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Ultrasound-guided (needle-in-plane) perineural catheter insertion: the effect of catheter-insertion distance on postoperative analgesia.

ABSTRACT: BACKGROUND:When using ultrasound guidance to place a perineural catheter for a continuous peripheral nerve block, keeping the needle in plane and nerve in short axis results in a perpendicular needle-to-nerve orientation. Many have opined that when placing a perineural catheter via the needle, the acute angle may result in the catheter bypassing the target nerve when advanced beyond the needle tip. Theoretically, greater catheter tip-to-nerve distances result in less local anesthetic-to-nerve contact during the subsequent perineural infusion, leading to inferior analgesia. Although a potential solution may appear obvious-advancing the catheter tip only to the tip of the needle, leaving the catheter tip at the target nerve-this technique has not been prospectively evaluated. We therefore hypothesized that during needle in-plane ultrasound-guided perineural catheter placement, inserting the catheter a minimum distance (0-1 cm) past the needle tip is associated with improved postoperative analgesia compared with inserting the catheter a more traditional 5 to 6 cm past the needle tip. METHODS:Preoperatively, subjects received a popliteal-sciatic perineural catheter for foot or ankle surgery using ultrasound guidance exclusively. Subjects were randomly assigned to have a single-orifice, flexible catheter inserted either 0 to 1 cm (n = 50) or 5 to 6 cm (n = 50) past the needle tip. All subjects received a single-injection mepivacaine (40 mL of 1.5% with epinephrine) nerve block via the needle, followed by catheter insertion and a ropivacaine 0.2% infusion (basal 6 mL/hr, bolus 4 mL, 30-min lockout), through at least the day after surgery. The primary end point was the average surgical pain as measured with a 0- to 10-point numeric rating scale the day after surgery. Secondary end points included time for catheter insertion, incidence of catheter dislodgement, maximum ("worst") pain scores, opioid requirements, fluid leakage at the catheter site, and the subjective degree of an insensate extremity. RESULTS:Average pain scores the day after surgery for subjects of the 0- to 1-cm group were a median of 2.5 (interquartile range, 0.0-5.0), compared with 2.0 (interquartile range, 0.0-4.0) for subjects of the 5- to 6-cm group (P = 0.42). Similarly, among the secondary end points, no statistically significant differences were found between the 2 treatment groups. There was a trend of more catheter dislodgements in the minimum-insertion group (5 vs 1; P = 0.20). CONCLUSIONS:This study did not find evidence to support the hypothesis that, for popliteal-sciatic perineural catheters placed using ultrasound guidance and a needle-in-plane technique, inserting the catheter a minimum distance (0-1 cm) past the needle tip improves (or worsens) postoperative analgesia compared with inserting the catheter a more traditional distance (5-6 cm). Caution is warranted if extrapolating these results to other catheter designs, ultrasound approaches, or anatomic insertion sites.

SUBMITTER: Ilfeld BM

PROVIDER: S-EPMC3085850 | biostudies-literature | 2011 May-Jun

REPOSITORIES: biostudies-literature

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Ultrasound-guided (needle-in-plane) perineural catheter insertion: the effect of catheter-insertion distance on postoperative analgesia.

Ilfeld Brian M BM Sandhu Navparkash S NS Loland Vanessa J VJ Madison Sarah J SJ Suresh Preetham J PJ Mariano Edward R ER Bishop Michael L ML Schwartz Alexandra K AK Lee Daniel K DK

Regional anesthesia and pain medicine 20110501 3

<h4>Background</h4>When using ultrasound guidance to place a perineural catheter for a continuous peripheral nerve block, keeping the needle in plane and nerve in short axis results in a perpendicular needle-to-nerve orientation. Many have opined that when placing a perineural catheter via the needle, the acute angle may result in the catheter bypassing the target nerve when advanced beyond the needle tip. Theoretically, greater catheter tip-to-nerve distances result in less local anesthetic-to- ...[more]

PMID: 21519311

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Project description:PurposePerineural catheter insertion using ultrasound guidance alone is a relatively new approach. Previous studies have shown that ultrasound-guided catheters take less time to place with high placement success rates, but the analgesic efficacy compared with the established stimulating catheter technique remains unknown. We tested the hypothesis that popliteal-sciatic perineural catheter insertion relying exclusively on ultrasound guidance results in superior postoperative analgesia compared with stimulating catheters.MethodsPreoperatively, subjects receiving a popliteal-sciatic perineural catheter for foot or ankle surgery were assigned randomly to either ultrasound guidance (bolus via needle with non-stimulating catheter insertion) or electrical stimulation (bolus via catheter). We used 1.5% mepivacaine 40 mL for the primary surgical nerve block and 0.2% ropivacaine (basal 8 mL·hr(-1); bolus 4 mL; 30 min lockout) was infused postoperatively. The primary outcome was average surgical pain on postoperative day one.ResultsForty of the 80 subjects enrolled were randomized to each treatment group. One of 40 subjects (2.5%) in the ultrasound group failed catheter placement per protocol vs nine of 40 (22.5%) in the stimulating catheter group (P = 0.014). The difference in procedural duration (mean [95% confidence interval (CI)]) was -6.48 (-9.90 - -3.05) min, with ultrasound requiring 7.0 (4.0-14.1) min vs stimulation requiring 11.0 (5.0-30.0) min (P < 0.001). The average pain scores of subjects who provided data on postoperative day one were somewhat higher for the 33 ultrasound subjects than for the 26 stimulation subjects (5.0 [1.0-7.8] vs 3.0 [0.0-6.5], respectively; P = 0.032), a difference (mean [95%CI]) of 1.37 (0.03-2.71).ConclusionFor popliteal-sciatic perineural catheters, ultrasound guidance takes less time and results in fewer placement failures compared with stimulating catheters. However, analgesia may be mildly improved with successfully placed stimulating catheters. Clinical trial registration number NCT00876681.

Project description:ObjectivesTo evaluate the accuracy of robotic CT-guided out-of-plane needle insertion in phantom and animal experiments.MethodsA robotic system (Zerobot), developed at our institution, was used for needle insertion. In the phantom experiment, 12 robotic needle insertions into a phantom at various angles in the XY and YZ planes were performed, and the same insertions were manually performed freehand, as well as guided by a smartphone application (SmartPuncture). Angle errors were compared between the robotic and smartphone-guided manual insertions using Student's t test. In the animal experiment, 6 robotic out-of-plane needle insertions toward targets of 1.0 mm in diameter placed in the kidneys and hip muscles of swine were performed, each with and without adjustment of needle orientation based on reconstructed CT images during insertion. Distance accuracy was calculated as the distance between the needle tip and the target center.ResultsIn the phantom experiment, the mean angle errors of the robotic, freehand manual, and smartphone-guided manual insertions were 0.4°, 7.0°, and 3.7° in the XY plane and 0.6°, 6.3°, and 0.6° in the YZ plane, respectively. Robotic insertions in the XY plane were significantly (p < 0.001) more accurate than smartphone-guided insertions. In the animal experiment, the overall mean distance accuracy of robotic insertions with and without adjustment of needle orientation was 2.5 mm and 5.0 mm, respectively.ConclusionRobotic CT-guided out-of-plane needle insertions were more accurate than smartphone-guided manual insertions in the phantom and were also accurate in the in vivo procedure, particularly with adjustment during insertion.Key points• Out-of-plane needle insertions performed using our robot were more accurate than smartphone-guided manual insertions in the phantom experiment and were also accurate in the in vivo procedure. • In the phantom experiment, the mean angle errors of the robotic and smartphone-guided manual out-of-plane needle insertions were 0.4° and 3.7° in the XY plane (p < 0.001) and 0.6° and 0.6° in the YZ plane (p = 0.65), respectively. • In the animal experiment, the overall mean distance accuracies of the robotic out-of-plane needle insertions with and without adjustments of needle orientation during insertion were 2.5 mm and 5.0 mm, respectively.

Project description:Objective:Ultrasound-guided lateral thoracolumbar interfascial plane block (US-TLIP block) is a novel regional technique for anesthesia or analgesia. However, there has been no prospective, randomized and controlled clinical trial investigating the perioperative analgesic effect of US-TLIP block on lumbar spinal fusion surgery. The aim of this study was to investigate the analgesic effect of bilateral single-shot US-TLIP in patients undergoing lumbar spinal fusion surgery. Methods:A prospective and randomized comparative clinical study was conducted. A total of 60 patients (ASA classes: I-II), aged 21-74 years who were scheduled for lumbar spinal fusion surgery were randomized and divided into the TLIP group (Group T, n = 30) and control group (Group C, n = 30). The patients in Group T received preoperative bilateral single-shot US-TLIP with 30 ml of 0.375% ropivacaine at the third lumbar spine (L3) vertebral level, and the patients in Group C received an injection of 30 ml 0.9% saline through same technique. All patients received patient-controlled analgesia (PCA) after their operation. The frequency of PCA compressions and rescue analgesic administrations were recorded. Opioids (sufentanil and remifentanil), anesthetic consumption, the number of postoperative days spent in a hospital bed, overall hospital stay time and postoperative complications were recorded. The Visual Analogue Scale (VAS) and Bruggemann Comfort Scale (BCS) scores for pain and comfort assessment were recorded at 1, 12, 24, 36, and 48 hours postoperatively. Results:Opioids and anesthetic consumption in the perioperative period decreased significantly in the TLIP group compared to the control group (P < 0.05). The VAS and BCS scores in the TLIP group were lower at 12, 24, and 36 hours postoperatively (P < 0.05). US-TLIP block has been shown to shorten postoperative hospital stays (P < 0.05). There was no significant difference in postoperative complications between the two groups. Conclusion:Our study findings show that bilateral US-TLIP block exhibits significant analgesia and safety in patients undergoing lumbar spinal fusion surgery.

Project description:PurposeTo evaluate and compare the efficacy of intermittent needle aspiration and continuous catheter drainage in ultrasound-guided management of liver abscesses.MethodsThis was a prospective, randomised study conducted on 100 patients (88 males and 12 females; age range 22-74 years) with liver abscess(es) and having abscess size more than 5 cm, divided into two groups: Percutaneous needle aspiration (PNA) (n = 50) and percutaneous catheter drainage (PCD) (n = 50). Criteria of exclusion were: rupture of abscess before intervention; prior intervention; uncorrectable coagulopathy; concomitant biliary tract malignancy. In the PNA group, pus was aspirated by an 18-gauge needle using freehand technique and the number of aspirations was limited to two. Failure of abscess size to decline below 50% of the original diameter or of clinical improvement after second aspiration was considered as failure of aspiration. In the PCD group, drainage was done by 12-French catheters using Seldinger technique. Drainage was considered as failure if abscess cavity did not resolve and laparotomy was needed to evacuate the pus cavity.ResultThe success rate in the PNA group was 88% and 92% in the PCD group; however, this difference was statistically not significant, suggesting that both are equally efficacious. The total duration of hospital stay (mean 6.8 days [PNA] vs 10.5 days [PCD]; p value: 0.011) and the average duration between intervention and discharge (5.9 days [PNA] vs 10.2 days [PCD]; p value:0.026) were significantly less in the PNA group. One major complication was seen in our study: peritonitis due to peri-catheter leak in PCD group.ConclusionBoth procedures are equally efficacious in the management of liver abscesses; however in view of less duration of hospital stay, patient safety and comfort, procedure simplicity, and the reduced cost, needle aspiration should be used as the first-line procedure in the treatment of liver abscess (even in abscesses more than 5 cm). Catheter drainage should be reserved for cases that do not respond to a second attempt of aspiration.

Project description:ObjectiveSerratus anterior plane block (SAPB) provides effective thoracic analgesia. This systematic review and meta-analysis was conducted to assess the safety and efficacy of SAPB for postoperative analgesia after breast surgery.MethodsA systematic literature search was performed using Embase, PubMed, Web of Science, and the Cochrane Library for eligible randomised controlled trials. The primary outcomes involved the administration of intraoperative and postoperative opioids. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used for rating the quality of evidence for making recommendations.ResultsOverall, 13 studies comprising 826 patients met the inclusion criteria (412 in the SAPB group and 414 in the control group). Patients treated with SAPB exhibited a significantly lower postoperative opioid consumption (mean difference, -38.51 mg of oral morphine equivalent; 95% confidence interval (CI), -60.97 to -16.05; P < 0.01; I 2 = 100%), whereas no difference was observed in the intraoperative opioid consumption (mean difference, -9.85 mg of oral morphine equivalent; 95% CI, -19.52 to -0.18; P=0.05; I 2 = 94%). In addition, SAPB significantly decreased the occurrence of postoperative nausea and vomiting (risk ratio, 0.32; 95% CI, 0.19-0.55; P < 0.05;I 2 = 38%) and reduced pain scores during the postoperative period (1 h: standardised mean difference (SMD), -1.23; 95% CI, -2.00 to -0.45; I 2 = 92%; 2 h: SMD, -0.71; 95% CI, -1.00 to -0.41; I 2 = 48%; 4 h: SMD, -1.52; 95% CI, -2.77 to -0.27; I 2 = 95%; 6 h: SMD, -0.80; 95% CI, -1.51 to -0.08; I 2 = 81%; 8 h: SMD, -1.12; 95% CI, -1.98 to -0.27; I 2 = 92%; 12 h: SMD, -0.78; 95% CI, -1.21 to -0.35; I 2 = 83%; and 24 h: SMD, -0.71; 95% CI, -1.20 to -0.23; I 2 = 87%; P < 0.05 for all).ConclusionSAPB was safe and effective after breast surgery to relieve postsurgical pain. However, additional well-developed trials are required to validate these findings.

Dataset Information

Ultrasound-guided (needle-in-plane) perineural catheter insertion: the effect of catheter-insertion distance on postoperative analgesia.

Publications

Ultrasound-guided (needle-in-plane) perineural catheter insertion: the effect of catheter-insertion distance on postoperative analgesia.

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