Analysis of peak magnitude and duration of analgesia produced by local anesthetics injected into sympathetic ganglia of complex regional pain syndrome patients. A randomized trial of the canalith repositioning procedure. Paracervical block in incomplete abortion using manual vacuum aspiration: randomized clinical trial. Ultrasonographic guidance improves the success rate of interscalene brachial plexus blockade. Monitoring of neuromuscular blockade at the P6 acupuncture point reduces the incidence of postoperative nausea and vomiting. A prospective, double-blind, randomized study on the use of a topical anesthetic, vasoconstrictor, and placebo during transnasal flexible fiberoptic endoscopy. Axillary brachial plexus blockade: an evaluation of three techniques. Brachial plexus anaesthesia in children: lateral infraclavicular vs axillary approach. Ultrasonographic guidance improves sensory block and onset time of three-in-one blocks.
Pain-relieving effects of lidocaine/bupivicaine local anesthetic (LA) and saline (S) block of sympathetic ganglia (stellate block, 4 patients; lumbar sympathetic block, 3 patients) were compared in 7 complex regional pain syndrome (CRPS) patients on a double-blind crossover basis to evaluate the diagnostic and therapeutic value of local anesthetic sympathetic blocks.
                Patients rated their pain on a visual analog scale before and after blocks and were tested for mechanical allodynia one-half hour after blocks. Thereafter, they rated their pain intensity in diaries four times a day for 7 days. Each patient received two blocks, S and LA, and served as his own control.
                Both S and LA injections of sympathetic ganglia produced large reductions in pain intensity in 6 of 7 patients 30 minutes after block. These large reductions were accompanied by the reversal of mechanical allodynia in both S and LA. The mean difference between initial peak reduction in pain intensity produced by saline (68.7%) and active local anesthetic (74.4%) did not approach statistical significance. In striking contrast, the mean duration of pain relief was reliably longer in the case of LA (3 days, 18 hours) as compared with S ( 19.9 hours), a difference that occurred in all 7 patients. In a larger sample of 41 CRPS patients, signs of sympathetic efferent blockade, including Homer' s syndrome or skin surface temperature change, were not predictive of initial peak magnitude of pain relief from sympathetic blockade but were predictive of duration of pain reduction.
                The combination of these results provides evidence that duration of pain relief is affected by injection of local anesthetics into sympathetic ganglia. These results indicate that both magnitude and duration of pain reduction should be closely monitored to provide optimal efficacy in procedures that use local anesthetics to treat CRPS. To compare the effectiveness and complications of our adaptation of the canalith repositioning procedure (CRP) with the expectation treatment for benign paroxysmal positional vertigo.
                A randomized, controlled trial in the setting of a neurotological clinic in Thailand.
                Fifty-eight patients with posterior benign paroxysmal positional vertigo were randomly assigned to treatment and control groups using a block of four. The treatment group was treated with the modified CRP technique until the nystagmus disappeared. A mastoid oscillator was not used, nor were any instructions given for patients after the maneuver. Both groups recorded the daily grading of symptoms and the amount of anti-vertiginous drugs (cinnarizine) taken. Objective and subjective assessments were made weekly until the nystagmus disappeared or until 4 weeks had passed since treatment began.
                The rates of effectiveness of CRP treatment and the control treatment for benign paroxysmal positional vertigo were 75.9% and 48.2%, respectively. There was a significant difference in the treatment outcomes of the CRP and control groups (P =.03). The CRP group used significantly fewer drugs than the control group (P =.001). Complications in the CRP group, such as lateral canalithiasis and fainting, were observed in 13.8% of the patients.
                The CRP was more effective than the expectation treatment for benign paroxysmal positional vertigo insofar as it provided faster recovery and required less dependence on medication. Complications of CRP were limited to 13.8% of patients. To estimate the effectiveness of paracervical block in controlling pain among women treated with manual vacuum aspiration for an incomplete abortion
                A randomized clinical trial was conducted at Nuestra Señora de Altagracia, a maternal and perinatal referral hospital in the Dominican Republic. The sample size was based on a clinical difference of 1.5 points in the level of pain measured with the visual analog scale using 90% power and a sampling error of 0.04. Women who were at 12 weeks of gestation or less with an incomplete abortion were eligible to participate. They were randomly assigned to receive either the standard treatment of care (manual vacuum aspiration for uterine evacuation with psychological support but no paracervical block) or manual vacuum aspiration treatment with psychological support and paracervical block using 1.0% lidocaine. Patients with active infections, severe illnesses, psychiatric disorders, or allergies to lidocaine were excluded. Intraoperative pain as reported by the women and as documented by an external observer was measured.
                Although the paracervical block technique used showed a slight reduction in severe pain, there were no clinically or statistically significant differences in intraoperative pain between the 2 groups (relative risk 0.73; 95% confidence interval 0.43, 1.23) with 50% of all patients registering 7 or higher score on a visual analog pain scale of 0-10. However, statistically significant differences were found in each group when comparing the level of preoperative and intraoperative pain described by the patient (P <.001). The manual vacuum aspiration technique and the paracervical block were not accompanied by complications.
                The paracervical block technique used in this study along with psychological support was comparable with pain control using psychological support alone; neither pain management regimen provided sufficient pain control. It is recommended that randomized comparative studies be designed to determine the effectiveness of other paracervical block techniques and the efficacy of the use of analgesics in patients suffering from incomplete abortion treated with manual vacuum aspiration. The use of ultrasonography in regional anesthetic blocks has rapidly evolved over the past few years. It has been speculated that ultrasound guidance might increase success rates and reduce complications. The aim of our study is to compare the success rate and quality of interscalene brachial plexus blocks performed either with direct ultrasound visualization or with the aid of nerve stimulation to guide needle placement.
                A total of 160 patients (American Society of Anesthesiologists physical status classification I-III) scheduled for trauma-related upper arm surgery were included in this randomized study and grouped according to the guidance method used to deliver 20 mL of ropivacaine 0.75% for interscalene brachial plexus blockade. In the ultrasound group (n = 80), the brachial plexus was visualized with a linear 5 to 10 MHz probe and the spread of the local anesthetic was assessed. In the nerve stimulation group (n = 80), the roots of the brachial plexus were located using a nerve stimulator (0.5 mA, 2 Hz, and 0.1 millisecond bandwidth). The postblock neurologic assessment was performed by a blinded investigator.
                Sensory and motor blockade parameters were recorded at different points of time. Surgical anesthesia was achieved in 99% of patients in the ultrasound vs 91% of patients in the nerve stimulation group (P < .01). Sensory, motor, and extent of blockade was significantly better in the ultrasound group when compared with the nerve stimulation group.
                The use of ultrasound to guide needle placement and monitor the spread of local anesthetic improves the success rate of interscalene brachial plexus block. Electrical stimulation of the P6 acupuncture point reduces the incidence of postoperative nausea and vomiting (PONV). Neuromuscular blockade during general anesthesia can be monitored with electrical peripheral nerve stimulation at the wrist. The authors tested the effect of neuromuscular monitoring over the P6 acupuncture point on the reduction of PONV.
                In this prospective, double-blinded, randomized control trial, the authors investigated, with institutional review board approval and informed consent, 220 women undergoing elective laparoscopic surgery anesthetized with fentanyl, sevoflurane, and rocuronium. During anesthesia, neuromuscular blockade was monitored by a conventional nerve stimulator at a frequency of 1 Hz over the ulnar nerve (n = 110, control group) or over the median nerve (n = 110, P6 group) stimulating at the P6 acupuncture point at the same time. The authors evaluated the incidence of nausea and vomiting during the first 24 h.
                No differences in demographic and morphometric data were found between both groups. The 24-h incidence of PONV was 45% in the P6 acupuncture group versus 61% in the control group (P = 0.022). Nausea decreased from 56% in the control group to 40% in the P6 group (P = 0.022), but emesis decreased only from 28% to 23% (P = 0.439). Nausea decreased substantially during the first 6 h of the observation period (P = 0.009). Fewer subjects in the acupuncture group required ondansetron as rescue therapy (27% vs. 39%; P = 0.086).
                Intraoperative P6 acupuncture point stimulation with a conventional nerve stimulator during surgery significantly reduced the incidence of PONV over 24 h. The efficacy of P6 stimulation is similar to that of commonly used antiemetic drugs in the prevention of PONV. The purpose of the present study was to compare patient comfort levels following administration of a topical anesthetic, vasoconstrictor, placebo, or nothing to the nasal mucosa prior to flexible fiberoptic transnasal endoscopy. Using a prospective, double-blind, randomized design, 152 consecutive patients were randomly assigned to receive a topical anesthetic (N = 54), vasoconstrictor (N = 50), or placebo (N = 48). No significant differences were found among the three variables. An additional 50 consecutive patients had endoscopy performed without administration of any substance to the nares, and no significant differences were found among the four variables (N = 202). It was concluded that speech-language pathologists can perform independent and comfortable transnasal endoscopy without administration of any substance to the nasal mucosa. Flexible fiberoptic endoscopy, however, should be performed by experienced clinicians with care taken to examine visually the patency of both nares for ease and comfort of scope insertion. Surgical procedures to the distal humerus, elbow, and proximal forearm are ideally suited to regional anesthetic techniques. Selection of the preferred approach is determined by the innervation of the surgical site, the risks of regional anesthesia-related complications, and the preference and experience of the anesthesiologist. The axillary approach to the brachial plexus is the most commonly used because of its ease of performance, patient acceptance, safety, and reliability, particularly for hand and forearm surgery. Nerve location technique does not affect success rate with the supraclavicular and interscalene approaches but it does with axillary approaches. The purpose of this study was to evaluate three techniques of plexus identification in axillary blockade. Sixty-nine American Society of Anesthesiologists grade I to II patients who had undergone orthopedic or traumatological surgical procedures on the upper extremity during a period of 1 year were chosen. After premedication, patients were divided randomly into three groups according to the technique of plexus identification. Group A (n = 23) consisted of those treated with the Winnie technique; group B (n = 23) consisted of those treated with the transarterial technique; group C (n = 23) consisted of those treated with the combination technique. Axillary blockade performed using the combined technique had higher a success rate than blockade performed with the transarterial and Winnie techniques. Our results suggest that all three techniques are reliable for axillary blockade. But the onset, complete blockade time, and quality of analgesia were better with the combined technique than with the transarterial and Winnie techniques. Brachial plexus blockade is a well-established technique in upper-limb surgery. In paediatric patients, the axillary route is usually preferred to infraclavicular approaches because of safety considerations. Recent reports on a lateral infraclavicular approach offering greater safety in adults prompted us to perform a prospective randomized study to assess the analgesic efficacy of axillary vs lateral vertical infraclavicular brachial plexus (LVIBP) blocks in paediatric trauma surgery.
                Forty paediatric trauma patients (ASA physical status I and II, age range 1-10 years) scheduled for forearm or hand surgery were randomly assigned to either axillary brachial plexus (ABP group) or LVIBP group blocks using 0.5 ml.kg(-1) ropivacaine 0.5%. Sensory blockade was evaluated by a visual analogue score and Vester-Andersen's criteria, the distribution of sensory and motor blockade was evaluated by a simplified pinprick test and motor tests.
                In the LVIBP group, Vester-Andersen's criteria were met by 100% of children, compared with 80% in the ABP group (P=0.035). Based on all assessable children, sensory blockade in the primary sensory regions of various nerves was significantly more effective in the LVIBP group (axillary: P < 0.0001; musculocutaneous: P=0.002; medial brachial cutaneous; P=0.008). Motor blockade was also significantly more effective (axillary: P < 0.0001; musculocutaneous: P=0.003). No major complications were observed in either group.
                We conclude that LVIBP blocks can be safely performed in children and that they add to the spectrum of sensory and motor blockade seen with the axillary approach. The use of ultrasound reduces the onset time, improves the quality of sensory block, and minimizes the risks associated with the supraclavicular approach for brachial plexus and stellate ganglion blockade. The present study was designed to evaluate whether ultrasound also facilitates the approach for 3-in-1 blocks. Forty patients (ASA physical status II or III) undergoing hip surgery after trauma were randomly assigned to two groups. In the ultrasound (US) group, 20 mL bupivacaine 0.5% was administered under US guidance, whereas in the control group, the same amount and concentration of local anesthetic was administered with the assistance of a nerve stimulator (NS). After US- or NS-based identification of the femoral nerve, the local anesthetic solution was administered, and the distribution of the local anesthetic solution was visualized and recorded on videotape in the US group. The quality and the onset of the sensory block was assessed by using the pinprick test in the central sensory region of each of the three nerves and compared with the same stimulation on the contralateral leg every 10 min for 60 min. The rating was performed using a scale from 100% (uncompromised sensibility) to 0% (no sensory sensation). Heart rate, noninvasive blood pressure, and oxygen saturation were measured at short intervals for 60 min. The onset of sensory blockade was significantly shorter in Group US compared with Group NS (US 16 +/- 14 min, NS 27 +/- 16 min, P < 0.05). The quality of the sensory block after injection of the local anesthetic was also significantly better in Group US compared with Group NS (US 15% +/- 10% of initial value, NS 27% +/- 14% of initial value, P < 0.05). A good analgesic effect was achieved in 95% of the patients in the US group and in 85% of the patients in the NS group. In the US group, visualization of the cannula tip, the femoral nerve, the major vessels, and the local anesthetic spread was possible in 85% of patients. Incidental arterial puncture (n = 3) was observed only in the NS group. We conclude that an US-guided approach for 3-in-1 block reduces the onset time, improves the quality of the sensory block and minimizes the risks associated with this regional anesthetic technique. Implications: The onset time and the quality of a regional anesthetic technique for the lower extremity is improved by ultrasonographic nerve identification compared with older techniques.
This systematic review revealed the scarcity of published evidence to support the use of local anesthetic sympathetic blockade as the 'gold standard' treatment for CRPS. The two randomized studies that met inclusion criteria had very small sample sizes, therefore, no conclusion concerning the effectiveness of this procedure could be drawn. There is a need to conduct randomized controlled trials to address the value of sympathetic blockade with local anesthetic for the treatment of CRPS.