Management of Patient with Limb Girdle Muscular Dystrophy for ERCP and Regional Anaesthesia for Laparoscopic Cholecystectomy: Case Report

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Vol 3 | Issue 1 | January-June 2022 | Page 27-30 | Shalini Saksena , Arnab Paul

DOI: 10.13107/ijra.2022.v03i01.051

Authors: Shalini Saksena [1], Arnab Paul [1]

[1] Department of Anaesthesia, PD Hinduja National Hospital & MRC, Mahim, Mumbai, Maharashtra, India.

Address of Correspondence:
Dr. Arnab Paul,
Department of Anaesthesia, PD Hinduja National Hospital & MRC, Mahim, Mumbai, Maharashtra, India.
E-mail: dr.arnabpaul88@gmail.com

Abstract

Limb-Girdle muscular dystrophies (LGMDs) are a clinically and genetically heterogeneous group of disorders characterized in general by predominantly limb-girdle weakness. It manifests as proximal muscle weakness involving the pelvic girdle and scapular girdle. We report the anaesthetic management of a patient who is a known case of limb-girdle muscular dystrophy, presented with cholecystitis to our institution. Patient underwent endoscopic retrograde cholangio pancreatography (ERCP) under total intravenous anaesthesia followed by laparoscopic cholecystectomy under spinal anaesthesia which were managed successfully.
Keywords: Muscular Dystrophies, Limb-Girdle, Malignant Hyperthermia, Anaesthesia

References

1. Jayadev S. Muscular Dystrophies. Brenner’s Encyclopedia of Genetics 2013; 2: 522-4.
2. Allen T, Maguire S. Anaesthetic management of a woman with autosomal recessive limb-girdle muscular dystrophy for emergency caesarean section. Int J Obstet Anesth 2007; 16:370–374.
3. Iyadurai SJ, Kissel JT. The Limb-Girdle Muscular Dystrophies and the Dystrophinopathies. Continuum (Minneap Minn). 2016;22(6, Muscle and Neuromuscular Junction Disorders):1954–77
4. Chu ML, Moran E. The limb-girdle muscular dystrophies: is treatment on the horizon? Neurotherapeutics. 2018; 15:849–62.
5. Richa FC. Anaesthetic management of a patient with limb-girdle muscular dystrophy for laparoscopic cholecystectomy. Eur J Anaesthesiol 2011; 28:72–73.
6. Segura LG, Lorenz JD, Weingarten TN, et al. Anaesthesia and Duchenne or Becker muscular dystrophy: review of 117 anesthetic exposures. Paediatr Anaesth 2013; 23:855–864.
7. Kim TW, Nemergut ME. Preparation of modern Anaesthesia workstations for malignant hyperthermia-susceptible patients: a review of past and present practice. Anesthesiology. 2011;114(1):205–12.
8. Wappler F. Anaesthesia for patients with a history of malignant hyperthermia. Curr Opin Anaesthesiol. 2010;23(3):417–22.
9. Bajwa SJ, Kulshrestha A. Anaesthesia for laparoscopic surgery: General vs regional anaesthesia. J Min Access Surg 2016; 12:4-9.
10. Catani M, Guerricchio R, De Milito R, et al. ‘Low-pressure’ laparoscopic cholecystectomy in high-risk patients (ASA III and IV): our experience. Chir Ital 2004; 56:71–80.
11. Van Obbergh LJ, Corteel J, Papadopoulos J, et al. Anaesthesia for a child suffering from a deletion in the Xp21 loci resulting in Duchenne disease, glycerol kinase deficiency and congenital adrenal hypoplasia. Paediatr Anaesth 2011; 21:1085–87.

How to Cite this Article: Saksena S, Paul A | Management of Patient With Limb Girdle Muscular Dystrophy for ERCP and Regional Anaesthesia for Laparoscopic Cholecystectomy: Case Report | International Journal of Regional Anaesthesia | January-June 2022; 3(1): 27-30.

 

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Dual Guidance in the Era of Ultrasound: An Overlooked Necessity or a Luxury!

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Vol 3 | Issue 1 | January-June 2022 | Page 35-36 | Vedhika Shanker, Tuhin Mistry, Gurumoorthi Palanichamy, Jagannathan Balavenkatasubramanian

DOI: 10.13107/ijra.2022.v03i01.53

Authors: Vedhika Shanker [1], Tuhin Mistry [1], Gurumoorthi Palanichamy [1], Jagannathan Balavenkatasubramanian [1]

[1] Department of Anaesthesiology, Ganga Medical Centre & Hospitals Pvt Ltd, Coimbatore, India.

Address of Correspondence
Dr. Tuhin Mistry,
Department of Anaesthesiology, Ganga Medical Centre & Hospitals Pvt Ltd, Coimbatore, India.
E-mail: tm.tuhin87@gmail.com

Short Communication

Real-time ultrasonography (USG) guidance has revolutionized the practice of regional anesthesia (RA). As an adjunct to USG, nerve stimulation has been advocated for accurate and safe delivery of local anesthetic (LA) while performing peripheral nerve blocks [1]. This letter highlights the importance of dual guidance infraclavicular brachial plexus block (BPB) in a polytrauma patient for forearm surgery.
A 54-year-old male was brought to the emergency with an alleged history of a road traffic accident and multiple injuries, including left middle third clavicle fracture, bilateral multiple rib fractures, closed distal third both bones fracture of right forearm, scalp hematoma of the left parietal area, and left-sided pneumothorax. On arrival at the resuscitation bay, the overall pain score was 9/10 on a numeric rating scale. An intercostal drain was inserted, and he had been placed on noninvasive ventilation (NIV). A multimodal analgesia regimen was started, including continuous thoracic epidural, intravenous paracetamol 15 mg/kg, tramadol 2 mg/kg, and transdermal 10 mg buprenorphine patch. The patient has been on regular treatment for type 2 diabetes mellitus and hypertension for 15 years. He had suffered two episodes of myocardial infarction 8 years ago, for which he had undergone percutaneous transluminal coronary angioplasty and was on dual antiplatelet therapy. The transthoracic echocardiography revealed mild left ventricular hypertrophy, hypokinetic posterior, lateral, and inferior walls with a left ventricular ejection fraction of 40%. He also suffered an ischemic cerebrovascular accident involving the left middle cerebral artery 6 years ago. The patient had residual weakness of the right-sided hemiparesis, dysphagia, and slurring of speech. He was scheduled for open reduction and internal fixation with plating both right forearm bones 3 days after admission. The plan was to provide surgical anesthesia with a right-sided diaphragm sparing BPB. The anesthesia plan was explained to the patient and relatives, and informed written consent was obtained.
The patient was positioned supine with head-end elevation at 30° in the operation theater, and the ipsilateral arm was abducted. Standard monitors were attached, and a scout scan was performed with a high-frequency linear array transducer (Sonosite HFL 38xp/13–6 MHz; Fujifilm SonoSite Inc., Bothell, WA, USA) to assess the viability of the anesthetic plan (Fig. 1a). The right infraclavicular BPB was performed under dual guidance (USG and electrostimulatilation) with a 100 mm nerve block needle and 15 ml 0.75% ropivacaine and 4 mg dexamethasone was administered (Fig. 1b). Each cord of the brachial plexus was simulated separately, and 5 ml of LA was deposited after obtaining desired responses at <0.5 mA current, 0.1 ms impulse duration, and a frequency of 2 Hz. The lateral, posterior, and medial cords were identified by elbow flexion, wrist extension, and wrist flexion, respectively. The block was successful, and the procedure went off without any complications.
BPB above the clavicle is widely practiced for various upper limb surgeries. We ruled out this option to avoid inadvertent phrenic nerve palsy. Our patient was on intermittent NIV, and the procedure was undertaken once the patient could tolerate NIV-free periods without any respiratory distress. However, the challenge of the patient’s inability to lie supine remained. The costoclavicular approach could not be instituted as the patient had a right-sided subclavian central venous catheter. Hence, correct transducer placement and proper visualization of the brachial plexus were not possible (Fig. 1c). We also excluded the possibility of axillary BPB due to the presence of fungal skin infection. We opted for USG guided infraclavicular BPB, but discrimination of individual cords was not feasible. Hence, we used a combination of ultrasound and nerve stimulation for a sure-fire successful RA technique.
A successful infraclavicular BPB can be achieved either with electrostimulation or ultrasound guidance in experienced hands. However, USG shortens performance time compared to the dual-motor endpoint stimulation [2]. Although the LA deposition at a single point, cranioposterior to the axillary artery, could result in successful infraclavicular BPB, the success rate was reported to be higher with multiple-injection (53–100%) [4]. Gurkan et al. reported a similar success rate between dual guidance (95%) and single motor endpoint stimulation (93%) [5]. Hence, the use of ultrasound without neurostimulation may be sufficient to achieve a successful infraclavicular BPB. However, in particular cases, electrostimulation as an adjunct may help in the identification of individual cords based on the motor response as well as act as a safety monitor to prevent intraneural injection [1].
To conclude, Dual guidance was necessary for our patient to perform the infraclavicular BPB. Ultrasound helped in real-time visualization of spread and reduced the LA volume, while peripheral nerve stimulation aided in accurate localization of cords with evoked motor responses.

References

1. Gadsden JC. The role of peripheral nerve stimulation in the era of ultrasound-guided regional anaesthesia. Anaesthesia 2021;76 Suppl 1:65-73.
2. Brull R, Lupu M, Perlas A, Chan VW, McCartney CJ. Compared with dual nerve stimulation, ultrasound guidance shortens the time for infraclavicular block performance. Can J Anaesth 2009;56:812-8.
3. Dingemans E, Williams SR, Arcand G, Chouinard P, Harris P, Ruel M, et al. Neurostimulation in ultrasound-guided infraclavicular block: A prospective randomized trial. Anesth Analg 2007;104:1275-80.
4. Sauter AR, Dodgson MS, Stubhaug A, Halstensen AM, Klaastad Ø. Electrical nerve stimulation or ultrasound guidance for lateral sagittal infraclavicular blocks: A randomized, controlled, observer-blinded, comparative study. Anesth Analg 2008;106:1910-5.
5. Gurkan Y, Acar S, Solak M, Toker K. Comparison of nerve stimulation vs. ultrasound-guided lateral sagittal infraclavicular block. Acta Anaesthesiol Scand 2008;52:851-5.

How to Cite this Article: Shanker V, Mistry M, Palanichamy G, Balavenkatasubramanian J | Dual Guidance in the Era of Ultrasound: An Overlooked Necessity or a Luxury! | International Journal of Regional Anaesthesia | January-June 2022; 3(1): 35-36.

 

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The Use of Stellate Ganglion Block and Interscalene Brachial Plexus Catheter to Treat Shoulder Hand Syndrome – A Case Report

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Vol 3 | Issue 1 | January-June 2022 | Page 23-26 | Amitav V. Philip, Kiran Sasi, Rahul Pillai, Sajan Philip George

DOI: 10.13107/ijra.2022.v03i01.050

Authors: Amitav V Philip [1], Kiran Sasi [2], Rahul Pillai [1], Sajan Philip George [1]

[1] Department of Anaesthesia, Christian Medical College, Vellore, Tamil Nadu, India
[2] Department of Hand and Leprosy Reconstructive Surgery, Paul Brand Centre, Christian Medical College, Vellore, Tamil Nadu, India.

Address of Correspondence
Dr. Amitav V Philip,
Assistant Professor, Department of Anaesthesia, Christian Medical College, Vellore, Tamil Nadu, India.
E-mail: a.philip442@gmail.com

Abstract

Complex regional pain syndrome (CRPS) may develop following trivial trauma and can lead to chronic debilitating pain and dysfunction. There is limited use of sympathetic blocks in the management of CRPS; however, in patients with sympathetically mediated pain, this modality may be of value. In this paper, we report the case of a 50-year-old milkman who was diagnosed with left sided Shoulder Hand Syndrome (CRPS type 1) following prolonged immobilization after sustaining a left 3rd metacarpal fracture. The management plan included the use of a single injection stellate ganglion block and an interscalene brachial plexus catheter which was maintained for one week in order to mitigate the pain cycle. The catheter was maintained for 7 days which improved the compliance to physical therapy and psychosocial rehabilitation of the patient. The patient reported excellent pain relief with return to his work.
Keywords: CRPS type 1, Interscalene brachial plexus catheter, Stellate ganglion block

References

1. Birklein F, Dimova V. Complex regional pain syndrome–up-to-date. PAIN Rep. 2017 Dec;2(6):e624.
2. Detaille V, Busnel F, Ravary H, Jacquot A, Katz D, Allano G. Use of continuous interscalene brachial plexus block and rehabilitation to treat complex regional pain syndrome of the shoulder. Ann Phys Rehabil Med. 2010 Aug;53(6–7):406–16.
3. Ferrillo MG. Treatment of complex regional pain syndrome with stellate ganglion local anesthetic blockade: a case report of one patient’s experiences with traditional bupivacaine HCl and liposome bupivacaine. Clin Case Rep. 2016 Jul 27;4(9):861–5.
4. Bruehl S. Complex regional pain syndrome. BMJ. 2015 Jul 29;h2730.
5. Bruehl S, Warner DS. An Update on the Pathophysiology of Complex Regional Pain Syndrome. Anesthesiology. 2010 Sep 1;113(3):713–25.
6. Ganty P, Chawla R. Complex regional pain syndrome: recent updates. Contin Educ Anaesth Crit Care Pain. 2014 Apr 1;14(2):79–84.
7. Albazaz R, Wong YT, Homer-Vanniasinkam S. Complex Regional Pain Syndrome: A Review. Ann Vasc Surg. 2008 Mar 1;22(2):297–306.
8. Cepeda MS, Lau J, Carr DB. Defining the Therapeutic Role of Local Anesthetic Sympathetic Blockade in Complex Regional Pain Syndrome: A Narrative and Systematic Review. Clin J Pain. 2002 Aug;18(4):216–33.
9. Yucel I, Demiraran Y, Ozturan K, Degirmenci E. Complex regional pain syndrome type I: efficacy of stellate ganglion blockade. J Orthop Traumatol Off J Ital Soc Orthop Traumatol. 2009 Dec;10(4):179.
10. Schürmann M, Gradl G, Wizgal I, Tutic M, Moser C, Azad S, et al. Clinical and Physiologic Evaluation of Stellate Ganglion Blockade for Complex Regional Pain Syndrome Type I. Clin J Pain. 2001 Mar;17(1):94–100.
11. Lierz P, Hoffmann P, Felleiter P, Hörauf K. [Interscalene plexus block for mobilizing chronic shoulder stiffness]. Wien Klin Wochenschr. 1998 Nov 13;110(21):766–9.
12. Detaille V, Busnel F, Ravary H, Jacquot A, Katz D, Allano G. Use of continuous interscalene brachial plexus block and rehabilitation to treat complex regional pain syndrome of the shoulder. Ann Phys Rehabil Med. 2010 Sep;53(6–7):406–16.

How to Cite this Article: Philip AV, Sasi K, Pillai R, George SP | The Use of Stellate Ganglion Block and Interscalene Brachial Plexus Catheter to Treat Shoulder Hand Syndrome – A Case Report | January-June 2022; 3(1): 23-26.

 

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Regional Anaesthesia to the Rescue: A Post-Covid Patient with Lumbar Spine Injury Undergoing Lower Limb Orthopedic Surgery

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Vol 2 | Issue 2 | July-December 2021 | Page 141-142 | Vandana Mangal, Hardika Mangal, Aashna Pareek, Tuhin Mistry

DOI: 10.13107/ijra.2021.v02i02.043

Authors: Vandana Mangal [1], Hardika Mangal [1], Aashna Pareek [1], Tuhin Mistry [2]

[1] Department of Anaesthesiology, Trauma Centre, S. M. S. Medical College, Jaipur, India.
[2] Department of Anaesthesiology, Ganga Medical Centre & Hospitals Pvt Ltd, Coimbatore, India.

Address of Correspondence
Dr Tuhin Mistry,
Department of Anaesthesiology, Ganga Medical Centre & Hospitals Pvt Ltd, Coimbatore, India.
E-mail: tm.tuhin87@gmail.com

Letter to Editor

Sir,
Coronavirus disease of 2019 (COVID-19) has revamped the management of trauma patients worldwide like many other specialties. Regional anaesthesia (RA) techniques such as central neuraxial block (CNB) and/or peripheral nerve block (PNB) have been advocated strongly over general anesthesia (GA) whenever feasible by various societies [1]. RA not only avoids aerosol generation in COVID-19 patients, but it may also reduce postoperative pulmonary complications, especially in covid recovered patients with compromised lung function. We wish to share our experience using peripheral nerve blocks as an alternative to central neuraxial blocks for managing lower limb fracture in a post-covid patient with lumbar spine injury.
A 33-years-old lady was brought to the emergency room with an alleged history of severe back pain and bilateral leg injury following a fall from height. On examination, her heart rate, blood pressure, and room air saturation were 118 beats/min, 90/70 mm Hg, and 56%, respectively. Following primary resuscitation, she was put on a non-rebreather mask with 15 L of oxygen. Radiological investigations revealed fractures of bilateral leg bones (both the tibia and fibula) and L1vertebral body (AO type A2) (Figure 1a). High-resolution computed tomography of the chest showed bilateral ground-glass opacities and a severity score of 18/25 (Figure 1b). Her Reverse Transcription Polymerase Chain Reaction test for COVID-19 was negative, but serum inflammatory markers were increased. Her injuries were managed conservatively, and the surgery was deferred. She was shifted to the intensive care unit and managed with antibiotics, steroids, anticoagulants, and noninvasive ventilation. She was gradually weaned off from oxygen support after 25 days. She was scheduled for intramedullary nailing of the left tibia and closed reduction and plaster cast application of the right leg. Her neurological assessment revealed normal sensory and medical research council grade 3 muscle powers. The anesthesia plan was discussed with the patient and her relatives and informed written consent was obtained.
In the operating room, standard monitors were attached, and one 18 G intravenous (IV) cannula was secured. The patient was placed in the supine position. Under all aseptic precautions, ultrasound-guided left-sided femoral nerve block (FNB) and popliteal sciatic nerve block (PSNB) were performed (Figure 1c,d,e,f) using a 23G 3.5 inch Quincke spinal needle and high-frequency linear transducer (L38e, 10-5 MHz, MicroMaxx, Fujifilm SonoSite Inc., Bothell, WA, USA). 10 ml of 0.5 % bupivacaine and 20 ml of 0.5% bupivacaine were administered for FNB and PSNB, respectively, after negative aspiration for blood. Intraoperatively, IV paracetamol 1 gm, ketorolac 30 mg, and 8 mg dexamethasone were given. Closed reduction and intramedullary nailing of the left tibia was completed in one hour. Then, IV fentanyl 25 µg was given, and closed reduction and cast application of the right leg was done. The patient was comfortable throughout the surgery without any significant change in hemodynamics and did not require oxygen or any additional anesthetic medication. She was under observation in the post-anesthesia care unit for the next 24 hours. She recovered well and was discharged after five days.
The CNB or PNB is the preferred RA technique as the respiratory functions are preserved. The subarachnoid block or combined spinal-epidural anesthesia is usually practiced for manipulations and fixation of lower limb fractures as it provides a dense sensory and motor blockade. We avoided CNB as our patient had a fracture of the lumbar spine. We preferred PNB over CNB or GA because of the second wave of COVID-19, superadded oxygen scarcity, and the compromised lung function following covid pneumonia. Ultrasound-guided combined PSNB and adductor canal block has been used for below-knee surgeries in high-risk patients to maintain hemodynamic stability and postoperative pain management [2]. We used a combination of FNB and PSNB for intramedullary tibial nailing in our patient. This combination is a simple and straightforward technique to avoid CNB or GA in below-knee surgeries where use of tourniquet is not necessary. However, this appears to be an underutilized RA technique as there is a paucity in the current literature. Selvi et al. used a combination of FNB and PSNB in a patient with severe emphysematous lung disease for femoral-popliteal arterial bypass surgery [3]. Imbelloni et al. used a lateral, continuous, combined FNB and high sciatic nerve block via a single skin puncture for postoperative analgesia in a supine adult patient undergoing tibial intramedullary nailing [4]. The detection of compartment syndrome may get delayed because of the insensibility of the nerves following the block. So, we objectively assess the patient every three hours for signs of compartment syndrome that did not develop.
We faced a challenge in performing PSNB as the patient was supine and could not be turned lateral or prone position due to the presence of multiple. The anterior approach to high sciatic nerve block would have been more appropriate, but the curvilinear probe was unavailable. Hence, we performed the PSNB via lateral approach in the supine position (Figure 1e,f) as described by Gray and colleagues [5]. This technique was convenient for the patient and offered optimal needle visibility.
The combination of FNB and PSNB suited our patient. More extensive studies need to be done on a combination of blocks for outpatients coming with closed fractures of leg bones in addition to high-risk patients where CNB has to be avoided.

References

1. Macfarlane AJR, Harrop-Griffiths W, Pawa A. Regional anaesthesia and COVID-19: first choice at last? Br J Anaesth. 2020;125:243-7.
2. Arjun B K, Prijith R S, Sreeraghu G M, Narendrababu M C. Ultrasound-guided popliteal sciatic and adductor canal block for below-knee surgeries in high-risk patients. Indian J Anaesth 2019; 63:635-9.
3. Selvi O, Bayserke O, Tulgar S. Use of Femoral and Sciatic Nerve Block Combination in Severe Emphysematous Lung Disease for Femoral Popliteal Arterial Bypass Surgery. Cureus. 2018;10:e2140.
4. Imbelloni L. E., Rava C., Gouveia M. A. A new, lateral, continuous, combined, femoral-sciatic nerve approach via a single skin puncture for postoperative analgesia in intramedullary tibial nail insertion. Local and Regional Anesthesia. 2013; 6:9–12.
5. Gray AT, Huczko EL, Schafhalter-Zoppoth I. Lateral popliteal nerve block with ultrasound guidance. Reg Anesth Pain Med. 2004;29:507-9.

How to Cite this Article: Mangal V, Mangal H, Pareek A, Mistry T | Regional Anaesthesia to the Rescue: A Post- Covid Patient with Lumbar Spine Injury Undergoing Lower Limb Orthopedic Surgery | International Journal of Regional Anaesthesia | July-December 2021; 2(2): 141-142.

 

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Shearing and Migration of Interscalene Catheter After an Uncomplicated Ultrasound Guided Placement

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Vol 2 | Issue 2 | July-December 2021 | Page 137-140 | Shashank Rane, Vijay Shetty, Sitaram Prasad, Rajat Bhargava

DOI: 10.13107/ijra.2021.v02i02.042

Authors: Shashank Rane [1], Vijay Shetty [1], Sitaram Prasad [2], Rajat Bhargava [3]

[1] Department of Anaesthesia, Fortis Hospital, Mumbai, Maharashtra, India.
[2] Department of Plastic Surgery, Fortis Hospital, Mumbai, Maharashtra, India.
[3] Department of Radiology, Fortis Hospital, Mumbai, Maharashtra, India.

Address of Correspondence
Dr. Shashank Rane,
Department of Anaesthesia, Fortis Hospital, Mumbai, Maharashtra, India.
E-mail: shankrane81@gmail.com

Abstract

We report on the case of shearing and migration of an interscalene nerve catheter in 68- year-old female who underwent a left shoulder surgery. The catheter was placed under ultrasound guidance without any apparent complications. Continuous interscalene nerve block was successfully used to complement General Anaesthesia and provide postoperative pain relief. On the second day, at the time of catheter removal, the catheter inadvertently sheared at the point of insertion with the distal 7 centimetres migrating under the skin. The axial and coronal CT scan sections confirmed the migration of the catheter posterolateral to subclavian artery in the vicinity of the Brachial plexus. Patient did not have any pain or neurological deficit. Surgery was performed to extract the catheter, which was found in brachial plexus sheath between lower end of Scalenus Anterior and Scalenus Medius.
Keywords: Interscalene catheter, Shearing, Migration

References

1. Capdevila X, Pirat P, Bringuier S, et al. Continuous peripheral nerve blocks in hospital wards after orthopedic surgery: A multicenter prospective analysis of the quality of postoperative analgesia and complications in 1,416 patients. Anesthesiology 2005;103:1035–45.
2. Ates Y, Yucesoy CA, Unlu MA, Saygin B, Akkas N. The mechanical properties of intact and traumatized epidural catheters. Anesth Analg 2000;90:393–9.
3. Hadzic A, ed. New York School of Regional Anesthesia. Textbook of Regional Anesthesia and Acute Pain Management. New York: McGraw-Hill Medical Pub. Division; 2007:412–3.
4. Despond O, Kohut GN. Broken interscalene brachial plexus catheter: surgical removal or not? Anesth Analg. 2010 Feb 1;110(2):643-4. doi: 10.1213/ane.0b013e3181c62a05. PMID: 20081147.
5. Mitra R, Fleischmann K. Management of the sheared epidural catheter: Is surgical extraction really necessary? J Clin Anesth 2007;19:310–4.
6.  Bowens C Jr, Briggs ER, Malchow RJ. Brachial plexus entrapment of interscalene nerve catheter after uncomplicated ultrasound-guided placement. Pain Med. 2011;12:1117-20.
7. Ilfeld BM, Morey TE, Enneking FK. Infraclavicular perineural local anesthetic infusion: A comparison of three dosing regimens for postoperative analgesia. Anesthesiology 2004;100:395–402.
8. Brenier G, Salces A, Magues JP, Fuzier R. Peripheral nerve catheter entrapment is not always related to knotting. Can J Anaesth 2010;57:183–4.

How to Cite this Article: Rane S, Shetty V, Prasad S, Bhargava R | Shearing and Migration of Interscalene Catheter After an Uncomplicated Ultrasound Guided Placement | International Journal of Regional Anaesthesia | July-December 2021; 2(2): 137-140.

 

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Clinical Pearl for a Successful and Safe PNS Guided Peripheral Nerve Block

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Vol 2 | Issue 2 | July-December 2021 | Page 143-144  | Ritesh Roy, Himjyoti Das, Neha Singh, Surajit Giri, Hetal Vadera, Vrushali Ponde

DOI: 10.13107/ijra.2021.v02i02.044

Authors: Ritesh Roy [1], Himjyoti Das [2], Neha Singh [3], Surajit Giri [4], Hetal Vadera [5], Vrushali Ponde [6]

[1] Department of Anaesthesia and Pain management Care Hospitals, Bhubaneswar, Odisha, India.
[2] Anesthesia and Critical care, Nazareth Hospital, Shillong, Assam, India.
[3] Department of Anesthesiology and Critical care, AIIMS, Bhubaneswar, Odisha, India.
[4] Department of Anesthesia, Pragati Hospital, Sivasagar, Assam, India.
[5] Department of Anaesthesia, Sterling Hospital, Rajkot, Gujarat, India.
[6] Department Anesthesiology, Surya Children Hospital, Mumbai, Maharashtra, India.

Address of Correspondence
Dr. Vrushali Ponde,
Consultant Paediatric Anaesthesiologist, Surya Children Anaesthesia Services, Mumbai, Maharashtra, India.
E-mail: vrushaliponde@yahoo.co.in

Clinical Pearl for a Successful and Safe PNS Guided Peripheral Nerve Block

PRE OP PREPARATION
 Pre-procedural evaluation with history of antiplatelet or antithrombotic drug use
 Assess neurological status in patient with trauma and neuropathy
 Explain the procedure and complications
 Possibilities of failure of the procedure, multiple injections and conversion to GA must be explained
 Obtain informed written consent

PRE PROCEDURE PREPARATION ( AORA Check list)
 Perform the block in a dedicated block room or in OT
 Confirm the site before starting the procedure
 Block room must be equipped with monitoring devices and equipment
 Ensure all resuscitative emergency drugs, equipment and Intralipid present in the cart
 Secure venous access before performing the procedure
 Connect monitor for ECG, Non-invasive blood pressure (NIBP), and peripheral oxygen saturation

BEFORE GIVING BLOCK
 STOP BEFORE YOU BLOCK: Confirm again about patient and site of block
 Calculate and keep drugs needed for block in labelled syringes ready before the procedure
 Maintain asepsis throughout the procedure
 A small dose of sedative / anxiolytic may be necessary for anxious patients. Infiltrate the injection site with lignocaine.
 Positive electrode is Red, and negative is Black (Positive is attached to patient, negative end is attached to the Needle). Machines may have different colour coding for the electrodes
 PNS stimulation is not possible in patient receiving neuromuscular blocking agent
 Presence of neuraxial anaesthesia doesn’t affect the stimulation of intact motor unit by PNS

BLOCK PROCEDURE
 Always use insulated needle
 For superficial blocks: Use 50 mm needle, current at 1.0 mA.
 For deeper blocks: Use 100 mm needle, current at 1.5 mA
 Set PNS in 0.2ms current duration & frequency at 2 Hz.
 End motor response (EMR) between 0.3mA to 0.5mA is considered safe and ideal (except lumbar plexus block where below 0.5mA is unsafe).
 For children 25mm needle is preferred.
 Repeated aspiration before injection of drug at 3-5ml aliquot is a safe practice.
 Never try to inject against high resistance, use of injection pressure monitoring device is advisable.
 Keep talking to the patient while injecting the drug for early detection of the signs of the toxicity.
 Injection of Dextrose solution is preferred over sodium chloride for hydro dissection as saline will abolish muscle twitches.

DESIRABLE END MOTOR RESPONSE

Nerve Block Response
Interscalene Brachial plexus block Any two contractions of pectoralis major, deltoid, triceps or biceps.
Supraclavicular Brachial plexus block Finger or wrist twitches (flexion or extension)
Infraclavicular Brachial Plexus Block Posterior cord response is desirable (Extension of wrist and fingers)
Axillary Brachial Plexus Block Median nerve- Flexion of first three fingers

Musculocutaneous nerve- Elbow flexion Radial nerve- Fingers extension

Ulnar nerve- Flexion of fourth &little finger along with apposition of thumb towards little finger
Femoral Nerve Block Dancing of patella (Twitches of quadriceps muscle)
Sciatic Nerve Block Planter flexion or dorsi flexion
Lumbar Plexus Block Quadriceps contraction
Ilioinguinal & Iliohypogastric Nerve Block Lower Abdominal muscle & Inguinal region Twitches (T10-L1 territory)
Thoracic Paravertebral Block Corresponding intercostal muscles twitches
Serratus Anterior Plane (SAP) Block Serratus anterior muscle twitches/ Dancing of Scapula.
PEC1 Block Pectoralis Major muscle twitches

AFTER PROCEDURE

 Document the procedure. Date, Time, Needle type, size, disappearance of EMR at what current, setting of the PNS before injection of the drug, injection resistance or ease of injection, tingling or numbness during or immediately after injection, vitals etc.
 Assessment of Dermatome, Myotome and osteotome at 30minute. If all are blocked, then only we can proceed for incision and surgery

 

How to Cite this Article: Roy R, Das H, Singh N, Giri S, Vadera H, Ponde V | Clinical Pearl For A Successful And Safe PNS Guided Peripheral Nerve Block | July-December 2021; 2(2): 143-144.

 

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Continuous Caudal Catheters in Neonatal Population: A Focussed Review

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Vol 2 | Issue 2 | July-December 2021 | Page 124-130 | Vrushali Ponde, Kriti Puri, Nandini Dave

DOI: 10.13107/ijra.2021.v02i02.040

Authors: Vrushali Ponde [1], Kriti Puri [2], Nandini Dave [3]

[1] Department of Anaesthesia, Surya Children Anaesthesia Services, Mumbai, Maharashtra, India.
[2] Department of Anaesthesia, Ganga Hospital, Coimbatore, Tamil Nadu, India.
[3] Department of Anaesthesia, NH SRCC Children’s Hospital, Mumbai, Maharashtra, India.

Address of Correspondence
Dr. Vrushali Ponde,
Consultant Paediatric Anaesthesiologist, Surya Children Anaesthesia Services, Mumbai, Maharashtra, India.
E-mail: vrushaliponde@yahoo.co.in

Abstract

Caudal epidural block is one of the most commonly administered blocks in paediatric population. Continuous caudal technique offers several advantages like its ability to cater to long duration surgeries, higher thoracic procedures and to deliver extended, titratable post-operative pain relief. Current advances in this technique like use of fluoroscopy, electrical stimulation and Ultrasound to secure continuous caudal catheters facilitate enhanced accuracy and safety and should be adopted wherever feasible. An understanding of local anaesthetic dosages for infusion and their fine tuning is a prerequisite. The potential benefits and risks should be assessed on a case-to-case bases
Keywords: Caudal anaesthesia, Post-operative pain, Neonatal regional anaesthesia

References

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12. Luz G, Ladner E, Innerhofer P, Deusch E. Accidents following extradural analgesia in children. The results of a retrospective study. Paediatr Anaesth 1995;5:273.
13. McNeely J, Faber N, Rusy L, Hoffman G. Epidural analgesia improves outcome following paediatric fundoplication: a retrospective analysis. Reg Anaesth 1997; 22: 16-23.
14. Lin, Y.C, Sentivany Collins S.K, Peterson K.L, Boltz M.G and Krane E.J. Outcomes after single injection caudal epidural versus continuous infusion epidural via caudal approach for postoperative analgesia in infants and children undergoing patent ductus ligation. Paediatr Anaesth 1999; 9:134-143.
15. Bosenberg A. Benefits of regional anesthesia in children. Paediatr Anaesth. 2012 Jan;22:10-8.
16. Koo BN, Hong JY, Song HT, Kim JM, Kil HK. Ultrasonography reveals a high prevalence of lower spinal dysraphismin childrenwith urogenital anomalies. Acta Anaesthesiol Scand. 2012;56:624–8.
17. Tsui BC, Seal R, Koller J. Thoracic epidural catheter placement via the caudal approach in infants by using electrocardio- graphic guidance. Anesth Analg. 2002;95:326–330.
18. Tsui BC, Seal R, Koller J, Entwistle L, Haugen R, Kearney R. Thoracic epidural analgesia via the caudal approach in pediat- ric patients undergoing fundoplication using nerve stimulation guidance. Anesth Analg. 2001;93:1152–1155.
19. Tobias J.D. Caudal epidural block : Review of test dosing and recognition of systemic injection in children. Anaesth Analg. 2001;93:1156-61.
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36. Kinirons B, Mimoz O, Lafendi L, et al. Chlorhexidine versus povidone iodine in preventing colonization of continuous epidural catheters in children: a randomized, controlled trial. Anaesthesiology 2001; 94:239-244.
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How to Cite this Article: Ponde V, Puri K, Dave N | Continuous Caudal Catheters in Neonatal Population: A Focussed Review | International Journal of Regional Anaesthesia | July-December 2021; 2(2): 124-130.

 

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Changing Scenario of Regional Anaesthesia Practice in Northeast India

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Vol 2 | Issue 2 | July-December 2021 | Page 117-123  | Himjyoti Das, Surajit Giri, Langpoklakpam Chaoba Singh

DOI: 10.13107/ijra.2021.v02i02.039

Authors: Himjyoti Das [1], Surajit Giri [2], Langpoklakpam Chaoba Singh [3]

[1] Department of Anaesthesia & Critical care, Nazareth Hospital, Shillong, Meghalaya.
[2] Department of Anaesthesia, Pragati Hospital & Research Centre, Sivasagar, Assam.
[3] Department of Anaesthesia & Critical care, RIMS, Imphal, Manipur.

Address of Correspondence
Dr. Surajit Giri,
Pragati Hospital & Research Centre, Sivasagar, Assam.
E-mail: drsurajitgiri@outlook.com

Abstract

The North-East (NE) region of India comprises of eight states- Arunachal Pradesh, Assam, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim and Tripura. (Fig 1) The anesthesia services in remote areas of this region are greatly restricted due to inadequate qualified manpower and infrastructure, as very few postgraduate and DNB (Diplomate National Board) seats are available each year across 4 out of 8 states through the NEET PG Test. (Fig 2a & 2b) Regional Anesthesia (RA) has several benefits in certain patients over general anesthesia. It not only allows for better post-operative pain management and a comfortable post-operative patient, but also allows for safer surgeries in patients with comorbidities that carry potentially life-threatening risks with general anesthesia, especially in a resource limited areas. The practice of RA took a backseat in the recent past due to lack of proper training in RA and the absence of a structured curriculum during PG training. However, during the last decade, we have witnessed a paradigm shift in RA and PNB (Peripheral nerve block) anesthesia with continued support from Academy of Regional Anaesthesia (AORA) & Indian Society of Anesthesiologists (ISA). For better understanding of the changing scenario of regional anesthesia practice in this region over years, we may divide the timeline into two phases, late 20th century and the 21st century.

How to Cite this Article: Das H, Giri S, Singh LC | Changing Scenario of Regional Anaesthesia Practice in Northeast India | International Journal of Regional Anaesthesia | July-December 2021; 2(2): 117-123.

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The Anatomy Table – Is it the Future Learning Tool for Regional Anaesthesiologists?

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Vol 2 | Issue 2 | July-December 2021 | Page 111-116 | Rajkumar Elanjeran, Anitha Ramkumar, Sandeep Ganni

DOI: 10.13107/ijra.2021.v02i02.038

Authors: Rajkumar Elanjeran [1], Anitha Ramkumar [1], Sandeep Ganni [2]

[1] Department of Emergency Medicine, GSL Medical College and General Hospital, Rajahmundry, Andhra Pradesh, India.
[2] Managing Director, GSL Educational Society, Rajahmundry, Andhra Pradesh, India.

Address of Correspondence
Dr. Rajkumar Elanjeran
Manager, Clinical Lead of Simulation, and Consultant Emergency Physician, GSL Medical College and General Hospital, Rajahmundry, Andhra Pradesh, India.
E-mail: seran50.raj@gmail.com

Abstract

Cadaveric dissection has been the main stay of anatomy training for regional anaesthesia over the years. Advent of advance visualisation hardware and software has revolutionised anatomy teaching and it is only a matter of time before this technology transcends into regional anaesthesia training. This article demonstrates the innumerable capabilities of virtual dissection table using one specific use case- the supraclavicular approach to the brachial plexus block.
Keywords: Simulation, Virtual dissection, Virtual anatomy

References

1. Fyfe, Sue & Fyfe, Georgina & Dye, Danielle & Radley-Crabb, Hannah. (2018). The Anatomage table: Differences in student ratings of usefulness from first implementation to established use.
2. Alessandro Stecco, Francesca Boccafoschi, Zeno Falaschi, Giulio Mazzucca, Andrea Carisio, Simone Bor, Irene Valente, Sergio Cavalieri, Alessandro Carriero,. Virtual dissection table in diagnosis and classification of Le Fort fractures: A retrospective study of feasibility, Translational Research in Anatomy, Volume 18, 2020, 100060.
3. Taoum, Alexandre & Sadqi, Rihab & Zidi, Mustapha & Tassigny, Alexandra & Megdiche, Kawtar & Ngote, Nabil. (2019). On the Use of Anatomage Table as Diagnostic Tool. 13. 20-25.
4. J. Brown, S. Stonelake, W. Anderson, M. Abdulla, C. Toms, A. Farfus, J. Wilton, Medical student perception of anatomage – A 3D interactive anatomy dissection table, International Journal of Surgery, Volume 23, supplement 1, 2015, Pages S17-S18.
5. Smith, K.E., Ruholl, H.O. and Gopalan, C. (2019), Utilization of Anatomage Table Technology Enhances Knowledge, Comprehension, and Application of Human Anatomy and Physiology in Multiple Settings. The FASEB Journal, 33: 598.19-598.19.

How to Cite this Article: Elanjeran R, Ramkumar A, Ganni S | The Anatomy Table – Is it the Future Learning Tool for Regional Anaesthesiologists? | International Journal of Regional Anaesthesia | July-December 2021; 2(2): 111-116.

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