Brachial Plexus Block

A 22-year-old male who was affected by epidermolysis bullosa (EB) and xeroderma pigmentosa (with structural and pathological changes that preclude orotracheal intubation) underwent right upper extremity amputation and ipsilateral axillary lymphadenectomy. The patient was operated without intubation, thereby assuring an optimal state of acute postoperative pain control by regional anesthesia. Intravenous administration of ketamine and remifentanil plus low-dose sevoflurane resulted in anesthesia with spontaneous breathing by the patient. Moreover, the intraoperative brachial plexus nerve block before amputation followed by positioning of an epidural catheter to deliver continuous infusion of local anesthetics close to the cut nerves during surgery obtained a very good level of acute postoperative pain control.

Reference:

Anesthetic management for right upper extremity amputation due to recidivous cutaneous carcinoma and acute postoperative pain control in patients affected by epidermolysis bullosa.

Meola S, Olivieri M, Mirabile C, Mastrandrea P.

Minerva Anestesiol. 2010 Feb;76(2):144-7. Epub 2009 Nov 11.

In this study, we investigated the efficacy of patient-controlled regional analgesia for outpatients undergoing moderately painful orthopedic surgery of the shoulder. Preoperatively, patients (n = 20) received an interscalene nerve block and perineural catheter. Postoperatively, patients were discharged home with both oral opioids and a portable infusion pump delivering either 0.2% ropivacaine or 0.9% saline, determined randomly in a double-blinded manner. Daily end points included pain scores, opioid use and side effects, sleep quality, and technique complications. Ropivacaine (n = 10) infusion significantly reduced pain compared with saline (n = 10) infusion. The average pain at rest (scale: 0-10) on postoperative day 1 (median, 25th-75th percentiles) was 4.8 (4.0-5.0) for the saline group, versus 0.0 (0.0-2.0) for the ropivacaine group (P < 0.001). Oral opioid use and related side effects were also significantly decreased in the ropivacaine group. On postoperative day 1, median tablet consumption was 8.0 (6.5-9.5) and 0.5 (0.0-1.0) for the saline and ropivacaine groups, respectively (P < 0.001). Sleep disturbance scores were nearly threefold greater on the first postoperative night for patients receiving saline (P = 0.013). We conclude that after moderately painful orthopedic surgery of the shoulder, ropivacaine infusion using a portable infusion pump and an interscalene perineural catheter at home decreased pain, opioid use and related side effects, and sleep disturbances. This randomized, double-blinded, placebo-controlled study demonstrated that ropivacaine, infused with a portable infusion pump via an interscalene perineural catheter for 3 days at home, significantly decreased postoperative pain after orthopedic surgery of the shoulder. In addition to providing potent analgesia and increasing patient satisfaction, perineural infusion decreased opioid requirements and their associated side effects.

Reference:

Continuous interscalene brachial plexus block for postoperative pain control at home: a randomized, double-blinded, placebo-controlled study.

Ilfeld BM, Morey TE, Wright TW, Chidgey LK, Enneking FK.

Anesth Analg. 2003 Apr;96(4):1089-95, table of contents.