Cancer Treatmentrelated Pain

Up to a third of women develop pain as a result of treatment of breast cancer.173 The pain is often described as a general burning and aching sensation referred to the axilla, the medial upper arm, the chest, or all of these areas. There may be paroxysmal episodes of shooting and lancinating pain. In addition, some women report phantom breast pain, mainly in the nipple. The pain may be exacerbated with arm movement, leading to a frozen shoulder as the patient attempts to

Outcome Studies Of Interpleural Analgesia In Cancer Pain

Interpleural analgesia may also be a useful addition to systemic analgesic medications in the treatment of moderate or severe cancer pain. There have been published reports of successful results from interpleural analgesic therapy for both nonmetastatic and metastatic cancers of the gastrointestinal tract, including the pancreas, kidney, breast, and lung as well as lymphoma, sarcoma, histiocytoma, and myeloma.11 1113 113 11531 11511 11551 11561 This evidence describing the use of interpleural...

Upper Extremity Blocks

Studies of perineural steroid injection, generally combined with local anesthetic, for the treatment of carpal tunnel syndrome were examined by Abram.143 Initial efficacy was found in multiple studies to range from 77 to 92 . However, many studies that followed patients for at least 1 year found continued benefit in only 13 to 22 . A prospective, randomized, double-blinded, placebo-controlled study measuring the short-term efficacy of steroid versus saline injection into the carpal tunnel was...

Superior Hypogastric Plexus

Pelvic pain states can be modified by neurolysis of the superior hypogastric plexus.143 Afferent nociceptive fibers originate in various pelvic viscera form a midline plexus in the retroperitoneum, extending from the lower third of the fifth lumbar vertebral body to the upper third of the first sacral vertebral body. These afferent fibers then pass centrally via the sympathetic nerves, trunks, ganglia, and rami. Previously, surgical presacral neurectomy was performed for some pelvic pain...

Epidural Steroid Injections

Epidural steroid injections (ESIs) have been used for low back and radicular pain for almost 50 years.13 Today they rank as one of the most common interventional procedures performed by pain management specialists. ESIs are primarily indicated as part of a nonoperative approach to the treatment of spinal and radicular pain. Pages first described his technique for accessing the epidural space via a paramedian approach in 1921s The technique involved the use of loss of resistance to the needle as...

Superior Hypogastric Plexus Block

Superior hypogastric plexus blockade was first described in 1990 as a treatment for cancer-related pelvic pain.173 This nerve block was performed using a fluoroscopically guided posterior approach, very similar to the posterior approach to the blockade of the celiac plexus or lumbar sympathetic trunk. Because the iliac crests of the pelvic bone can be an anatomic barrier to proper needle placement, computed tomography (CT) has been used to guide superior hypogastric plexus blocks.173 123 153...

Outcome Studies For Superior Hypogastric Plexus Block

Presacral neurectomy has been performed for years as a treatment for chronic pelvic pain. 82 Presacral neurectomy involves a surgical resection of the superior hypogastric plexus by either an open or a laparoscopic approach. Large retrospective series and case reports describe successful relief of pain in approximately 60 to 80 of patients with chronic noncancerous pelvic pain. 82 83 84 More recently, a randomized, controlled study compared a conservative surgical approach with presacral...

Adrenal And Renal Hormones And Catecholamines

In studies using rather large volumes of bupivacaine (0.5 ) and a well-described neural blockade, the intra- and postoperative increases in plasma cortisol, aldosterone, and renin, as well as catecholamines, have been inhibited. Although no systematic studies are available, rather large doses of bupivacaine seem to be necessary to achieve eradication of these stress parameters. -Lipotropic - Endorphin t ACTH4 GHI AVPJ-TSHt LH FSH* Prolactin t Testes ovaries Testosterone Estradiol...

Aids To Block Performance

In patients with difficult anatomy (e.g., morbidly obese), in whom the interscalene groove is difficult to palpate, the interscalene groove may be located by drawing lines laterally from the cricoid and along the lateral border of the clavicular head of the sternocleidomastoid muscle as described. Where these lines intersect, a mark should be made 2 cm laterally along the line from the cricoid. The insulated needle should be inserted at this mark perpendicular to skin planes, and slightly...

Aids To Nerve Location By Radiologic Imaging

Lanz and Theiss056 reported that the brachial plexus block near the first rib at the level of the trunks and divisions provided the most reliable efficacy. Despite this advantage, the use of the approach near the first rib is limited because of the risk of pneumothorax.053 0581 0591 Eliciting paresthesias is also important to obtain a high degree of success.13 1621 However, paresthesias are uncomfortable for patients and may result in nerve injury.0631 0641 0651 0661 063 To perform the brachial...

Amide Local Anesthetics

In contrast to the ester-linked drugs, the amide-linked local anesthetics must be transported by the circulation to the liver before biotransformation can take place. The two major factors controlling the clearance of amide-linked local anesthetics by the liver are (1) hepatic blood flow (delivery of the drug to the liver) and (2) hepatic function (drug extraction by the liver). Factors that decrease hepatic blood flow or hepatic drug extraction result in an increased elimination half-life. For...

Brachial Plexus And Branches

Fractures of the upper extremity, especially at the elbow and wrist, are common injuries during the summer months when children are outside playing on jungle gyms and riding skateboards. These patients are often brought for treatment in the late afternoon or early evening, having eaten just before the traumatic event. Surgery focuses on reduction and realignment procedures with hardware insertion and casting. Use of a sedative may complicate the anesthetic considerations of a full stomach. In...

Brachial Plexus Block

In 1884, less than a year after the discovery of the anesthetic properties of cocaine, William Halsted performed the first regional blockade of the brachial plexus. His technique involved surgical exposure of the plexus in the neck with subsequent intraneural blocking of individual nerves.143 Effectively providing complete anesthesia to the upper extremity, the procedure itself was, at times, nearly as extensive as the surgery for which it was being provided. Unfortunately, an addiction to...

Branko M Weiss Eli Alon

Outcome and Seven Pillars of Quality Avedis Donabedian 13 asserted that the seven pillars, or attributes, that define quality in healthcare13 are (1) efficacy (ability to bring improvements) (2) effectiveness (degree to which the care could attain the level of improvement that studies of efficacy have established as attainable in the clinical practice) (3) efficiency (if two approaches are equally efficacious or effective, the less costly one is the more efficient) (4) optimality (relationship...

Caudal Block

Caudal Anesthesia Landmarks

This is the most useful pediatric block, because it is widely applicable and technically simple. Indeed, caudal anesthesia is very easy to administer to a child rather than an adult in whom the caudal block is often difficult and occasionally impossible. The caudal block can provide analgesia for surgery up to and including the umbilicus. This technique can be used successfully in neonatal rectal surgery.123 The anesthetic agent is injected through the sacral hiatus, which is formed by failure...

Central Nervous System Toxicity

CNS symptoms of local anesthetic toxicity usually occur before cardiovascular changes. In humans, the first signs of CNS toxicity include drowsiness progressing to numbness of lips, slurring of speech, agitation, tinnitus, diplopia, fine tremors, and grand mal seizures large doses produce generalized CNS depression (an isoelectric electroencephalogram EEG ). Ironically, there is no evidence that epileptics have a heightened susceptibility to the CNS toxicity of these drugs. In fact, local...

Cervical Facet Joints

The anatomy of the cervical facet joints is considerably different from that of the lumbar region. Although they are still composed of the superior articular process of the vertebra below and the inferior articular process of the vertebra above, their capsular anatomy, orientation, and biomechanics differ significantly from their lumbar counterparts. The configuration of the joints also depends on the cervical level that is being addressed, as upper cervical segments differ substantially from...

Cervical Nerve Roots

Selective blockade of the C3 to C8 nerve roots is performed in the same manner. The patient is placed in the supine position with the head in the neutral position. After obtaining an anteroposterior (AP) fluoroscopic view of the cervical spine, the C-arm is positioned obliquely until the neuroforamina are clearly visualized. The proper angle causes the ipsilateral vertebral laminae to appear as a string of beads. A skin wheal is raised with local anesthetic just posterior to the posterior...

Cervical Nerves Anatomy

Skin of a great proportion of the dorsal scalp, the neck, and the shoulders is supplied by sensory branches of the upper four cervical nerves ( Fig. 20-13 ). The dorsal rami of C2 to C4 supply the back of the neck and the scalp as the greater occipital nerve. The ventral rami of C1 to C4 form the cervical plexus. The deep branches supply the muscles of the neck and the diaphragm. The superficial cervical plexus pierces the posterior border of the sternocleidomastoid at its midpoint to fan out...

Cervical Spine

In the cervical spine, the posterior compartment, comprised of facet joints and intrinsic back muscles (semispinalis capitis, semispinalis cervicis, multifidus, and interspinalis), is innervated by the cervical posterior rami. The spinal nerve divides into anterior and posterior rami as it exits the foramen. After a short trajectoryof 2 to 5 mm, the posterior ramus divides into a medial and a lateral branch. In the cervical region, these branches are separated by the semispinalis capitis...

Clinical Research

Introduction and Historical Perspective It is the purpose of this chapter to review some of the clinical research in regional anesthesia as it relates to current developments in surgery and pain management. These advances in clinical research are related to the use of drugs, administration techniques, and equipment. Many of these developments are far from recent, and it is important to place them in historical perspective to understand the development of regional anesthesia. The origins of...

Subarachnoid and Epidural Anesthesia

Subarachnoid Anesthesia

MIGUEL ANGEL REINA JOSE DE ANDR S ANDRES L PEZ The meninges envelop the brain and spinal cord and consist of three membranes (external to internal) dura mater, arachnoid, and pia mater, respectively. Tn association with their cellular and fibrillar components, these membranes constitute an organ in their own right. The cellular and fibrillar components in turn are morphologically and physiologically implicated in the mechanical, immunologic, and thermal protection of the brain and spinal cord....

Radiographic Imaging in Regional Anesthesia

Use of radiography in regional anesthesia and pain management has grown more important as the field has developed. Radiographic diagnostic tests such as plain films, computed tomography (CT), magnetic resonance imaging (MRI), and bone scans are frequently obtained to find simple fractures or degenerative joints, disc bulges, herniations, and spinal cord or nerve impingement. During the performance of many procedures, fluoroscopy or CT is used to place the nerve blocks with precision. Because of...

Trigeminal Ganglion Procedures

Nimbus Radiofrequency Needle Fluoroscopy

The trigeminal ganglion, which is an intercranial structure located just proximal and lateral to the foramen ovale, has three branches ophthalmic, maxillary, and mandibular. These are primarily sensory branches, except for the third division. This third division, the mandibular branch, exits through the foramen ovale and has motor branches that are involved in mastication. The procedures that anesthesiologists are involved in center around the different target sites that lend themselves to...

Chloroprocaine

2-Chloroprocaine (Nesacaine), an ester local anesthetic introduced in 1952, is a chlorinated derivative of procaine (see Fig. 13-12 ). Its major assets are its rapid onset and short duration of action and its reduced acute toxicity due to its rapid metabolism (plasma half-life approximately 25 s). Enthusiasm for its use has been tempered by reports of prolonged sensory and motor block after epidural or subarachnoid administration of large doses. Figure 13-12 Local anesthetic chemical structures...

Christopher J Jankowski

Complications from neuraxial anesthesia have been recognized since August Bier reported the first spinal anesthetic over 100 years ago.12 Fortunately, serious complications of neuraxial anesthesia remain rare but can be devastating when they occur. As morbidity and mortality from anesthesia and surgery continue to decline, the relative importance of these problems increases. Safe, effective practice of neuraxial anesthesia requires a detailed knowledge of the potential complications, their...

Christopher L Wu

Over the past two decades, a growing body of knowledge has accumulated from investigation of the effect of regional anesthesia and postoperative analgesia on patient outcomes. Use of regional anesthesia and analgesia results in many beneficial physiologic effects and is strongly associated with favorable outcomes in several organ systems (i.e., gastrointestinal and coagulation) however, the efficacy of regional anesthesia may not be as apparent in other areas, such as postoperative cognitive...

Coagulopathy

Neuraxial anesthesia is contraindicated in the presence of a coagulopathy. Spinal hematoma may result in permanent neurologic damage if not diagnosed and decompressed within 6 to 12 hours after onset of symptoms.1323 Unfortunately, it is often difficult to assess whether patients with abnormal laboratory coagulation parameters have a clinical coagulopathy. In general, an international normalized ratio greater than 1.41113 or a prolonged aPTT are considered contraindications to neuraxial...

Cocaine

Cocaine occurs in abundance in the leaves of the coca shrub and is an ester of benzoic acid and methylecgonine. Ecgonine is an amino alcohol base closely related to tropine, the amino alcohol in atropine. It has the same fundamental structure as the synthetic local anesthetics. Pharmacologic Actions and Preparations The clinically desired actions of cocaine are the blockade of nerve impulses as a consequence of its local anesthetic properties, and local vasoconstriction secondary to inhibition...

Complications

Monitoring of Efficiency of the Block. Akinesia of the extraocular muscles is tested by observing whether the patient can move the eye in the four opposite directions (up, down, right, and left). The patient is asked to squeeze the eye to check the orbicularis oculi paralysis. Because the superior oblique muscle is anatomically located outside the muscle cone, it may not be completely paralyzed after a retrobulbar block. If the patient is asked to look downward, an intorsion movement of the eye...

Continuous Spinal Anesthesia

Seven years after Bier's landmark work on the administration of cocaine via lumbar puncture, Henry Percy Dean, a British surgeon, introduced a modification of the technique called continuous spinal anesthesia.123 Unfortunately, many of his colleagues who attempted the procedure encountered difficulties such as needle trauma and breakage. Therefore, the technique fell into disfavor, as can be evidenced by the lack of citations referring to continuous spinal anesthesia in the English language...

D

Individual, group, and family psychotherapy 2. Cognitive-behavioral therapies 3. Biofeedback and relaxation techniques IV. Specific types of painful conditions to be included in the fellow's educational program A. Pain associated with cancer, including issues of death and dying, palliative care, and hospice care B. Postoperative and post-trauma pain C. Pain associated with nervous system injuries D. Pain associated with chronic disease V. Regional pain syndrome to be included in the fellow's...

Definition Of Terms

The following terms are defined briefly in this section a more complete description of the characteristics of each type of facility appears in subsequent portions of this chapter. 1. Pain Treatment Facility. This generic term is used to describe all forms of pain treatment facilities without regard to personnel involved or types of patients served. Pain unit is a synonym for pain treatment facility. 2. Multidisciplinary Pain Center. This organization of healthcare professionals and basic...

Desirable Characteristics Of Peripheral Nerve Stimulators

Many specialized PNSs are now commercially available, and most contain complex and sophisticated electronics that are far from the primitive machines of the early pioneers. The desirable features of PNSs have been elucidated by Galindo and by Ford and colleagues. 113 Table 17-7 lists the features PNSs should include for optimum efficiency. 1. The device should have a constant level of current output. This implies that the stimulator should have a high internal resistance. Because it is a...

Development Of Other Local Anesthetics

It was only natural that discoveries in organic chemistry, both analytic and synthetic, should have led to efforts to find preparations with good anesthetic properties and without the drawbacks of cocaine. Besides its highly acute toxicity and the risk of addiction (which came to play a greater role as time went by), cocaine is easily decomposed when the solution is sterilized. It is also expensive. As emphasized by Willstatter, the vegetable bases, such as cocaine, are often so complex that...

Development of the Technique of Regional Anesthesia

In 1908, August Bier devised a very effective method of bringing about complete anesthesia and motor paralysis of a limb. He injected a solution of procaine into one of the subcutaneous veins that was exposed between two constricting bands in a space that had previously been rendered bloodless by an elastic rubber bandage extending from fingers or toes. The injected solution permeated the entire section of the limb very quickly, producing what Bier called d rect ve n anesthes a in 5 to l5...

Effects Of Regional Anesthesia Techniques On The Neonate

General versus Regional Anesthesia and Neonatal Outcome The comparisons of regional versus general anesthesia for cesarean delivery are typically focused on the fetal status and neonatal outcome data, such as acid-base values, Apgar score, and ventilatory pattern, which may or may not represent the outcome. The studies in the 1970s and 1980s reported, variably, some or no differences in the neonatal status regarding the type of anesthesia given. In a 1975 to 1983 retrospective analysis, Ong and...

Femoral Nerve

Femoral nerve blocks are easily performed and can provide significant postoperative analgesia for femoral shaft fractures or other anterior thigh procedures. When combined with a sciatic nerve block, an obturator nerve block, and a lateral femoral cutaneous nerve block, lower extremity anesthesia can be obtained. Because of the proximity of the femoral nerve to the femoral artery, intravascular injection or hematoma formation may occur. Direct injury to the femoral nerve can result from...

General Technical Considerations

Spinal Cord Transection Succinylcholine

As with any anesthetic, appropriate equipment must be at hand (and checked) to treat a patient with any potential complication. This means that an oxygen source and appropriately sized airway equipment (bag, mask, laryngoscope, endotracheal tube, laryngeal mask airway, and oral airway) must be readied in advance. Drugs to rapidly induce general anesthesia and paralysis (thiopental and succinylcholine) are required, as is a functioning source of suction. Before the administration of the regional...

Head And Neck

Pain related to a malignant neoplasm of the head and neck poses one of the most challenging pain management problems because of the overlapping sensory innervation of the area. Most of the pain can be managed with medical regimens however, neural blockade can be a very effective addition. 194 1951 Sensory innervation of the head and neck arises from cranial nerves V, VTT, TX, and X, and dorsal roots of the second, third, and fourth cervical nerves. Sympathetic innervation derives from the T1...

History

Knapp (1884) 2 first used cocaine for retrobulbar block, but the technique failed to gain popularity until the 1930s, after the discovery of procaine.12 Atkinson2 described a cone injection technique, which became standard teaching ( Fig. 20-14 ). In the Atkinson method, the patient directs the gaze upward and inward however, this technique results in many complications,12 including damage to the optic nerve. To avoid contact with the orbital nerve, the needle should not pass more than 31 mm...

Inferior Dental And Lingual Nerve Blocks

The foramen is located in the center of the medial aspect of the ascending ramus of the mandible. The foramen is found by rolling the index finger over the concavity of the retromolar trigone. With the barrel of the syringe resting on the contralateral premolars, the needle is directed to a point just beyond the midpoint of the palpating finger. While anesthetic is injected, the needle is directed medially and more posteriorly for a distance of 1 to 2 cm. A column of 2 mL blocks both nerves.

Info

Current needed to stimulate a nerve depends on the pulse width or the duration of the stimulus. The chronaxie can be used as a measure of the threshold for any particular nerve and is useful when comparing different nerves or nerve fiber types. Table 17-1 shows values obtained for chronaxies for mammalian peripheral nerves. Note that smaller unmyelinated fibers have larger chronaxies. This supports the observation that the larger the fiber, the easier it is to stimulate at any given distances...

Innervation Of The Thorax

The nerve supply to the thorax and upper abdomen runs along the intercostal spaces via the corresponding intercostal nerves and branches. The lateral cutaneous branch of the intercostal nerve supplies the thoracic wall from the midaxillary line. In addition, the anterior and posterior portions of the chest wall are innervated by brachial plexus. There is overlapping innervation anteriorly from the lateral edge of the sternum bilaterally, from the anterior cutaneous branch of the intercostal...

Interpleural Block

Interpleural administration of local anesthetic for the control of pain was described initially by Reiestad in 1984 and has been the subject of several investigations in the past several years. Indications for the technique have expanded and include postoperative pain relief after thoracic and upper abdominal surgical procedures including cholecystectomy, nephrectomy, unilateral breast surgery, and gastric fundoplication. Additionally, the technique has been used for treatment of patients with...

Intraperitoneal Local Anesthetics

Eds And Local Anesthesia

In keeping with the idea that pain should be treated at the peripheral site, efforts have been made to elucidate the effect of intraperitoneal local anesthetics, but the results have been fairly negative with regard to both pain relief and modification of the surgical stress response.13 Figure 23-2 Neural blockade techniques that may influence the response to surgical injury. (From Kehlet H Endocrine-metabolic effects. In Raj PP ed Clinical Practice of Regional Anesthesia. New York, Churchill...

Intrathecal Pump Delivery Systems

As stated earlier in this chapter, intraspinal drugs can be delivered externally through externalized epidural or intrathecal catheters or delivered internally through implanted pump systems. Because external delivery systems are discussed in another chapter, our discussion in this chapter is focused on implanted drug delivery systems. The first drug delivery system approved for the delivery of intraspinal analgesics was the Infusaid model 400 pump, which is no longer in production. The...

L2 Communicating Ramus

Percutaneous facet denervation and percutaneous partial rhizotomy have traditionally been the minimally invasive RF techniques used in the treatment of back pain. Recent advances in knowledge of the innervation of the anterior vertebral compartment have led to the development of performing RF lesions close to the exiting segmental nerves, with the aim of interrupting part of the afferent impulses from the anterior mechanical compartment. Based on anatomic considerations, the following technique...

Lateral Popliteal Sciatic Block

Using anatomic studies performed by Vloka and colleagues193 and Zetlaovi and associates, the patient is asked to slightly flex the knee, which enhances palpation Figure 20-52 Sciatic nerve block Lateral popliteal approach. Figure 20-52 Sciatic nerve block Lateral popliteal approach. of the groove between the vastus lateralis and biceps femoris muscles. After the groove is identified, the leg is straightened. Where the lateral line from the patella intersects the groove is the point of needle...

Local Anesthetics For Eye Surgery

Anesthesia of the cornea and conjunctiva can be obtained readily by topical application of local anesthetics. However, most of the local anesthetics described earlier are too irritating for ophthalmologic use. The Figure 13-18 Structurally similar to procaine the difference is that it lacks the terminal diethylamino group. Figure 13-18 Structurally similar to procaine the difference is that it lacks the terminal diethylamino group. Figure 13-19 The most frequently used local anesthetics in...

Local Anesthetics For Skin And Mucous Membranes

Some anesthetics are either too irritating or too ineffective to be applied to the eye. However, they are useful as topical anesthetic agents on the skin, mucous membranes, or both. These preparations are effective in the symptomatic relief of anal and genital pruritus, poison ivy rashes, and numerous other acute and chronic dermatoses. They are sometimes combined with a glucocorticoid or antihistamine and are available in a number of proprietary formulations. Dibucaine (Nupercainal) is a...

Local Infiltration

Infiltration of wound edges with local anesthetics (field block) or by directly instilling local anesthetic into a wound (splash) effectively provides intra- and postoperative analgesia for many minor (e.g., inguinal herniorrhaphy, laceration repair, tonsillectomy) and some major surgical procedures (e.g., craniotomy). Many studies have demonstrated the effectiveness of tetracaine-adrenaline (epinephrine)-cocaine (TAC), lidocaine-epinephrine-tetracaine (LET), and bupivacaine-norepinephrine (BN)...

Lumbar Facet Pain

Intravertebral Anesthesia

The implications of the lumbar facet joint as the primary and sole source of pain have been debated. In the lumbar region, the prevalence of facet joint pain has been determined to range between 7.7 and 75 . 13 rn m m m ra The diagnosis of zygapophyseal joint pain on clinical grounds is challenging. Historically, a patient who had a clinical presentation of low back pain and a normal neurologic examination was diagnosed with an arthropathy of a lumbar zygapophyseal joint. However, provocative...

Lumbar Plexus And Branches

Innervation of the skin, muscles, periosteum, and joints of the hip, thigh, and knee make the blockade of the lumbar plexus particularly useful in pediatric patients. Analgesia for lower extremity procedures in children frequently involves areas innervated by branches of the lumbar plexus. Procedures involving joint or bone realignment, especially with insertion of hardware, are common, particularly in a disabled child whose ability to sit upright in a wheelchair or to manage transfers from...

Management Of Chronic Nonmalignant Pain

Patients with cancer may also suffer from chronic, nonmalignant pain that may be unrelated to the malignancy. Interpleural analgesia may be a useful adjunct to conventional analgesic therapy consisting of nonopioid and opioid analgesic medications. These pain states may include painful herpes zoster or postherpetic neuralgia in a thoracic dermatomal area, chronic pancreatitis,143 and upper extremity reflex sympathetic dystrophy and causalgia. Chronic administration of interpleural local...

Management Of Unsuccessful Block

An alternate technique should be chosen. The structures of the head and neck are supplied by twelve cranial and four cervical nerves. A large proportion of the nerve supply to the head and neck is of a specialized sensory or secretomotor nature and is of minimal relevance to the practice of regional anesthesia. Another unique feature is the separation of sensory and motor functions, which allows anesthesia of the Figure 20-7 Line drawing of innervation of the...

Mechanism Of Action

Regional Anesthesia Mechanism

Glutamate and aspartate are arguably the major excitatory transmitters in the vertebrate central nervous system, whereas GABA is a major inhibitory transmitter. The cell surface receptors that mediate the effects of glutamate release can be found at most excitatory synapses throughout the central nervous system. These receptors they are divided into the slow, G-protein-coupled metabotropic receptors and the fast, ligand-gated ion channels (ionotropic receptors). The latter class is again...

Morphology Of Arachnoid Sheaths And A Novel Hypothesis On The Origin Of Cauda Equina Syndrome And Transient Root

The trabecular arachnoid component arises from the reticular arachnoid lamina and merges with the cellular plane of the pia mater. This trabecular component emits arachnoid projections to all the structures that traverse the subarachnoid space. 91 193 Variable diameter vessels and nerves are in turn enveloped by this component (see Fig. 19-11 ). 113 In this way, the nerve roots enveloped by the pia mater are not found free within the dural sac but are surrounded by arachnoid structures known as...

Neck Dissection And Reconstruction

The trigeminal nerve and cervical plexus cover the greater part of the skin and mucosal surface that are involved in major surgery for excision of carcinoma Figure 24-19 Field block for neck surgery involving cervical plexus block, superior laryngeal nerve block, and extended laryngeal nerve block, along with subcutaneous infiltration of the field of surgery. (Redrawn from Labat G Regional Anesthesia Its Technique and Clinical Application. Philadelphia, WB Saunders, 1923.) Figure 24-19 Field...

Nerve Stimulation With Insulated And Uninsulated Needles

Bashein and colleagues 1111 addressed the question of nerve stimulation with two in vitro stimulation models, one digital and one analogue. In both models, they considered a square region of tissue with a needle connected to one electrode and inserted perpendicular to the free border representing the skin, whereas the other three sides were connected to the so-called indifferent electrode. Their model differed from that of Montgomery and coworkers171 in that the region was large compared with...

Neural Compression And Invasion

The cervical, brachial, and lumbar plexuses are vulnerable to compression from metastatic tumors. The brachial plexus is quite vulnerable to metastatic breast cancer, metastatic melanoma, and superior sulcus lung tumors.1 Lumbar plexus compression can result from cervical, rectal, or metastatic cancer. Pain is often an early sign of plexus compression and often precedes any neurologic deficits. The pain is characterized as a diffuse ache in the distribution of the plexus innervation and...

Neurolysis Of The Stellate Ganglion

Although there exist anecdotal reports of good results and minimal complications with the use of 1 to 2 mL of 6 aqueous phenol or less than 1.5 mL of absolute Figure 28-2 Anteroposterior view of a C7 stellate ganglion block. A, The stellate ganglion is the fusion of the inferior cervical and first thoracic ganglia. It is located between the medial portions of the transverse processes of the seventh cervical (C7) and first thoracic vertebrae (white .structure). The needle should be advanced...

Normovolemic Patients

The cardiovascular effects of regional anesthesia are well documented.113 113 113 Peripheral nerve blocks rarely cause significant hemodynamic changes, whereas the hemodynamic alterations caused by spinal and epidural anesthesia depend on the sensory level of anesthesia. For example, spinal anesthesia to the T5 dermatome level decreases mean arterial blood pressure by 21.3 , although the decline in total peripheral resistance is only 5 . The hypotension seen with spinal anesthesia is,...

Ophthalmic Surgery

The majority of patients who need ophthalmic surgery are frequently at the extremes of age. Aged patients often suffer from multiple systemic diseases. In fact, the eye problem may be a reflection of ongoing systemic disease with multiple end-organ involvement. For example, if diabetic patients need surgery for diabetically caused advanced retinopathy, they may have coronary artery disease, peripheral vascular disease, cardiovascular disease, kidney disease, peripheral neuropathy, or autonomic...

P Prithvi Raj Molly Johnston

A nerve block facility where regional anesthesia and advanced interventional techniques are performed should provide a comfortable and relaxing area for patients who are scheduled for nerve blocks. Adequate space, equipment, and comfortable environment are imperative to ensure proper preparation and care of the patient undergoing such procedures. Radiologic localization is indicated when difficulty is anticipated because of poor landmarks or anatomic anomalies, when deep nerves or plexuses are...

Paravertebral Blockade

Paravertebral local anesthetic administration may provide postoperative pain relief by simultaneous somatic and visceral neural blockade and may provide a small reduction in the catecholamine, glucose, and cortisol response to cholecystectomy. 2 The majority of data that demonstrate that regional anesthesia with local anesthetics may modify the surgical stress response come from studies in which epidural local anesthetics were used.12 12 These studies also document that most of the classic...

Pca

Blood pressure, ECG, pulse oximetry, fluoroscopy, CT scan, respiratory function, neurologic status evaluation CT, Computed tomography ECG, electrocardiogram PCA, patient-controlled anesthesia. Modified from Lake CL, Hines RL, Blitt CD Clinical Monitoring Practical Applications for Anesthesia and Critical Care. Philadelphia, WB Saunders, 2001. According to the World Health Organization (WHO), management of cancer pain is principally obtained with opioids however, 10 to 20 of patients with...

Perineal Pain

The differential diagnosis of perineal pain associated with primary or metastatic tumor is extensive. Pain of neuropathic origin may occur from invasion of the lumbar spinal cord, spinal roots, sacral plexus, and individual peripheral nerves. Phantom rectal pain has also been described. 11861 The perineum consists of the area between the ischial tuberosities, extending from the pubis to the coccyx. The area is divided into two triangles, which are the urogenital triangle anteriorly and the anal...

Permanent Implantation

Regardless of the technique used, if a patient with a simple pain pattern (e.g., pain in one leg) is being treated, placement of a single array of electrodes is useful for a permanent system. This can be accomplished either through a catheter-type electrode that has four or eight contacts or through an open incision and laminotomy ( Figs. 37-1 and 37-2 ). With laminotomy, a plate-type electrode is placed. Again, this can have four or eight contacts. The catheter-type electrode is easier to...

Preanesthesia Evaluation

Preoperative evaluation of the patient is extremely important because many ophthalmic patients are elderly and in poor health. They may have advanced coronary artery disease, hypertension, peripheral vascular disease, diabetes, renal insufficiency, arthritis, or chronic obstructive lung disease, and they may be receiving multiple medications. Many anesthesiologists are reluctant to administer general anesthetics to ophthalmic patients who are in poor general health, which may encourage the use...

Preparation Of The Patient

While these injections are being performed, systemic complications such as generalized convulsions or respiratory or cardiovascular depression may occur. These complications are rare13 but, if not handled promptly and appropriately, can result in a fatal outcome. Thus, before performing a block, adequate intravenous access should be obtained. Placing an intravenous catheter in an elderly patient may be difficult because the veins Figure 24-4 The extraocular muscles, which can move the eye in...

Prognostic Value Of Muscle Twitch For Block Success

Raj Infraclavicular

During electrical stimulation to locate nerves, it was observed by Montgomery and others1111 that after good muscle contraction was obtained, 2 mL of local anesthetic would diminish or abolish that muscle contraction within 10 seconds in successful blocks ( Fig. 17-3 ). Conversely, if the muscle contraction did not diminish within 10 seconds, the block usually was patchy and inadequate ( Fig. 17-4 ). It appeared that a 2-mL test dose would indicate the success of the block if muscle twitch was...

Pudendal Nerve Block

A pudendal nerve block is indicated for perineal surgery, such as obstetric vaginal procedures (vaginal delivery, forceps delivery) and for hemorrhoidectomy. To Cutaneous Branches of the Superficial Peroneal Nerve Great Saphenous Vtein -Mad. Malleolus- Figure 20-56 Transverse section through the ankle showing the needle placement for blocking the superficial and deep peroneal, saphenous, sural, and posterior tibial nerves. (From Raj PP Clinical Practice of Regional Anesthesia. New York,...

References

Kehlet H Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 78 606, 1997. 2. Desborough JP The stress response to trauma and surgery. Br J Anaesth 85 109, 2000. 3. Hasselgren P-O. Catabolic response to stress and injury Implications for regulation. World J Surg 24 1452, 2000. 4. Hill AG Initiators and propagators of the metabolic response to injury. World J Surg 24 624, 2000. 5. Wilmore DW Metabolic response to severe surgical illness Overview. World J...

Renal And Perirenal Surgery

The kidney can be approached through lumbar, thoracoabdominal, or transabdominal incisions. For the lumbar approach, the patient is in the lateral position with the operative side up and the kidney elevator beneath the 12th rib. Flexion of the table causes the muscles of the loin to be taut, and elevation of the kidney bridge makes more space available between the 12th rib and the ilium when the incision is made ( Fig. 24-21 ). This position may be uncomfortable for a conscious patient but may...

Results

Questionnaires were posted to 61 institutions. Twenty-six were returned by the second week of January 1999, giving a response rate of 42.6 . One letter sent to Iraq was returned with the word service suspended (presumably, the postal service). Eighteen university teaching hospitals, six state general hospitals, one provincial hospital, and one urban private hospital responded from India, China, Malaysia, Sri Lanka, Myanmar, Taiwan, Korea, Thailand, Papua New Guinea, Hong Kong, Singapore, and...

Side Effects Of Vasoconstrictors

Vasoconstrictors are added to local anesthetics to increase the duration of action of the block and to serve as intravascular markers. The two most common vasoconstrictors are epinephrine and phenylephrine. Epinephrine is usually added to the local anesthetic in a dosage of 5 g mL, or 1 200,000. This can be achieved by adding 0.1 mL of a 1 1000 solution of epinephrine to 20 mL of local anesthetic. Phenylephrine is typically added to local anesthetics in a 1 20,000 concentration. Dosages of...

Single Injection Of Epidural Analgesics

Berde used daily single-shot injections of caudal morphine in a 5-month-old infant with neuroblastoma and massive abdominal distension.1 The team had feared that systemic opioids would precipitate respiratory failure. They did not place a neuraxial catheter because of the child's profound neutropenia and short expected lifespan (days). Outcomes included the following 1. Improved respiratory mechanics (less grunting and better arterial Pco2 ). 2. More alertness and better interaction with...

Spinal Analgesia

Spinal analgesia refers to the use of opioids and analgesic concentrations of local anesthetics to produce pain relief by either intrathecal or epidural administration. The epidural route has been used much more extensively for postoperative pain control. Reasons include popularity of the technique along with, or in combination with, light general anesthesia during surgery willingness to leave an epidural catheter in place for extended periods to maintain analgesia familiarity with...

Supraclavicular Plumb Bob Technique

The patient's head is turned slightly to the contralateral side. The patient is asked to raise the head slightly off the table so that the lateral border of the clavicular head of the sternocleidomastoid muscle can be identified as it inserts onto the clavicle. This point is marked as the entry point. After skin preparation, an insulated needle is inserted at the entry site as if it were a weight (plumb bob) under gravitational pull (i.e., in a parasagittal direction) ( Fig. 2026 ). If...

Surgery On The Lower Third Of The Face

Surgery of the lower third of the face requires a block of the mandibular nerve. Mandibular nerve block can be done anywhere from the foramen ovale to the mental foramen for surgery of the mandible, lower teeth, or superficial operations of the mandibular region. This block is useful for minor reduction of mandibular fractures or extraction of teeth. Dentists prefer intraoral routes, whereas anesthesiologists commonly use the extraoral route at the coronoid notch. The first two divisions of the...

Surgery On The Middle Third Of The Face

Anesthesia of the maxillary nerve and its subdivisions is indicated for dental pain management and surgical procedures. By using techniques of local infiltration, nerve blocks, and field blocks, these areas can quite easily be anesthetized. The following blocks can be performed on the maxillary nerve and its following branches (1) supraperiosteal, (2) infraorbital, (3) nasopalatine, (4) greater palatine, and (5) posterosuperior alveolar. Anatomy. The maxillary (second) division of the...

Surgery On The Upper Third Of The Face

The trigeminal nerve is the largest of the cranial nerves. It contains both sensory and motor fibers ( Fig. 24-13 ). General somatic afferent fibers convey both exteroceptive and proprioceptive impluses ( Fig. 24-14 ). Somatic exteroceptive impulses carried by the trigeminal nerve include touch, pain, and thermal senses. These impulses are transmitted from the skin of the face and forehead, the mucous membranes of the nasal surfaces and oral cavity, the teeth, the anterior two thirds of the...

Surgical Procedures

The vast majority of ophthalmic operations, whether involving the anterior segment of the eye (e.g., cataract extraction and corneal transplantation), the posterior segment of the eye (e.g., retinal detachment, vitrectomy, scleral buckling), or the ocular adnexa (e.g., strabismus, ptosis surgery), as well as evisceration of the eye, can all be done under regional anesthesia. Very lengthy procedures, however, may constitute a relative contraindication to regional anesthesia because the patient...

Table 172 Distancevoltage Relationship

And the minimal voltages needed to produce motor stimu lation at various distances from the exposed nerve were recorded. Table 17-2 shows the voltage needed to stimulate the motor fibers at varying distances. The second question Raj and coworkers113 asked was How can one tell that the needle tip is on the nerve His group recorded the twitch height of contracting muscles while performing infraclavicular blocks with a PNS. In Figure 172 , it appears that as the needle tip nears the nerve, the...

Table 184 Total Dose And Maternal And Fetal Blood Levels Of Bupivacaine

Semilateral Position

CSE block Group A (Mean s.e. mean) Epidural block Group B (Mean s.e. mean) Maternal blood concentration (rig g) From Rawal N, Schollin J, Wesstrom G Epidural versus combined spinal epidural block for cesarean section. Acta Anesthesiol Scand 32 6166,1988 *Mean total dose of 8 mg for spinal block in addition to mean total dose of 32.0 mg for epidural block. *Mean total dose of 8 mg for spinal block in addition to mean total dose of 32.0 mg for epidural block. Figure 18-13 This figure shows the...

Table 61 Commonly Identified Dimensions Of Quality Of Life

From Cella DF, Tulsky DS Measuring quality of life today Methodologi cal aspects. Oncology 4 29 38, 1990. A comprehensive view of palliative medicine requires that QOL be considered with regard to the specific disease and the treatment of symptoms. This involves not only patients in advanced stages of the disease but also those in the early stages, when more aggressive therapies are usually performed. Calman described QOL in relation to the size of the gap between an individuals expectations...

Table 97 Categories Of Local Anesthetic Toxic Reactions

Figure 9-22 Location and chemical structure of sodium channels in peripheral axons. A, Axon drawing is included for orientation. B, Schematic drawings of lipid bilayer. C, Working hypothesis for a channel. The channel is drawn as a transmembrane macromolecule with a hole through the center. The external surface of the molecule is glycosylated. The functional regions, selectivity filter, gate, and voltage sensor are deduced from voltage clamp experiments and are beginning to be charted by...

The Birth of Regional Anesthesia

The decisive step in the development of regional anesthesia was taken by C. Koller (1858-1944), a young Viennese physician who had been working for some time in S. Stricker's experimental pathology laboratory, and who also devoted himself to the study of ophthalmology ( Fig. 1-5 ). Both these circumstances were of importance, because Koller became familiar with experimental methods and also had personal experience with the need for using local anesthesia when operating on the eyes. He had...

The First Spinal Anesthetic

James Corning ( Fig. 2-1 ), a New York City neurologist, heard in 1885 of the local anesthetic properties of cocaine, which had been discovered by the Viennese ophthalmologist, Carl Koller, in 1884. 3 Corning began a series of experiments to determine whether local medication of the spinal cord was within the range of practical achievement. He reasoned that cocaine might be the ideal agent to treat neurologic disease if applied in the vicinity of the venae spinales of the cord. If it were...

Thoracic Sympathectomy T23

Segmental radiation pain, with sympathetic burning component at upper dorsal levels Complex regional pain syndrome (CRPS) type I (upper limb) Hyperhidrosis of upper limbs Intractable coronary pain and tachyarrhythmias SMK 10-cm needle, 23-G active tip, 0.5 cm 10-cm curved blunt Racz-Finch needle with 10-mm active tip and introducer needle Patient is in a prone decubitus position, with pillow under the chest Superficial intravenous sedation Local anesthesia of the zone to be incised Finger...

Tibial Nerve Block

The tibial nerve lies under the flexor retinaculum at the midpoint between the medial malleolus and calcaneus. Figure 20-53 Saphenous nerve block at the knee. The needle is placed at the level of the patella on the medial condyle of the femur between the tendons of the sartorius muscle and the gracilis muscle. (From Raj PP Clinical Practice of Regional Anesthesia. New York, Churchill Livingstone, 1991, p 321.) Figure 20-53 Saphenous nerve block at the knee. The needle is placed at the level of...

Time in Regional Anesthesia

The time spent in the healthcare structures, represented by the period spent in the operating room, the ICU, or the ward, constitutes one of the most important variables to study in an examination of the economic impact of any new anesthesia procedure. This is because the major economic impact of the healthcare assistance is made not by materials and equipment but especially by the personnel's work, which needs to be well organized. In the literature, no studies exist that have dealt with this...

Trial Stimulation

When the needle enters the foramen ovale, the patient is ready for trial stimulation. In many patients, the third division is affected. The mandibular nerve has some motor fibers. If the nerve is stimulated at 2 Hz with 0.1 to 1.5 volts, the muscle contraction of the lower mandible is observed. This is also a method for verifying that the needle has passed through the foramen ovale and is in the retrogasserian rootlets. If the first and second divisions are affected, there should be no motor...

Upper Extremity Surgery

Basically, the upper extremity can be divided into four regions (1) the shoulder, (2) the elbow, (3) the forearm, and (4) the wrist and hand. The shoulder region ( Fig. 24-23 ) is innervated by C3 to C6 nerve roots. The C3 and C4 nerves are derived from the cervical plexus and innervate the skin on top of the shoulder. The rest of the skin and deeper tissues Figure 24-23 Dermatomal innervation, block required for shoulder anesthesia. (From Raj PP Ancillary measures to assure success. Reg Anesth...

Vertebroplasty And Kyphoplasty

More than 200,000 symptomatic osteoporotic vertebral compression fractures (VCFs), primarily in elderly women, occur annually in the United States. These fractures, which are associated with substantial pain and disability, typically lead to more than 100,000 hospital admissions for extended rehabilitation stays. After the first compression fracture, the average risk increases fivefold for the second. The pain lasts on average 4 to 6 weeks it typically localizes one or two levels below the...

Volume And Baricity Of Local Anesthetic Drugs

There appears to be considerable debate about the optimal volume and baricity of local anesthetic solutions that are needed to provide spinal anesthesia. Several studies have been published to determine the most effective volume and type of local anesthetic drugs that can ensure adequate spinal anesthesia for various types of surgery. Table 7-1 shows a summary of studies that have investigated the extent of sensory and motor blocks with different volumes and types of local anesthetic agents....

Intravenous Local Anesthetics

The effect of intravenously administrated local anesthetics on postoperative pain and endocrine metabolic responses is minimal.13 PERIPHERAL INFILTRATION INSTILLATION OF LOCAL ANESTHETICS IN THE WOUND Application of local anesthetics at the wound site may modify the injury response by a dual mechanism inhibition of an afferent neural stimulus and a reduction in afferent firing because of the anti-inflammatory effects of local anesthetics.13 Although instillation or infiltration of the wound...

Efficacy Of Peripheral Nerve Block

By interrupting neural input into the CNS, peripheral nerve blocks may also minimize the surgical stress response after surgery. For instance, patients receiving regional anesthesia (interscalene block) for shoulder surgery have significantly lower serum epinephrine levels in the immediate postoperative period.122 Unlike those receiving general anesthesia, patients receiving regional anesthesia (retrobulbar block) for cataract surgery do not have a significant increase in catecholamines,...

Table 463 Overview Of Immune Function

Preservation of lymphocyte and natural killer cell activity I Cell-mediated (T lymphocyte) and humoral (immunoglobulin) response Possible potentiation by stress response Cortisol and epinephrine may reduce neutrophil chemotaxis and decrease NK cell activity. 3 Also, perioperative administration of morphine diminishes NK cell and lymphocyte activity. In animal studies, morphine induces a decrease in lymphoid organ weight and inhibits ability to combat active infections. Immunosuppression is not...