, Staender S, Whitaker DK, Smith AF. The Helsinki Declaration on Patient Safety in Anaesthesiology. Eur J Anaesthesiol. 2010;27(7):592-597. doi:10.1097/EJA.0b013e32833b1adf
2. Kettner SC, Willschke H, Marhofer P. Does regional anaesthesia really improve outcome?. Br J Anaesth. 2011;107 Suppl 1:i90-i95. doi:10.1093/bja/aer340
3. Jin Z, Hu J, Ma D. Postoperative delirium: perioperative assessment, risk reduction, and management. Br J Anaesth. 2020;125(4):492-504. doi:10.1016/j.bja.2020.06.063
4. Fanelli A, Balzani E, Memtsoudis S, Abdallah FW, Mariano ER. Regional anesthesia techniques and postoperative delirium: systematic review and meta-analysis. Minerva Anestesiol. 2022;88(6):499-507. doi:10.23736/S0375-9393.22.16076-1
5. Association of Anaesthetists of Great Britain and Ireland, Obstetric Anaesthetists’ Association, Regional Anaesthesia UK, Campbell J, Plaat F, Checketts M et al. Safety guideline: skin antisepsis for central neuraxial blockade. Anaesthesia 2014; 69: 1279e86
6. Dumville JC, McFarlane E, Edwards P, Lipp A, Holmes A. Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database Syst Rev. 2013;(3):CD003949. Published 2013 Mar 28. doi:10.1002/14651858.CD003949.pub3
7. Bomberg H, Bayer I, Wagenpfeil S et al. Prolonged catheter use and infection in regional anesthesia: a retrospective registry analysis. Anesthesiol J Am Soc Anesthesiol 2018; 128: 764e73
8. Keys M, Sim BZ, Thom O, Tunbridge MJ, Barnett AG, Fraser JF. Efforts to Attenuate the Spread of Infection (EASI): a prospective, observational multicentre survey of ultrasound equipment in Australian emergency departments and intensive care units. Crit Care Resusc J Australas Acad Crit Care Med 2015; 17: 43e6
9. Ecoffey C, Bosenberg A, Lonnqvist PA, Suresh S, Delbos A, Ivani G. Practice advisory on the prevention and management of complications of pediatric regional anesthesia. J Clin Anesth. 2022;79:110725. doi:10.1016/j.jclinane.2022.110725
10. Neal JM. Ultrasound-guided regional anesthesia and patient: update of an evidence-based analysis. Reg Anesth Pain Med 2016; 41: 195e204
11. Topor B, Oldman M, Nicholls B. Best practices for safety and quality in peripheral regional anaesthesia. BJA Educ. 2020;20(10):341-347. doi:10.1016/j.bjae.2020.04.007
12. Dohlman LE, Kwikiriza A, Ehie O. Benefits and Barriers to Increasing Regional Anesthesia in Resource-Limited Settings. Local Reg Anesth. 2020;13:147-158. Published 2020 Oct 22. doi:10.2147/LRA.S236550
13. Mulroy MF, Weller RS, Liguori GA. A checklist for performing regional nerve blocks [published correction appears in Reg Anesth Pain Med. 2014 Jul-Aug;39(4):357]. Reg Anesth Pain Med. 2014;39(3):195-199. doi:10.1097/AAP.0000000000000075
14. Stop before you block. Available from: https://www.ra-uk.org/index.php/stop-before-you-block. [Accessed 25 March 2020]

How to Cite this Article:   Bartakke AA | Making Regional Anaesthesia Safe | International Journal of Regional Anaesthesia | July-December 2023; 4(2): 21-26 | DOI: https://doi.org/10.13107/ijra.2023.v04i02.079

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Brachial Plexus Block in Lateral Position for Fracture Shaft Humerus in Severe Thoracic Kyphoscoliosis- A Case Report

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Vol 4 | Issue 2 | July-December 2023 | Page 18-20 | Sandeep Mutha, Sushmitha K, Rajan Kothari, Deepak Phalgune

DOI: https://doi.org/10.13107/ijra.2023.v04i02.078

Submitted: 24-03-2023; Reviewed: 16-04-2023; Accepted: 11-10-2023; Published: 10-12-2023

Authors: Sandeep Mutha [1], Sushmitha K [1], Rajan Kothari [2], Deepak Phalgune [3]

[1] Department of Anaesthesiology, Poona Hospital and Research Centre, Pune, Maharashtra, India.
[2] Department of Orthopaedic Surgery, Poona Hospital and Research Centre, Pune, Maharashtra, India.

Address of Correspondence
Dr. Deepak Phalgune
Research Consultant, Poona Hospital & Research Centre, Pune, Maharashtra, India.
Email- dphalgune@gmail.com

Abstract

Patients with spine deformities, present unique challenges to the anaesthesiologists. These patients have abnormalities such as cardiovascular, pulmonary, musculo-skeletal, etc. Spinal deformities may cause difficulties with ventilation, tracheal intubation, regional anaesthesia and positioning. Due to problems associated with respiratory system, regional anaesthesia is widely preferred, though it is technically and logistically difficult. We present a case report of the anaesthetic management of an elderly female with severe thoracic kyphoscoliosis who could not lie supine on bed. She had a fracture of left upper 1/3rd shaft humerus. She was posted for open reduction and internal fixation of fractured shaft of left humerus under brachial plexus nerve block in right lateral position with a pillow under the head. The patient was given left interscalene and costoclavicular (infraclavicular) brachial plexus block under ultrasonography and peripheral nerve stimulator guidance. Major problems for brachial plexus block were positioning, approach, dosage of medications and respiratory compromise. Another difficulty was the position of the patient during the surgical procedure. The surgery was successful and the patient was pain free both intra and postoperatively. Intraoperatively no sedation or anxiolysis were required
Keywords: Kyphoscoliosis, Brachial plexus block, Fracture humerus, Patient position.

References

1) Roberta H, Katherine M. Stoelting’s Anesthesia and Co-existing Disease. 5th ed. Philadelphia: Churchill Livingstone; 2008. pp. 459–60.
2) Kaur M, Aujla KS, Gosal JS. Anesthetic Challenges in a Patient with Severe Thoracolumbar Kyphoscoliosis. Anesth Essays Res. 2020; 14 (1): 170–2.
3) Libby DM, Briscoe WA, Boyce B, Smith JP. Acute respiratory failure in scoliosis or kyphosis: prolonged survival and treatment. Am J Med. 1982; 73 (4):532–8.
4) Misra S, Shukla A, Rao KG. Subarachnoid block in kyphoscoliosis: A reliable technique? Med J DY Patil Univ. 2016; 9 (6):761–4.
5) Kearon C, Viviani GR, Kirkley A, Killian KJ. Factors determining pulmonary function in adolescent idiopathic thoracic scoliosis. Am Rev Respir Dis 1993; 148 (2):288-94.
6) Kulkarni AH, Ambareesha M. Scoliosis and anesthetic considerations. Indian J Anaesth. 2007; 51 (6):486–95.
7) Gupta S, Singariya G. Kyphoscoliosis and pregnancy- A case report. Indian J Anaesth. 2004; 48 (3):215–20.
8) Bansal N, Gupta S. Anaesthetic management of a parturient with severe kyphoscoliosis. Kathmandu Univ Med J. 2008; 6 (23):379–82.

How to Cite this Article:   Mutha S, Sushmitha K, Kothari R, Phalgune D | Brachial Plexus Block in Lateral Position for Fracture Shaft Humerus in Severe Thoracic Kyphoscoliosis- A Case Report | International Journal of Regional Anaesthesia | July-December 2023; 4(2): 18-20 | DOI: https://doi.org/10.13107/ijra.2023.v04i02.078

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Comments on- Time to Adequately Heed Acute Pain in the Emergency Department – More Regional Blocks Warranted

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Vol 4 | Issue 1 | January-June 2023 | Page 33-34 | Arun Nagdev

DOI: https://doi.org/10.13107/ijra.2023.v04i01.074

Authors: Arun Nagdev [1]

[1] Highland Hospital/Alameda Health System.
[2] University of California, San Francisco, USA.

Address of Correspondence
Dr. Arun Nagdev,
Director, Emergency Ultrasound, Highland Hospital/Alameda Health System.
Associate Clinical Professor, University of California, San Francisco, USA.
E-mail: arunnagdev@gmail.com

To the Editor,

I read the recent article “Time to Adequately Heed Acute Pain in the Emergency Department – More Regional Blocks Warranted” by Dr. Zundert, et al. with much interest [1]. The central argument of offering adequate multimodal acute pain control to our most vulnerable patients has been the core tenant of my clinical practice and research for the last 15 years. I completely agree that If we (as the field of medicine) hope to succeed in equitable acute pain management, leveraging the skill of numerous clinicians (emergency physicians, surgeons, orthopedics, etc.) to perform single injection regional blocks will be needed [2]. Like other skills (endotracheal intubation, lumbar puncture, central venous cannulation, etc.) that have been adapted from innovators in one field and then taught to the various other specialties, ultrasound-guided regional anesthesia needs to be brought from the expert regional anesthesiologists and to the clinicians who are at the bedside caring for this cohort of patients.

Working at an academic trauma center in a low resource setting, we have had to build patient-centered pain pathways that both treat acute pain as well as ensure a reduction in opioid use. With the help of our anesthesia colleague at University of California, San Francisco, we have integrated ultrasound-guided regional blocks into our clinical practice for more than 10 years in the emergency department (ED). Just as Dr. Zundert has pointed out, this collaboration between our Anesthesia and Emergency Medicine colleagues has been an amazing success, leading to timely pain control in our acutely injured patients as well as improved patient care. For hip fractures specifically, we have worked with our anesthesia and orthopedic colleagues to develop a practice standard that asks our clinicians to perform a block in under 1 hour after recognition of a hip fracture [3]. This collaborative non-siloed based practice standard between all services dealing with acutely injured patients (trauma surgery, orthopedics, anesthesia and emergency medicine) has fostered interdepartmental education, multiple research publications and most importantly improved patient care [4, 5,6, 7].

Sincerely,

Arun Nagdev, MD
Director, Emergency Ultrasound
Highland Hospital/Alameda Health System
Associate Clinical Professor
University of California, San Francisco

References

[1] Van Zundert TCRV, Van Zundert AAJ. Time to adequately heed Acute Pain in the Emergency Department – More Regional Blocks Warranted. Int J Reg Anaesth. 2022;3(2):37-41.
[2] Wroe P, O’Shea R, Johnson B, Hoffman R, Nagdev A. Ultrasound-guided forearm nerve blocks for hand blast injuries: case series and multidisciplinary protocol. Am J Emerg Med. 2016;34(9):1895-1897.
[3] Johnson B, Herring A, Shah S, Krosin M, Mantuani D, Nagdev A. Door-to-block time: prioritizing acute pain management for femoral fractures in the ED. Am J Emerg Med. 2014;32(7):801-803.
[4] Lin DY, Woodman R, Oberai T, et al. Association of anesthesia and analgesia with long-term mortality after hip fracture surgery: an analysis of the Australian and New Zealand hip fracture registry. Reg Anesth Pain Med. 2023;48(1):14-21.
[5] Morrison RS, Dickman E, Hwang U, et al. Regional Nerve Blocks Improve Pain and Functional Outcomes in Hip Fracture: A Randomized Controlled Trial. J Am Geriatr Soc. 2016;64(12):2433-2439.
[6] Pawa A, El-Boghdadly K. Regional anesthesia by nonanesthesiologists. Curr Opin Anaesthesiol. 2018;31(5):586-592.
[7] Stone A, Goldsmith AJ, Pozner CN, Vlassakov K. Ultrasound-guided regional anesthesia in the emergency department: an argument for multidisciplinary collaboration to increase access while maintaining quality and standards. Reg Anesth Pain Med. 2021;46(9):820-821.

How to Cite this Article: Nagdev A | Comments on- Time to Adequately Heed Acute Pain in the Emergency Department – More Regional Blocks Warranted | International Journal of Regional Anaesthesia | January-June 2023; 4(1): 33-34 | DOI: https://doi.org/10.13107/ijra.2023.v04i01.074

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Foot Drop after Hip Surgery – An Anaesthetic Perspective

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Vol 4 | Issue 1 | January-June 2023 | Page 31-32 | Vighnesh C S, Sheetal, Avneet Singh, Rajeev Kansay

DOI: https://doi.org/10.13107/ijra.2023.v04i01.073

Authors: Vighnesh C S [1], Sheetal [1], Avneet Singh [1], Rajeev Kansay [2]

[1] Department of Anaesthesia and Intensive Care, Government Medical College Hospital, Sector 32 Chandigarh, India.
[2] Department of Orthopaedics, Government Medical College Hospital, Sector 32 Chandigarh, India.

Address of Correspondence
Dr. Avneet Singh,
Assistant Professor, Department of Anaesthesia and Intensive Care, Government Medical College Hospital Sector 32, Chandigarh, India.
E-mail: avneetsinghch@gmail.com

To the Editor,

Foot drop is characterized by reduced muscle strength in the ankle dorsiflexors and inability to lift the forefoot. Foot drop occurring after an orthopedic procedure can occur due to various causes [1-5] (Figure 1). Epidural anaesthesia may sometimes attract undue attention in such a situation and presence of an epidural air pocket does not rule it out altogether as a cause. We describe an algorithmic approach to investigate the cause of foot drop after acetabular surgery performed under combined spinal-epidural anaesthesia.
A 35-year-old male, American Society of Anesthesiologists’-physical status (ASA-PS) II patient admitted with an alleged history of road-traffic accident and left acetabulum and 3rd–5th left rib fractures and hemothorax. He was initially managed for hypovolemic shock and mechanically ventilated for three days in the intensive care unit. The acetabular fracture was stabilized with tibial skeletal traction under local anesthesia. After hemodynamic stabilization, and an ICU stay duration of five days, he was planned for an acetabular fracture repair by posterior approach under combined spinal epidural anaesthesia. The preoperative evaluation and patient preparation were done as per institutional guidelines. Under aseptic precautions, combined spinal anaesthesia was applied in sitting position and midline approach at L3–L4 interspace. Epidural anaesthesia was given using 18 G Tuohy’s needle using the loss of resistance to 3 ml air at a depth of 5 cm and catheter fixed at 11 cm. The spinal anaesthesia was given with 26 G in the same lumbar space, with a clear flow of cerebrospinal fluid and 15 mg of 0.5% bupivacaine (hyperbaric) was given. The procedures were uneventful, and the patient did not report any paresthesia. The duration of surgery was 210 minutes, and 0.5% bupivacaine 5 mL was administered after 2 hours. The intraoperative period was uneventful. The postoperative analgesia was managed with epidural 0.125% bupivacaine (isobaric) with 2 μg/ml fentanyl infusion at 0.05–0.1 ml/kg/hour. On the second postoperative day, on initiating passive limb physiotherapy, the patient complained of difficulty in upward movement of ankle joint of operated limb. The clinical examination and investigations are depicted in Figure 2. A non-contrast computed tomography of the spine showed air pockets in the lumbar epidural space without hematoma (Figure 3). Initially, the epidural air pocket was considered the cause. However, this was unlikely due to the unilateral and singular peripheral nerve involvement. The diagnosis of left deep peroneal nerve injury that could have occurred due to tibial pin was made. He was initiated on limb physiotherapy and foot drop splint was applied. He was discharged with tablet diclofenac 50 mg 8th hourly and vitamin B12. On follow-up, 7 days after discharge with good physiotherapy and regular medications the patient had regained full power of dorsi-flexion.

References

[1] Carolus AE, Becker M, Cuny J, et al. The Interdisciplinary Management of Foot Drop. Dtsch Ärztebl Int. 2019;116: 347.
[2] Issack PS, Helfet DL. Sciatic Nerve Injury Associated with Acetabular Fractures. HSS J. 2009;5: 12.
[3] Giannoudis PV, Da Costa AA, Raman R, et al. Double-crush syndrome after acetabular fractures. J Bone Joint Surg Br. 2005;87-B: 401–7.
[4] Liporace FA, Yoon RS, Kesani AK. Transient common peroneal nerve palsy following skeletal tibial traction in a morbidly obese patient – case report of a preventable complication. Patient Saf Surg. 2012;6:4.
[5] Ng J, Marson BA, Broodryk A. Foot drop following closed reduction of a total hip replacement. BMJ Case Rep. 2016;2016: bcr2016215010.

How to Cite this Article: Vighnesh CS, Sheetal, Singh A, Kansay R | Foot Drop after Hip Surgery – An Anaesthetic Perspective | International Journal of Regional Anaesthesia | January-June 2023; 4(1): 31-32 | DOI: https://doi.org/10.13107/ijra.2023.v04i01.073

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Efficacy of Butorphanol and Tramadol as an Adjuvant to Levobupivacaine for Postoperative Analgesia in Brachial Plexus Block – A Randomized Double-Blind Study

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Vol 4 | Issue 1 | January-June 2023 | Page 07-12 | Jaya Lalwani, A. Sashank, Ravi Chaudhari

DOI: https://doi.org/10.13107/ijra.2023.v04i01.068

Authors: Jaya Lalwani [1], A. Sashank [1], Ravi Chaudhari [1]

[1] Department of Anaesthesia and Pain Management, Pt Jawaharlal Nehru Memorial Medical College, Raipur, Chhattisgarh, India.

Address of Correspondence
Dr. Ravi Chaudhari,
Department of Anaesthesia and Pain Management, Pt Jawaharlal Nehru Memorial Medical College, Raipur, Chhattisgarh, India.
E-mail: ravichaudharicc@gmail.com

Background: Supraclavicular brachial plexus block has evolved as a safe alternative to general anaesthesia with good postoperative analgesia. In an attempt to hasten the onset of block and increase the duration of postoperative analgesia, various adjuvant drugs are used along with local anesthetic agents.
Aim: The present study was undertaken to assess the analgesic efficacy of butorphanol (2mg) and tramadol (100 mg) as an adjuvant to levobupivacaine in supraclavicular brachial plexus block during perioperative period.
Study Design: This was a prospective, randomized, double blind study done on 100 adult patients of ASA I-III aged between 18-65 years and scheduled for various upper limb surgeries below the level of elbow.
Materials and Methodology: Patients were allocated by computer generated random draw into two groups of 50 each and were administered the study drugs under ultrasonographic guidance. Both groups received 22ml of the study drug (Group B 20 ml 0.5% levobupivacaine + Butorphanol 2mg and Group T 0.5% levobupivacaine + Tramadol 100 mg). Patients were assessed for duration of postoperative analgesia, onset & duration of sensory as well as motor blockade and occurrence of any side effects.
Results: Duration of postoperative analgesia was significantly elevated in group B (683±88.58 min), as compared to group T (483.2±45.24 min.) with p<0.001. Onset of sensory and motor blockade was comparable among both groups (p>0.05). Duration of sensory and motor block in group B was significantly longer compared to group T (p<0.001). Hemodynamics were stable and side effects were minimal in both the groups.
Conclusion: Butorphanol 2mg when added to 20ml 0.5% levobupivacaine in brachial plexus block, significantly prolongs the duration of postoperative analgesia, sensory and motor block as compared to addition of 100 mg tramadol, with minimal side effects and hemodynamic changes. However, these adjuvants shorten the onset times of sensory and motor block to a similar extent.
Keywords: Brachial plexus block, Levobupivacaine, Butorphanol, Tramadol, Analgesia.

References

[1] Glajchen M. Chronic pain: treatment barriers and strategies for clinical practice. J Am Board Fam Prac. 2001;14: 211-18.
[2] El-Boghdadly K, Pawa A, Chin KJ. Local anesthetic systemic toxicity: current perspectives. Local Reg Anesth. 2018; 11:35-44
[3] Swain A, Nag DS, Sahu S, Samaddar DP. Adjuvants to local anesthetics: Current understanding and future trends. World J Clin Cases. 2017;5: 307-323.
[4] Bajwa SS, Kaur J. Clinical profile of levobupivacaine in regional anesthesia: A systematic review. J Anaesthesiology Clinical Pharmacology 2013;29: 530-39.
[5] Howard BG, Huda A. Opioid Analgesics. In:Goodman GA, Hardman G, Lee EL, editors. The pharmacological basis of therapeutics, Opioid analgesics. 10th ed. NewYork: McGraw Hill 2001.
[6] Vazzana M, et al. Tramadol hydrochloride: Pharmacokinetics, pharmacodynamics, adverse side effects, co-administration of drugs and new drug delivery systems. Biomed Pharmacother. 2015; 3586:1-5.
[7] Kumari A, Chhabra H, Gupta R, Kaur H. Comparative Study of Effectiveness of Tramadol and Butorphanol as Adjuvants to Levobupivacaine for Supraclavicular Brachial Plexus Block. Anesth Essays Res. 2019;13: 446-51.
[8] Foster RH, Markham A. Levobupivacaine: A review of its pharmacology and use as a local anaesthetic Drugs. 2000; 59:551–79.
[9] Edinoff A N et al. Adjuvant Drugs for Peripheral Nerve Blocks: The Role of Alpha-2 Agonists, Dexamethasone, Midazolam, and Non-steroidal Anti-inflammatory Drugs. Anesth Pain Med. 2021;11: 1-10.
[10] Desai N, Kirkham KR, Albrecht E. Local anaesthetic adjuncts for peripheral regional anaesthesia: A narrative review. Anaesthesia.2021;76: 100–09.
[11] Yilmaz E, Hough KA, Gebhart GF, Williams BA, Gold MS. Mechanisms underlying midazolam-induced peripheral nerve block and neurotoxicity. Reg Anesth Pain Med. 2014;39: 525–33.
[12] Krishna Prasad GV, Khanna S, Jaishree SV. Review of adjuvants to local anesthetics in peripheral nerve blocks: Current and future trends. Saudi J Anaesth 2020; 14:77‑84.
[13] Laudren PM. Axonal transport of opiate receptors in capsaicin-sensitive neurons. BrainResearch 1984; 68:413.
[14] Srikala V, Kumar MT. A Comparative Study of Buprenorphine Versus Butorphanol in Supraclavicular Brachial Plexus Block for Postoperative Analgesia. European Journal of Molecular & Clinical Medicine, 2022; 9: 2918-24.
[15] Bhavsar GM, Shah RB, Chavda HK, Shah VD, Bateriwala KM. Use of butorphanol as an adjuvant to local anaesthetics in brachial plexus block for upper limb surgery. PIJR. 2016;5: 169–72.
[16] Vinod CN, Talikoti DG. Comparison of Butorphanol and Buprenorphine as an Adjuvant to Local Anesthesia in Supraclavicular Brachial Plexus Block for Post-Operative Analgesia. Journal of Evolution of Medical and Dental Sciences 2014; 3: 4287-93
[17] Khosa A.H. & Asad, Naqibullah & Durrani, HAQ DAD. Does the addition of Tramadol to local anaesthetic mixture improve the quality of axillary brachial plexus block: A comparative study at the teaching hospital, Dera Ghazi Khan. Pakistan Journal of Medical and Health Sciences 2015;9: 1120-23.
[18] Bhatia U, Panjabi G, Patel A. Comparison of butorphanol and tramadol as an adjuvant to local anesthetic drug in axillary brachial plexus block. Ain-Shams J Anaesthesiology 2017;10: 242-46.
[19] Sharan R, Singh M, Attri J.P, Singh D. Additive effect of butorphanol in supraclavicular brachial plexus block. Int J Med Res Rev 2016;4: 910-17.
[20] Bharathi B, Praveena BL, Krishnaveni KN. Supraclavicular Brachial Plexus Block: Comparison of Varying Doses of Butorphanol Combined with Levobupivacaine – A Double-Blind Prospective Randomized Trial. Anesthesia Essays and Research. 2019;13: 174-78.
[21] Bommalingappa B, Channabasappa SM. Butorphanol as an adjuvant to levobupivacaine in supraclavicular brachial plexus block for upper limb orthopaedic surgeries: a randomized, double blind, placebo controlled study. J. Evolution Med. Dent. Sci. 2016;5: 4194-97.

How to Cite this Article: Lalwani J, Sashank A, Chaudhari R | Efficacy of Butorphanol and Tramadol as an Adjuvant to Levobupivacaine for Postoperative Analgesia in Brachial Plexus Block – A Randomized Double-Blind Study | International Journal of Regional Anaesthesia | July-December 2023; 4(1): 07-12 | DOI: https://doi.org/10.13107/ijra.2023.v04i01.0068

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To Remove or Not to Remove a Broken Perineural Catheter Fragment?

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Vol 4 | Issue 1 | January-June 2023 | Page 26-28 | Trupti Pethkar, Harshal Wagh

DOI: https://doi.org/10.13107/ijra.2023.v04i01.071

Authors: Trupti Pethkar [1], Harshal Wagh [1]

[1] Department of Anaesthesia, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India.

Address of Correspondence
Dr. Trupti Pethkar,
Department of Anaesthesia, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India.
E-mail: truptipethkar@yahoo.co.in

Fracture of femoral perineural catheter during insertion is the extremely rare complication of an otherwise low risk procedure. In such a scenario, whether to leave the catheter in situ or extract it by surgical exploration is the dilemma. We present two cases of broken femoral perineural catheter incurred during insertion. Since patients do not complain of any kind of immediate pain or discomfort, after shearing of the catheter, the decision making regarding the further management is difficult. But, there are incidences of long term complication like femoral neuritis leading to constant dragging pain. This makes us uncomfortable and force to think whether these broken fragments should left in situ.
Keywords: Femoral perineural catheter, Femoral nerve block, Fractured catheter fragment

References

[1] Joshi G, Gandhi K, Shah N, Gadsden J, Corman SL. Peripheral nerve blocks in the management of postoperative pain: challenges and opportunities. Journal of Clinical Anesthesia 2016;35:524-9.
[2] Aveline C, Le Hetet H , Le Roux A, Vautier P, Gautier JF, Cognet F. Perineural ultrasound-guided catheter bacterial colonization: a prospective evaluation in 747 cases. Reg Anesth Pain Med 2011;36:579-84.
[3] Ilfeld BM. Continuous peripheral nerve blocks: a review of the published evidence. Anesth Analg 2011;113:904-25.
[4] Adam F, Jaziri S, Chauvin M. Psoas Abscess Complicating Femoral Nerve Block Catheter. Anesthesiology 2003;99:230–1.
[5] Sharma S, Iorio R, Specht LM, Davies-Lepie S, Healy WL. Complications of femoral nerve block for total knee arthroplasty. Clin Orthop Relat Res 2010;468(1):135-40.
[6] Lee BH and Goucke CR. Shearing of a Peripheral Nerve Catheter. Anesthesia & Analgesia 2002;95(3):760-1.
[7] Guerci P, Novy E, Guibert J, Vial F, Malinovsky JM, Bouaziz H. Cisaillements accidentels de cathéters périnerveux lors de poses échoguidées [Inadvertent peripheral nerve catheter shearing occurring during ultrasound guidance]. Ann Fr Anesth Reanim. 2013;32(5):364-7(in French).
[8] Khabiri B, Hamilton C, Norton J, Arbona F, Carlson L. The Difficulty to Remove Perineural Catheter: A Technique for Removing an Intact Catheter. Open Journal of Anesthesiology 2013;3(6):304-7.

How to Cite this Article: Pethkar T, Wagh H | To Remove or Not to Remove a Broken Perineural Catheter Fragment? | International Journal of Regional Anaesthesia | January-June 2023; 4(1): 26-28 | DOI: https://doi.org/10.13107/ijra.2023.v04i01.071

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