Efficacy of Lumbar Erector Spinae Plane Block for Postoperative Analgesia in Hip Arthroplasty Patients– A Prospective Case Series

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Vol 3 | Issue 2 | July-December 2022 | Page 98-101 | Bharati A. Adhye, Sandeep M. Diwan, Rajeev Joshi, Parag K. Sancheti

DOI: 10.13107/ijra.2022.v03i02.062

Authors: Bharati A. Adhye [1], Sandeep M. Diwan [1], Rajeev Joshi [1], Parag K. Sancheti [2]

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

Address of Correspondence
Dr. Bharati A. Adhye,
Chief Anaesthesiologist, Department of Anesthesiology, Sancheti Hospital, Pune, Maharashtra, India.
E-mail: bharatiadhye@gmail.com

Abstract

The Thoracic Erector spinae plane block (ESPB) has been incorporated in multimodal analgesia protocols since 2016. In a series of 20 Total Hip Arthroplasty (THA) patients, done under spinal anaesthesia, we studied the efficacy of Lumbar Erector spinae plane block (L-ESPB) for post operative analgesia. L-ESPB was administered at L4 with Ropivacaine 0.2% (0.4 mg/kg). Time to first analgesia (TTFA) request (mean 15.03 hours) and total opioid consumption in first 24 hours (mean 27.5 mg Tramadol) was noted. A median NRS at TTFA was 3.5. Our study demonstrates L-ESPB as an effective alternate technique for postoperative analgesia in THA patients.
Keywords: Lumber ESP block, Hip Arthroplasty

References

1. Singh R, Bajaj JK, Singh D. Comparison of psoas compartment block and epidural block for postoperative analgesia in hip surgeries. Astrocyte 2018;4(4):221.
2. Capdevila X, Macaire P, Dadure C, Choquet O, Biboulet P, Ryckwaert Y, et al. Continuous psoas compartment block for postoperative analgesia after total hip arthroplasty: new landmarks, technical guidelines, and clinical evaluation. Anesth Analg. 2002;94(6):1606-1613.
3. Grant CR, Checketts MR. Analgesia for primary hip and knee arthroplasty: the role of regional anaesthesia. Contin Educ Anaesthesia, Crit Care Pain. 2008;8(2):56-61.
4. 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(5):621-627.
5. Tsui BCH, Fonseca A, Munshey F, McFadyen G, Caruso TJ. The erector spinae plane (ESP) block: a pooled review of 242 cases. J Clin Anesth. 2019;53:29-34.
6. Chin KJ, Adhikary S Das, Forero M. Erector spinae plane (ESP) block: A new paradigm in regional anesthesia and analgesia. Curr Anesthesiol Rep. 2019;9(3):271-280.
7. Tulgar S, Ermis MN, Ozer Z. Combination of lumbar erector spinae plane block and transmuscular quadratus lumborum block for surgical anaesthesia in hemiarthroplasty for femoral neck fracture. Indian J Anaesth. 2018;62(10):802.
8. Tulgar S, Senturk O. Ultrasound guided Erector Spinae Plane block at L-4 transverse process level provides effective postoperative analgesia for total hip arthroplasty. J Clin Anesth. 2017;44:68.
9. Ahiskalioglu A, Tulgar S, Celik M, Ozer Z, Alici HA, Aydin ME. Lumbar erector spinae plane block as a main anesthetic method for hip surgery in high risk elderly patients: initial experience with a magnetic resonance imaging. Eurasian J Med. 2020;52(1):16.
10. Tulgar S, Aydin ME, Ahiskalioglu A, De Cassai A, Gurkan Y. Anesthetic techniques: focus on lumbar erector spinae plane block. Local Reg Anesth. 2020;13:121.
11. González SJDL, Pomés J, Prats-Galino A, Gracia J, Martínez-Camacho A, SalaBlanch X. Estudio anatómico de la distribución del volumen administrado tras bloqueo en el plano profundo del erector espinal a nivel lumbar. Rev Esp Anestesiol Reanim. 2019;66(8):409-416.
12. R. Shane T, Matthew R, Levin B.S., Marios Loukas, Eric A. Potts, Aaron A. Cohen-Gadol. Anatomy and landmarks for the superior and middle cluneal nerves: application to posterior iliac crest harvest and entrapment syndromes. J. Neurosurg: Spine/ Volume13/ September 2010
13. Diwan S, Nair A. Lumbar erector spinae plane block obtunding knee and ankle reflexes. Saudi J Anaesth. 2021;15(2):222.

How to Cite this Article: Adhye BA, Diwan SM, Joshi R, Sancheti PK | Efficacy of Lumbar Erector Spinae Plane Block for Postoperative Analgesia in Hip Arthroplasty Patients– A Prospective Case Series | International Journal of Regional Anaesthesia | July-December 2022; 3(2): 98-101.

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Ischiorectal Abscess Under Bilateral Pudendal Nerve Block for Perioperative Analgesia in a Patient with Severe Ischaemic Heart Disease- A Case Report

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Vol 3 | Issue 2 | July-December 2022 | Page 102-104 | Kartik Sonawane, Jagannathan Balavenkatasubramanian

DOI: 10.13107/ijra.2022.v03i02.063

Authors: Nitin Gawai [1], Sandeep Diwan [1], Abhishek Lonikar [1], Ganesh Bhong [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. Nitin Gawai,
Department of Anesthesiology, Sancheti Hospital, Pune, Maharashtra, India
E-mail: drnitingawai@yahoo.com

Abstract

Anorectal abscess, an infection in the anal area is a potentially debilitating and painful condition requiring urgent drainage to prevent septicemia. Commonly performed under neuraxial anaesthesia, we report surgical drainage of bilateral ischiorectal abscess under bilateral pudendal nerve blocks and general anaesthesia in a patient with severe ischaemic heart disease. Through our case we add to the existing literature, the importance of administrating peripheral nerve block in highly co-morbid patients.
Keywords: Anorectal abscess, Bilateral pudendal block, Severe ischaemic heart disease.

References

1. Steele SR, Kumar R, Feingold DL, Rafferty JL, Buie WD; Standards Practice Task Force of the American Society of Colon and Rectal Surgeons. Practice parameters for the management of perianal abscess and fistula-in-ano. Dis Colon Rectum. 2011;54(12):1465-74. https://doi.org/10.1097/DCR.0b013e31823122b3 [ Links ]
2. Chahal HS, Garg K, Bose A, Kaur S. Anorectal Surgeries under Local Anaesthesia: A Single Center Experience. MGM J Med Sci 2017;4(2):75-7
3. Hedge J, Balajibabu PR, Sivaraman T. The patient with ischaemic heart disease undergoing non cardiac surgery. Indian J Anaesth. 2017;61(9):705-711. doi:10.4103/ija.IJA_384_17.
4. Narouze S, Benzon HT, Provenzano D, Buvanendran A, De Andres J, Deer T, Rauck R, Huntoon MA. Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition): Guidelines From the American Society of Regional Anaesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain. Reg Anesth Pain Med. 2018 Apr;43(3):225-262. doi: 10.1097/AAP.0000000000000700. PMID: 29278603.
5. Gruber H, Kovacs P, Piegger J, Brenner E. New, simple, ultrasound-guided infiltration of the pudendal nerve: topographic basics. Dis Colon Rectum. 2001;44:1376–1380.
6. Bellingham GA, Bhatia A, Chan CW, Peng PW. Randomized controlled trial comparing pudendal nerve block under ultrasound and fluoroscopic guidance. Reg Anesth Pain Med. 2012;37:262–266.

How to Cite this Article: Gawai N, Diwan S, Lonikar A, Bhong G, Sancheti P | Ischiorectal Abscess Under Bilateral Pudendal Nerve Block for Perioperative Analgesia in a Patient with Severe Ischaemic Heart Disease- A Case Report | International Journal of Regional Anaesthesia | July-December 2022; 3(2): 102-104.

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Landmark Guided Lower Interscalene Block as a Rescue Approach in a Case of Elusive Supraclavicular Block for Elbow Surgery

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Vol 3 | Issue 2 | July-December 2022 | Page 105-106 | Pratibha Jain, A. Sashank, Divyanand Mishra

DOI: 10.13107/ijra.2022.v03i02.064

Authors: Pratibha Jain [1], A. Sashank [1], Divyanand Mishra [1]

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

Address of Correspondence
Dr. Divyanand Mishra,
Department of Anaesthesia and Pain Management, Pandit Jawaharlal Nehru Memorial Medical College, Raipur, Chhattisgarh, India.
E-mail: itsdnmishra09@gmail.com

Letter to Editor

Dear Editor,
Our case was an 18 yrs/m, weighing 54 kg without co morbidities presented with pain in right elbow and was posted for screw fixation of fracture capitulum. His routine blood work and airway examination were normal to undergo the surgery under supraclavicular block (SCB). On arrival, patient’s PR was 84/min, BP- 118/72 mm Hg, SpO2- 98% on room air.
For right sided SCB, patient was placed supine, head turned to left side with shoulder depressed and needle was inserted lateral to subclavian artery pulsation just above the clavicle, posterolaterally. There was inadvertent puncture of subclavian artery each time, despite using standard techniques. Hence we decided to abandon standard SCB and proceed with lower interscalene block (LISB).Using modified Winnie’s approach interscalene groove was palpated and needle was inserted 2-3 cm below the classical interscalene block (ISB) site. Paresthesia was attained over whole upper limb and then Inj. Lignocaine + Adrenaline (2%) 10 ml along with inj. Bupivacaine 0.5% 10 ml was injected after repeated negative aspirations. A satisfactory sensory and motor blockade was obtained after 15 minutes of injection. Throughout the procedure, patient was continuously monitored and surgery was completed within 1.5h without any adverse event. The patient was shifted to ward. The block weaned off in 6 hrs and his vitals were stable throughout his course of stay in the hospital.
Traditionally, the subclavian artery is an important relation of the brachial plexus for landmark guided SCB. However, anatomical variation may be present in as much as 50% of the population. [1] T1 nerve root supplies skin both above and below the elbow. Some authors have suggested a combined ISB + axillary block to get profound anaesthesia for elbow surgery. [2,3] Axillary nerve block was not contemplated in our case as optimal arm positioning was precluded due to severe pain at elbow. The advantages of LISB over SCB and ISB or ISB + axillary block are that it significantly reduces the risk of pneumothorax , inadvertent arterial puncture, ulnar sparing (as lower trunks of brachial plexus are more superficial in LISB) and avoids multiple injections. LISB also provides adequate anaesthesia and analgesia to whole upper limb which could be due to the relative proximity of the inferior trunks to the other components of brachial plexus as they become tightly bundled between the clavicle and first rib at this level.[2] Performing an LISB is easier due to its accessibility and shallow location of the brachial plexus, which may be favourable to those who disfavour or may not be comfortable with the supraclavicular approach. [4]
Our case exemplifies that in those centres where ultrasound machine is unavailable and access to the brachial plexus for SCB by landmark technique remains elusive despite troubleshooting, lower interscalene block can be safely used to provide similar quality and extent of surgical anaesthesia.

References

1. Uysal I, Sekar M, Karabulut AK, Buyukmumcu M, Ziylan T. Brachial plexus variations in human foetuses. Neurosurgery 2003;53(3):676-684.
2. Gadsden JC, Tsai T, Iwata T, Somsundarum L, Robards C, Hadzic A. Low interscalene block provides reliable anesthesia for surgery at or about the elbow. Journal of Clinical Anesth 2009;21:98-102.
3. Faryniarz D, Morelli C, Coleman S, et al. Interscalene block anesthesia at an ambulatory surgery center performing predominantly regional anesthesia: a prospective study of one hundred thirty-three patients undergoing shoulder surgery. J Shoulder Elbow Surg 2006;15:686-90.
4. Brown AR, Parker GC. The use of a reverse axis (axillary interscalene) block in a patient presenting with fractures of the left shoulder and elbow. Anesth Analg 2001;93:1618-20.

How to Cite this Article: Jain P, Sashank A, Mishra D | Landmark Guided Lower Interscalene Block as a Rescue Approach in a Case of Elusive Supraclavicular Block for Elbow Surgery | International Journal of Regional Anaesthesia | July-December 2022; 3(2): 105-106.

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Modified Clavipectoral Fascial Plane Block to The Rescue: Polytrauma Patient with Brachial Plexus Injury Undergoing Awake Clavicle Surgery

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Vol 3 | Issue 2 | July-December 2022 | Page 107-109 | Chetana V Bhalerao, Tuhin Mistry, Stephan Jebaraj, Jagannathan Balavenkatasubramanian

DOI: 10.13107/ijra.2022.v03i02.065

Authors: Chetana V Bhalerao [1], Tuhin Mistry [1], Stephan Jebaraj [1], Jagannathan Balavenkatasubramanian [1]

[1] Department of Anaesthesiology and Perioperative Care, Ganga Medical Centre & Hospitals Pvt Ltd, Coimbatore, Tamil Nadu, India.

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

Letter to Editor

Dear Editor,
Clavipectoral fascial plane block (CFPB) is an attractive alternative to traditional regional anaesthesia (RA) techniques for clavicle surgery. It was reported to provide motor-sparing, diaphragm-sparing stand-alone surgical anaesthesia, or perioperative analgesia [1]. We want to highlight the application of CFPB as the sole RA technique in a polytrauma patient with brachial plexus injury for surgical management of clavicle fracture. Consent was obtained for the publication of this letter.
A 30-year-old American Society of Anesthesiologist physical grade I male (weight 75 kg, height 170 cm) patient was admitted with an alleged history of a fall from a two-wheeler. He had displaced comminuted right clavicle fracture (Allman type I) (Figure 1a), displaced fracture of right transverse processes of C6-T1, and right brachial plexus injury. He had undergone emergency left fronto-temporo-parietal craniotomy and evacuation of an acute subdural hematoma under general anaesthesia. The patient was transferred to the intensive care unit following surgery and weaned off from ventilatory support after three days. A Follow-up computed tomography (CT) scan revealed a significant reduction of cerebral edema and a thin rim of residual left frontal, bilateral tentorial, and interhemispheric subdural hematoma. Magnetic resonance imaging of the right brachial plexus revealed C5-C8 complete nerve root avulsion with hematoma and soft tissue edema in the adjacent area. After ten days of craniotomy, the patient was scheduled for right clavicle open reduction and internal fixation with plating (Figure 1b). The plan was to provide motor-sparing, phrenic nerve-sparing surgical anaesthesia without brachial plexus block (BPB). The anaesthesia plan was explained to the patient and relatives, and informed written high-risk consent was obtained.
Standard monitors were attached inside the operating room, and an infusion of ringer lactate was started. Oxygen supplementation using a Hudson mask at 5 L/min flow was provided. The patient was placed supine with the head turned towards the contralateral side. Ultrasound-guided modified right CFPB was performed as described by Sonawane et al.[2] A high-frequency linear probe (Sonosite HFL 38xp/13–6 MHz; Fujifilm SonoSite Inc., Bothell, WA, USA) was placed on the skin over the anterior surface of the clavicle. The local anesthetic (LA) was deposited on the medial (10 ml) and lateral (10 ml) third of the clavicle between the clavipectoral fascia and periosteal collar using an in-plane technique (Figure 1c,d). In addition, the probe was kept over the fracture site, and LA (5 ml) was deposited around it under vision. Also, the skin over the incision site was covered by an additional subcutaneous infiltration (5 ml). The total volume of the LA was 30 ml (1:1 of 0.25% Bupivacaine and 1% Lignocaine-adrenaline, 8 mg Dexamethasone). The patient’s vitals remained stable, and the procedure was completed without complications.
Clavicle innervation is complex and controversial. The pain-generating elements in clavicle surgeries include the skin and the richly innervated periosteum. The brachial plexus roots involved in complete innervation (dermatome, myotome, and osteotome) of the clavicle are C3-C7. Proximal BPB has been a standard practice for anaesthesia or analgesia for clavicle fracture surgeries. Hemidiaphragmatic paresis due to blockade of the phrenic nerve can be detrimental in polytrauma patients with lung injury or pneumothorax. Recently, the C5 ventral ramus block and selective supraclavicular nerve and upper trunk (SCUT block) with a low volume of LA have been described as site-specific and phrenic-sparing RA techniques for clavicle surgeries [3, 4]. However, BPB is contraindicated in patients with ipsilateral brachial plexus injury. Bhat et al. reported an incident of apnoea and cardiac arrest following paraesthesia-guided subclavian perivascular BPB in a polytrauma patient with undiagnosed brachial plexus injury [5]. The spread of injected LA to the subarachnoid space through the dural tear around the ruptured nerve roots resulted in total spinal anaesthesia and cardio-respiratory arrest. A CT myelogram after the resuscitation revealed a traumatic meningocele of the C8 nerve root. We avoided BPB in our patient, considering such dreaded consequences.
In 2017, Dr. Luis Valdes described CFPB as an RA technique for clavicle surgeries targeting the sensory nerves that traverse the clavipectoral fascia [1]. CFPB creates a field block by depositing the LA at the medial and lateral third of the clavicle between the clavipectoral fascia and the periosteum of the clavicle involving all the nerves piercing the fascia to enter the clavicle. Rosale et al. managed a case where CFPB with intravenous Dexmedetomidine sedation provided intraoperative surgical anaesthesia and postoperative analgesia up to 16 hours after the block [6]. However, the skin incision may not be covered with the CFPB alone. So, an additional supraclavicular nerve block, cervical plexus block, or skin infiltration is required. The spread of LA in CFPB depends on the integrity of the clavipectoral fascia, which is lost in displaced or comminuted fractures due to a breach in the continuity of the fascia around the fractured site. Hence, an additional injection or hematoma block at the fracture site may improve the quality of the RA. We opted for the modified CFPB, which covered all the innervations and provided optimal surgical anaesthesia or analgesia.
To conclude, the modified CFPB can be a better alternative to general anaesthesia or other available RA techniques in providing incision congruent surgical anaesthesia or postoperative analgesia for awake clavicle fracture surgery, especially in polytrauma patients with brachial plexus injury. However, randomized controlled trials are warranted for further validation.

References

1. Sonawane K, Dixit H, Balavenkatasubramanian J, Gurumoorthi P. Uncovering secrets of the beauty bone: a comprehensive review of anatomy and regional anaesthesia techniques of clavicle surgeries. Open J Orthop Rheumatol. 2021(6):19-29.
2. Sonawane K, Dharmapuri S, Saxena S, et al. Awake Single-Stage Bilateral Clavicle Surgeries Under Bilateral Clavipectoral Fascial Plane Blocks: A Case Report and Review of Literature. Cureus 13(12): e20537.
3. Diwan S, Feigl G, Nair A. C5 ventral ramus block for clavicle surgery: How low concerning the volume can we go? J Anaesthesiol Clin Pharmacol. 2021 Oct-Dec;37(4):561-564.
4. Sivashanmugam T, Areti A, Selvum E, Diwan S, Pandian A. Selective blockade of supraclavicular nerves and upper trunk of brachial plexus “The SCUT block” towards a site-specific regional anaesthesia strategy for clavicle surgeries – A descriptive study. Indian J Anaesth. 2021;65(9):656–61.
5. Bhat VR, Kumar M, Sabapathy SR. Cardiac Arrest Following Brachial Plexus Block in a Patient with Missed Brachial Plexus Injury. Ind. J. Trauma. Anaesth. Crit. Care. 2003; 4(1): 177-178.
6. Rosales AL, Aypa NS. Clavipectoral plane block as a sole anesthetics technique for clavicle surgery – A case report. Anesth Pain Med. 2022;17(1):93-97.

How to Cite this Article: Bhalerao CV, Mistry T, Jebaraj S, Balavenkatasubramanian J | Modified Clavipectoral Fascial Plane Block to The Rescue: Polytrauma Patient with Brachial Plexus Injury Undergoing Awake Clavicle Surgery | International Journal of Regional Anaesthesia | July-December 2022; 3(2): 107-109.

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Current Concepts in Regional Analgesia Techniques for Postoperative Pain Management after Total Shoulder Arthroplasty: A Narrative Review

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Vol 3 | Issue 2 | July-December 2022 | Page 42-48 | Prasanna Khare, Rijuta Kashyapi, Manjiri Ranade

DOI: 10.13107/ijra.2022.v03i02.055

Authors: Prasanna Khare [1], Rijuta Kashyapi [1], Manjiri Ranade [1]

[1] Department of Anaesthesiology, Deenanath Mangeshkar Hospital & Research Centre, Pune, Maharashtra, India.

Address of Correspondence
Dr. Manjiri Ranade
Department of Anaesthesiology, Deenanath Mangeshkar Hospital & Research Centre, Pune, Maharashtra, India.
E-mail: manjirir47@gmail.com

Abstract

Postoperative pain management after total shoulder arthroplasty (TSA) can be challenging. Interscalene brachial plexus block, which is administered either as since injection (ssISB) or with continuous catheter (ccISB) technique, is the gold standard. Ultrasonography (USG) guidance facilitates a faster, more accurate block with a lower local anaesthetic volume in ssISB. USG also helps for accurate catheter placement in ccISB. Hemi-diaphragmatic palsy is a common complication of ISB. This can be a major concern for patients with a respiratory compromise so it necessitates the administration of diaphragm-sparing nerve blocks. Phrenic nerve sparing block like suprascapular nerve block (SSNB) singly or along with axillary nerve block, subomohyoid anterior suprascapular block, superior trunk block, erector spinae plane block, individually, provide perioperative analgesia non-inferior to ISB. Subacromial or intraarticular infiltration of local anaesthesia (SAIA) is not recommended due to its limited clinical efficacy. Extended analgesic effects have been observed with liposomal bupivacaine when used as a field block. This article provides an overview of regional anaesthesia techniques for postoperative analgesia following Total shoulder arthroplasty (TSA)
Keywords: Shoulder arthroplasty, Pain management, Regional anaesthesia, Interscalene brachial plexus block

References

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8. Gabriel RA, Nagrebetsky A, Kaye AD, Dutton RP, Urman RD. The Patterns of Utilization of Interscalene Nerve Blocks for Total Shoulder Arthroplasty. Anesth Analg. 2016 Sep;123(3):758-61.
9.Winnie AP. Interscalene brachial plexus block. Anesth Analg. 1970 May-Jun;49(3):455-66. PMID: 5534420.
10. Abrahams MS, Aziz MF, Fu RF, Horn JL. Ultrasound guidance compared with electrical neurostimulation for peripheral nerve block: a systematic review and meta-analysis of randomized controlled trials. Br J Anaesth. 2009 Mar;102(3):408-17.
11. Gautier P, Vandepitte C, Ramquet C, DeCoopman M, Xu D, Hadzic A. The minimum effective anesthetic volume of 0.75% ropivacaine in ultrasound-guided interscalene brachial plexus block. Anesth Analg. 2011 Oct;113(4):951-5.
12. Abdallah FW, Halpern SH, Aoyama K, Brull R. Will the Real Benefits of Single-Shot Interscalene Block Please Stand Up? A Systematic Review and Meta-Analysis. Anesth Analg. 2015 May;120(5):1114-1129.
13. 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 Jan-Mar;14(1):77-84.
14. Pehora C, Pearson AM, Kaushal A, Crawford MW, Johnston B. Dexamethasone as an adjuvant to peripheral nerve block. Cochrane Database Syst Rev. 2017 Nov 9;11(11):CD011770.
15. Brummett CM, Williams BA. Additives to local anesthetics for peripheral nerve blockade. Int Anesthesiol Clin. 2011 Fall;49(4):104-16.
16. Vorobeichik L, Brull R, Bowry R, Laffey JG, Abdallah FW. Should continuous rather than single-injection interscalene block be routinely offered for major shoulder surgery? A meta-analysis of the analgesic and side-effects profiles. Br J Anaesth. 2018 Apr;120(4):679-692.
17. Fredrickson MJ, Leightley P, Wong A, Chaddock M, Abeysekera A, Frampton C. An analysis of 1505 consecutive patients receiving continuous interscalene analgesia at home: a multicentre prospective safety study. Anaesthesia. 2016 Apr;71(4):373-9.
18. Hewson DW, Oldman M, Bedforth NM. Regional anaesthesia for shoulder surgery. BJA Educ. 2019 Apr;19(4):98-104.
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20. Riazi S, Carmichael N, Awad I, Holtby RM, McCartney CJ. Effect of local anaesthetic volume (20 vs 5 ml) on the efficacy and respiratory consequences of ultrasound-guided interscalene brachial plexus block. Br J Anaesth. 2008 Oct;101(4):549-56.
21. Hasan SS, Rolf RH, Sympson AN, Eten K, Elsass TR. Single-Shot Versus Continuous Interscalene Block for Postoperative Pain Control After Shoulder Arthroplasty: A Prospective Randomized Clinical Trial. J Am Acad Orthop Surg Glob Res Rev. 2019 Jun 11;3(6):e014.
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27. Siegenthaler A, Moriggl B, Mlekusch S, Schliessbach J, Haug M, Curatolo M, Eichenberger U. Ultrasound-guided suprascapular nerve block, description of a novel supraclavicular approach. Reg Anesth Pain Med. 2012 May-Jun;37(3):325-8.
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How to Cite this Article: Khare P, Kashyapi R, Ranade M | Current Concepts in Regional Analgesia Techniques for Postoperative Pain Management after Total Shoulder Arthroplasty: A Narrative Review | International Journal of Regional Anaesthesia | July-December 2022; 3(2): 42-48.

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Current Concepts in Pain Management of Total Knee Replacement Surgeries: A Narrative Review

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Vol 3 | Issue 2 | July-December 2022 | Page 56-75 | Kartik Sonawane, Jagannathan Balavenkatasubramanian

DOI: 10.13107/ijra.2022.v03i02.057

Authors: Kartik Sonawane [1], Jagannathan Balavenkatasubramanian [2]

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

Address of Correspondence
Dr. Jagannathan Balavenkatasubramanian,
Department of Anaesthesia, Ganga Medical Centre & Hospital, Coimbatore, Tamil Nadu, India.
E-mail: drbalavenkat@gmail.com

Abstract

Total knee replacement/arthroplasty (TKR/TKA) is considered a life-changing surgery as it not only corrects the pathology and associated joint deformity but also renders the patient pain-free allowing them to perform activities of daily living as before. Such favorable outcomes depend entirely on the perioperative pain management strategies. Structuring such strategies requires background knowledge of the goals set, the process of pain generation before and after the surgery, and innervations of the pain-generating components involved in each surgical step.
The multifactorial origin of TKR pain requires a multidimensional pain management strategy such as multimodal analgesia (MMA). It should incorporate all the essential ingredients that target each step of the pain generation process. Apart from pharmacological agents and nonpharmacological techniques, regional analgesia (RA) plays a very important role as an adjunct to MMA to provide quality analgesia that promotes enhanced recovery and mobility. However, the choice of RA technique remains dependent on its motor-sparing effect, procedure-specific analgesic coverage, opioid-sparing effect, and suitability for enhanced recovery after surgery (ERAS). Psychological analgesia is also an important aspect of MMA, aiding in resolving psychological concerns and postoperative pain management and empowering patients in their own pain management process by encouraging active participation. In addition to providing appropriate pain management services, assessing expected outcomes in the postoperative period is also important to close loopholes and provide rescue analgesics when needed.
This narrative review article highlights important aspects of pain management strategies and the essential requirements for implementing them to achieve desired outcomes. We believe this article will help readers design or modify their pain management strategy to meet all of their goals.
Keywords: Total knee replacement, Total knee arthroplasty, Pain management, Motor-sparing regional anesthetic technique, Multimodal analgesia, Procedure-specific analgesia.

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How to Cite this Article: Sonawane K, Balavenkatasubramanian J | Current Concepts in Pain Management of Total Knee Replacement Surgeries: A Narrative Review | International Journal of Regional Anaesthesia | July-December 2022; 3(2): 56-75.

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Current Concepts in Postoperative Pain Management Surgeries of Hip Joint: A Narrative Review

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Vol 3 | Issue 2 | July-December 2022 | Page 49-55 | Anju Gupta, Mallika Kaushal, Amit Malviya, Shalender Kumar, Sandeep Diwan

DOI: 10.13107/ijra.2022.v03i02.056

Authors: Anju Gupta [1], Mallika Kaushal [1], Amit Malviya [1], Shalender Kumar [1], Sandeep Diwan [2]

[1] Department of Anaesthesia, All India Institute of Medical Sciences, New Delhi, India.
[2] Department of Anaesthesia, Sancheti Hospital, Pune, Maharashtra, India.

Address of Correspondence
Dr. Anju Gupta,
Assistant Professor, Department of Anaesthesia, All India Institute of Medical Sciences, New Delhi, India.
E-mail: drajugupta09@gmail.com

Abstract

Hip surgery is a common surgical procedure in the elderly and leads to significant pain postoperatively. The hip joint has a complex innervation which is unlikely to be covered with any single modality of pain relief. Multimodal analgesia has been critical in facilitating early recovery and rehabilitation in these patients. Regional analgesia is an important component of multimodal analgesia regimens and is instrumental in achieving optimal patient outcomes. Single shot or continuous central or peripheral nerve blocks provide effective and safe postoperative analgesia, lower opioid consumption, faster rehabilitation, and a high level of patient satisfaction. An ideal regional anaesthesia technique for hip surgery should be motor sparing while providing effective perioperative pain relief. Regional anaesthesia has seen enormous growth in the recent past due to advances in technology and research. These blocks have shown analgesic efficacy, have an opioid-sparing effect, and enable better patient positioning for central neuraxial blocks. Some of the novel interfascial plane blocks like Pericapsular Nerve Group (PENG) block are now being explored for hip analgesia. Within a few years of being described, these novel nerve blocks have seen tremendous favour in the literature and are being extensively used in the current practice of analgesia for hip surgery. In the present review, we aim to discuss the various modalities of analgesia which have been utilised in the past and would discuss few of the newer blocks for hip surgery.
Keywords: Nerve blocks, Ultrasonography, Analgesics, Total hip arthroplasty, Fascia illiaca block,
Multimodal analgesia, Transmuscular, Quadratus lumborum block

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27. Mujahid OM, Dey S, Nagalikar S, Arora P, Dey CK. Ultrasound-guided lumbar ESP block for post-operative analgesia as an alternative mode of analgesia in hip arthroplasty with multiple systemic issues: a case report. Ain-Shams Journal of Anesthesiology. 2021;13:47
28. Singh S, Ranjan R, Lalin D. A new indication of erector spinae plane block for perioperative analgesia is total replacement surgery – A case report. Indian J Anaesth. 2019;63(4):310-1
29. Kinjo S, Schultz A. Continuous lumbar erector spinae plane block for postoperative pain management in revision hip surgery: a case report. Rev Bras Anestesiol. 2019;69(4):420-2
30. Ahiskalioglu A, Tulgar S, Celik M, Ozer Z, Alici HA, Aydin ME. Lumbar erector spinae plane block as a main anesthetic method for hip surgery in high risk elderly patients: initial experience with a magnetic resonance imaging. Eurasian J Med. 2020;52(1):16-20
31. Xu L, Leng JC, Elsharkawy H, Hunter OO, Harrison TK, Vokach-Brodsky L et al. Replacement of fascia iliaca catheters with continuous erector spinae plane blocks within a clinical pathway facilitates early ambulation after total hip arthroplasty. Pain Medicine. 2020;21(10):2423-9
32. Blanco R. TAP block under ultrasound guidance: the description of a ‘non pops technique’. Reg Anesth Pain Med. 2007;32:130
33. Gupta A, Sondekoppam R, Kalagara H. Quadratus Lumborum Block: A technical review. Curr Anesthesiol Rep. 2019;9:257-62
34. Tiwari P, Bhatia R, Asthana V, Maheshwari R. Role of ultrasound-guided lumbar “Erector spinae plane block” and ultrasound-guided transmuscular “Quadratus lumborum block” for postoperative analgesia after hip surgeries: A randomized, controlled study. Indian Anaesth Forum. 2021;22:60-6
35. Li J, Wei C, Huang J, Li Y, Liu H, Liu J et al. Efficacy of quadratus lumborum block for pain control in patients undergoing hip surgeries: a systematic review and meta-analysis. Front Med. 2022;8:771859
36. Girón-Arango L, Peng PWH, Chin KJ, Brull R, Perlas A. Pericapsular Nerve Group (PENG) block for hip fracture. Regional Anesthesia and Pain Medicine. 2018;43:859-63
37. Pascarella G, Costa F, Del Buono R, Pulitano R, Strumia A, Piliego C et al. Impact of the pericapsular nerve group (PENG) block on postoperative analgesia and functional recovery following total hip arthroplasty: a randomised, observer-masked, controlled trial. Anaesthesia. 2022;76:1492-8
38. Teles AS, Altinpulluk EY, Sahoo RK, Galluccio F, Simón DG, İnce İ et al. Beyond the Pericapsular Nerve Group (PENG) block; a narrative review. Turk J Anaesthesiol Reanim. 2022;50(3):167-72.

How to Cite this Article: Gupta A, Kaushal M, Malviya A, Kumar S, Diwan S | Current Concepts in Postoperative Pain Management Surgeries of Hip Joint: A Narrative Review | International Journal of Regional Anaesthesia | July-December 2022; 3(2): 49-55.

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Ultrasound Guided Regional Anaesthesia for Breast Surgery in High Risk Patients- A Retrospective Observational Study

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Vol 3 | Issue 2 | July-December 2022 | Page 93-97 | Harshal D Wagh, Shruthi Pendalya, Mandar Nadkarni

DOI: 10.13107/ijra.2022.v03i02.061

Authors: Harshal D Wagh [1], Shruthi Pendalya [1], Mandar Nadkarni [2]

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

Address of Correspondence
Dr. Harshal D Wagh,
Department of Anaesthesia, Kokilaben Ambani Hospital, Mumbai, Maharashtra, India.
E-mail: drhdw2701@gmail.com

Abstract

Introduction: Modified radical mastectomy (MRM) or breast conservative surgery (BCS) done under general anaesthesia (GA) in high-risk patients may be associated with significant morbidity, Intensive Care Unit stay and increased hospital stay leading to cost issues. In this case-series, we describe our experience with regional anesthesia for MRM or BCS and sentinel / complete axillary clearance in 61 patients with breast carcinoma who were high risk for perioperative complications in view of their co-morbidities. None required ICU or increased hospital stay postoperatively.
Material & Methods: Sixty-one ASA III/IV patients operated under regional anaesthesia for carcinoma of the breast were included. Multiple level USG guided thoracic paravertebral block (PVB), PECS block (1/2), Pecto-intercostal fascial block (PIFB), Serratus-anterior plane block (SAPB), brachial plexus block, Superficial cervical plexus blocks (SCPB), Erector spinae block (ESB) were given in different combinations.
Result: There were 60 female patients (Age: 30-97 years) and 1 male patient (59 years) (Left side -27 patients, right side- 34 patients). Of the total 61 patients, 23 patients underwent BCS with axillary dissection, 36 patients underwent MRM with axillary dissection, 2 patients had MRM with Pectoralis Major muscle resection. Patients received different combinations of blocks PVB or ESB, PECS1/2 and SAPB. 43 patients received the PVB, 61 got the PECS1/2, 12 patients received ESP, 32 patients required SCPB, 1 infra-clavicular block and 35 patients got PIFB. All procedures were completed under regional anaesthesia with 51 patients getting intravenous midazolam (0.01-0.02mg/kg), 59 patients were given IV fentanyl (1-3ug/kg , 43 patients were given IV propofol (1-2mg/kg), These were given in small aliquots during the duration of the procedure. 2 patients had IV ketamine (0.5mg/kg) and 1 patient had IV dexmeditomidine (0.2-0.3ug/kg/hr). IV paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDS) ie. Inj Diclofenac Sodium IV in the dose of 1mg/kg (max 75mg) were given when not contraindicated.
There was single case of axillary hematoma with no other complications. No patient required ICU care postoperatively and were discharged as routine.
Conclusion: A combination of blocks may be an option for surgical anaesthesia for breast surgeries in high risk patients. Careful planning, patient counseling and attention to toxic dose of local anaesthetics must always be considered.
Keywords: Paravertebral block, Thoracic wall blocks, PECS block, Serratus Anterior plane block, Pecto-intercorstal fascial block, Superficial cervical plexus, Modified radical mastectomy, Breast conservative surgery.

References

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2. Vadivelu N, Schreck M, Lopez J, Kodumudi G, Narayan D. Pain After Mastectomy And Breast Reconstruction. Am Surg. 2008; 74: 285-96.
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5. Blanco R. The ‘Pecs block’: a novel technique for providing analgesia after breast surgery. Anaesthesia. 2011;66:847–848.
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8. De la Torre PA, García PD, Alvarez SL, Miguel FJ, Pérez MF. A novel ultrasound-guided block: a promising alternative for breast analgesia. Aesthet Surg J. 2014;34:198–200.
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11. Sopena-Zubiria LA, Fernández-Meré LA, Valdés Arias C, Muñoz González F, Sánchez Asheras J, Ibáñez Ernández C. [Thoracic paravertebral block compared to thoracic paravertebral block plus pectoral nerve block in reconstructive breast surgery]. Rev Esp Anestesiol Reanim. 2012 Jan;59(1):12-7.
12. Pawa A1, Wight J1, Onwochei DN1, Vargulescu R1, Reed I1, Chrisman L1, Pushpanathan E1, Kothari A2, El-Boghdadly K1.Combined thoracic paravertebral and pectoral nerve blocks for breast surgery under sedation: a prospective observational case series. Anaesthesia. 2018 Apr;73(4):438-443.
13. Greengrass R1, O’Brien F, Lyerly K, Hardman D, Gleason D, D’Ercole F, Steele S. Paravertebral block for breast cancer surgery. Can J Anaesth. 1996 Aug;43(8):858-61.
14. Schnabel A1, Reichl SU, Kranke P, Pogatzki-Zahn EM, Zahn PK.Efficacy and safety of paravertebral blocks in breast surgery: a meta-analysis of randomized controlled trials. Br J Anaesth. 2010 Dec;105(6):842-52.
15. Robert B. Maniker, Rebecca L. Johnson, De Q. Tran. Interfacial Plane Blocks for Breast Surgery: Which Surgery to Block, and Which Block to Choose? www.anesthesia-analgesia.org June 2020 • Volume 130 • Number 6.

How to Cite this Article: Wagh HD, Pendalya S, Nadkarni M | Ultrasound Guided Regional Anaesthesia for Breast Surgery in High Risk Patients- A Retrospective Observational Study | International Journal of Regional Anaesthesia | July-December 2022; 3(2): 93-97.

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Deciding the Better Dose- A Prospective Randomized Double Blind Study of Two Different Doses of Perineural Dexmedetomidine in Axillary Brachial Block

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Vol 3 | Issue 2 | July-December 2022 | Page 83-87 | Sheetal Y Chiplonkar, Jalpa A Kate, Dinesh B Vadranapu, Pratibha Toal

DOI: 10.13107/ijra.2022.v03i02.059

Authors: Sheetal Y Chiplonkar [1], Jalpa A Kate [1], Dinesh B Vadranapu [2], Pratibha Toal [1]

[1] Department of Anaesthesiology, BARC Hospital, Anushaktinagar, Mumbai, Maharashtra, India.
[2] Department of Critical Care, P.D. Hinduja Hospital and Research Centre, Mumbai, Maharashtra, India.

Address of Correspondence
Dr. Jalpa A Kate,
Consultant, Department of Anaesthesiology, BARC Hospital, Anushaktinagar, Mumbai, Maharashtra, India.
E-mail: dr.japs@gmail.com

Abstract

Background: Axillary brachial plexus block is generally regarded as the safest and reliable technique for forearm and hand surgeries. Dexmedetomidine, a potent alpha (α)-2-adrenergic receptor agonist when used as an additive in any peripheral nerve block can improve quality of block and postoperative analgesia, though uncertainity prevails regarding the dose in patients undergoing hand and forearm surgeries.
Methods: In this prospective, randomized, comparative, double blind study, 80 patients were included. Each participant fulfilling the inclusion criteria then received axillary brachial plexus block using 15cc 2% lignocaine with adrenaline (1:200000)and 0.5% bupivacaine 5cc mixed with dexmedetomidine either 0.5 µg /kg (group A) or 1 µg /kg ( group B)in 2cc normal saline. Duration of post-operative analgesia was the primary outcome.
Result: Duration of analgesia was significantly prolonged in group B (493.77±115.62 min) compared to group A (434.62±45.18 min, P <0.01).
Conclusion: Between the two doses of dexmedetomidine, block characteristics and analgesia obtained were better with higher dose (1 µg/kg) but chances of side effects like bradycardia increased. Hence 0.5 µg/kg can be a better dose with improved block characteristics yet negligible side effects.
Keywords: Brachial plexus block, Dexmedetomidine Perineural, Peripheral nerve stimulator, Ultrasonography

References

1. Thakur A, Singh J, Kumar S, Rana S, Sood P, Verma V. Efficacy of Dexmedetomidine in two Different Doses as an Adjuvant to Lignocaine in Patients Scheduled for Surgeries under Axillary Block. J Clin Diagn Res JCDR. 2017; 11(4):UC16–21.
2. Klein SM, Pietrobon R, Nielsen KC, Warner DS, Greengrass RA, Steele SM. Peripheral Nerve Blockade with Long-Acting Local Anesthetics: A Survey of The Society for Ambulatory Anesthesia. Anesth Analg. 2002; 94(1):71–76.
3. Sanghvi KS, Shah VA, Patel KD. Comparative study of bupivacaine alone and bupivacaine along with buprenorphine in axillary brachial plexus block: a prospective, randomized, single blind study. Int J Basic Clin Pharmacol. 2013; 2(5):640–644.
4. Biradar PA, Kaimar P, Gopalakrishna K. Effect of dexamethasone added to lidocaine in supraclavicular brachial plexus block: A prospective, randomised, double-blind study. Indian J Anaesth. 2013; 57(2):180–4.
5. Lee AR, Yi H, Chung IS, Ko JS, Ahn HJ, Gwak MS, et al. Magnesium added to bupivacaine prolongs the duration of analgesia after interscalene nerve block. Can J Anesth Can Anesth. 2012; 59(1):21–27.
6. Rojas González A. Dexmedetomidine as an adjuvant to peripheral nerve block. Rev Soc Esp Dolor 2019; 26(2):115-117.
7. Cai, H., Fan, X., Feng, P, et al. Optimal dose of perineural dexmedetomidine to prolong analgesia after brachial plexus blockade: a systematic review and Meta-analysis of 57 randomized clinical trials. BMC Anesthesiol 21, 233 (2021).
8. Jie F, Yuncen S, Fang D et al. The effect of perineural dexamethasone on rebound pain after ropivacaine single injection nerve block: A randomised controlled trial. BMC Anesthesiology 2021; 21(1) doi: 10.1186/s12871-021-01267-z.
9. Agarwal S, Aggarwal R, Gupta P. Dexmedetomidine prolongs the effect of bupivacaine in supraclavicular brachial plexus block. J Anaesthesiol Clin Pharmacol. 2014; 30(1):36–40.
10. Gupta A, Mahobia M, Narang N, Mahendra R. A comparative study of two different doses of dexmedetomidine as adjunct to lignocaine in intravenous regional anaesthesia of upper limb surgeries. Int J Sci Study. 2014; 2(3):53–62.
11. Kaygusuz K, Kol IO, Duger C, Gursoy S, Ozturk H, Kayacan U, et al. Effects of adding dexmedetomidine to levobupivacaine in axillary brachial plexus block. Curr Ther Res Clin Exp. 2012; 73(3):103–11.
12. Brummett CM, Hong EK, Janda AM, Amodeo FS, Lydic R. Perineural Dexmedetomidine Added to Ropivacaine for Sciatic Nerve Block in Rats Prolongs the Duration of Analgesia by Blocking the Hyperpolarization-activated Cation Current. Anesthesiology. 2011; 115(4):836–43.
13. Esmaoglu A, Yegenoglu F, Akin A, Turk CY. Dexmedetomidine Added to Levobupivacaine Prolongs Axillary Brachial Plexus Block. Anesth Analg. 2010 Dec; 111(6):1548–1551.
14. Bangera A, Manasa M, Krishna P. Comparison of effects of ropivacaine with and without dexmedetomidine in axillary brachial plexus block: A prospective randomized double-blinded clinical trial. Saudi J Anaesth. 2016; 10(1):38–44.
15. Koraki E, Stachtari C, Kapsokalyvas I, Stergiouda Z, Katsanevaki A, Trikoupi A. Dexmedetomidine as an adjuvant to 0.5% ropivacaine in ultrasound-guided axillary brachial plexus block. J Clin Pharm Ther. 2018; 43(3):348–52.
16. Paranjpe JS. Dexmedetomidine: Expanding role in anesthesia. Med J Dr DY Patil Univ. 2013; 6(1):5.
17. Leudi MM, Upadek V, Vogt AP, Steinfeldt T, Eichenberger U, Sauter AR. Swiss nationwide survey shows that dual guidance is the preferred approach for peripheral nerve blocks. SciRep.2019 24:9(1):9178.doi:10.1038/s41598-019-45700-3.

How to Cite this Article: Chiplonkar SY, Kate JA, Vadranapu DB, Toal P| Deciding the Better Dose- A Prospective Randomized Double Blind Study of Two Different Doses of Perineural Dexmedetomidine in Axillary Brachial Block | International Journal of Regional Anaesthesia | July-December 2022; 3(2): 83-87.

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Serratus Anterior Block for Rib Fractures: A Systematic Review and Meta-analysis

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Vol 3 | Issue 2 | July-December 2022 | Page 76-82 | Lijiin Zhen, Matthew Bright, Matthew McHugh, Damon Reardon, Leigh White

DOI: 10.13107/ijra.2022.v03i02.058

Authors: Lijiin Zhen [1], Matthew Bright [2], Matthew McHugh [2], Damon Reardon [2], Leigh White [1, 3]

[1] Department of Anaesthesia, Sunshine Coast University Hospital, Queensland, Australia.
[2] Department of Anaesthesia, Princess Alexandra Hospital, Queensland, Australia.
[3] Department of Anaesthesia, Griffith University, Queensland, Australia.

Address of Correspondence
Dr. Lijiin Zhen,
Department of Anaesthetics, Sunshine Coast University Hospital, Birtinya QLD 4575, Australia.
E-mail: lijiin.zhen@health.qld.gov.au

Abstract

Background: Effective analgesia is the mainstay of the management of traumatic rib fractures. Serratus anterior block is a newer regional anaesthesia technique used in traumatic rib fractures which may have a favourable safety profile compared to other regional techniques. There is currently a lack of evidence for serratus anterior block and its role in the improvement of mortality, pain, duration of stay and pulmonary complications in patients with traumatic rib fractures in comparison to other regional anaesthesia techniques.
Methods: Web of Science and PubMed were searched from inception until April 2022 for studies reporting on the use of a serratus anterior block compared to another therapy for the management of traumatic rib fractures. Primary outcomes were measures of analgesic efficacy. Secondary outcomes were the incidence of intervention related adverse events, hospital length of stay, intensive care unit length of stay and mortality.
Results: Seven studies with 649 patients were included. No significant difference was found between serratus anterior block and intravenous opiates in terms of resting pain scores and achievement of mild or no pain after the chosen intervention(p>0.05). There was a statistically, but not clinically significant difference post block pain scores compared to other regional techniques (WMD= 0.63; 95% CI= 0.45 to 0.80; p< 0.00001). Significant differences were found in favour of blocks, specifically thoracic epidural and paravertebral blocks over serratus anterior block in terms of achieving mild or no pain after the block (OR= 0.54; 95% CI=0.32 to 0.90; I2= 0%; p= 0.02). No significant difference was found for any other outcomes.
Conclusions: Current literature comparing the serratus anterior block to alternative analgesic options is limited by the end points assessing block success. No data was available assessing the effect on pain during deep inspiration and coughing. This meta-analysis demonstrated similar analgesic efficacy to other regional anaesthesia techniques but a lower incidence of mild or no pain post block compared to traditional epidural or paravertebral techniques. Future studies need to be directed towards important outcomes such as dynamic pain scores and respiratory complication rates.
Keywords: Rib fractures, Serratus Anterior, Chest trauma

References

1. Flagel, B.T.; Luchette, F.A.; Reed, R.L.; Esposito, T.J.; Davis, K.A.; Santaniello, J.M.; Gamelli, R.L. Half-a-dozen ribs: the breakpoint for mortality. Surgery. 2005 Oct;138(4):717-723; discussion 723-715.
2. Griffiths, R.; Surendra Kumar, D. Major trauma in older people: implications for anaesthesia and intensive care medicine. Anaesthesia. 2017 Nov;72(11):1302-1305.
3. Barry, R.; Thompson, E. Outcomes after rib fractures in geriatric blunt trauma patients. Am J Surg. 2018 Jun;215(6):1020-1023.
4. El-Boghdadly, K.; Wiles, M.D. Regional anaesthesia for rib fractures: too many choices, too little evidence. Anaesthesia. 2019 May;74(5):564-568.
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11. Higgins, J.P.; Altman, D.G.; Gotzsche, P.C.; Juni, P.; Moher, D.; Oxman, A.D.; Savovic, J.; Schulz, K.F.; Weeks, L.; Sterne, J.A.; Cochrane Bias Methods, G.; Cochrane Statistical Methods, G. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011 Oct 18;343:d5928.
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13. Abu-Elwafa, W.A.E-G.; Ragab, I.A.; Abdelrahman, A.H.; Mahmoud, W.A. Comparative Study between Efficacy of Serratus Anterior Muscle Block as A Regional Analgesia Technique and I.V Morphine Infusion in Patient with Fracture Ribs. The Egyptian Journal of Hospital Medicine. 2021 Jan;82(2):348-353.
14. Beard, L.; Hillermann, C.; Beard, E.; Millerchip, S.; Sachdeva, R.; Gao Smith, F.; Veenith, T. Multicenter longitudinal cross-sectional study comparing effectiveness of serratus anterior plane, paravertebral and thoracic epidural for the analgesia of multiple rib fractures. Reg Anesth Pain Med. 2020 May;45(5):351-356.
15. Bhalla, P.I.; Solomon, S.; Zhang, R.; Witt, C.E.; Dagal, A.; Joffe, A.M. Comparison of serratus anterior plane block with epidural and paravertebral block in critically ill trauma patients with multiple rib fractures. Trauma Surg Acute Care Open. 2021;6(1):e000621.
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How to Cite this Article: Zhen L, Bright M, McHugh M, Reardon D, White L | Serratus Anterior Block for Rib Fractures: A Systematic Review and Meta-analysis | International Journal of Regional Anaesthesia | July-December 2022; 3(2): 76-82.

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