Regional Anesthesia and Pain Medicine • Volume 40, Number 2, March-April 2015
Letters to the Editor 4. Ishiguro S, Yokochi A, Yoshioka K, et al. Technical communication: anatomy and clinical implications of ultrasound-guided selective femoral nerve block. Anesth Analg. 2012;115: 1467–1470. 5. Jaeger P, Zaric D, Fomsgaard JS, et al. Adductor canal block versus femoral nerve block for analgesia after total knee arthroplasty: a randomized, double-blind study. Reg Anesth Pain Med. 2013; 38:526–532. 6. Hanson NA, Allen CJ, Hostetter LS, et al. Continuous ultrasound-guided adductor canal block for total knee arthroplasty: a randomized, double-blind trial. Anesth Analg. 2014;118: 1370–1377.
Block Awake or Asleep Still a Conundrum? Accepted for publication: December 9, 2014. To the Editor: read with interest the report from the Pediatric Regional Anesthesia Network by Taenzer et al1 regarding pediatric regional block complications. Performance of regional blocks in the awake versus anesthetized or heavily sedated state is a controversial topic in regional anesthesia. This report supports the safety of regional blocks in anesthetized children, which all pediatric anesthesiologists will agree with and in fact is paramount for the safe performance of pediatric regional anesthesia. Concerns of neural damage in anesthetized adults cannot be warranted. Currently, there are no specific or sensitive indicators of nerve injury. Subjective symptoms of neural injury such as pain and paresthesia are unreliable even in awake patients.2 Evidence shows that intraneural injection occurs quite frequently even in experienced hands, not invariably resulting in nerve damage.3 Perception of high injection pressures, too, is unreliable and can be confounded by needle make and design.4 With the use of ultrasound, high injection pressures should prompt the clinician to refocus on needle tip position. I suggest that block performance in adults should be individualized to the particular patient with emphasis on the risk-benefit ratio. Heavy sedation/anesthesia should be offered to anxious patients as well as for procedures near critical structures to prevent unintentional movement. Trainee anesthesiologists, too, would benefit from block performance in such patients by the provision of precious time and a still target, thereby improving relative safety.
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I do not entirely agree with the comments in the related editorial by Dalens and Albert5 that “individual perception of sound decisions is no longer deemed appropriate.” The human-factors movement recognizes the importance of “gut feeling” borne out of years of experience in the medical field, suggesting that it is something that should be valued.6 Jayaprakash J. Patil, MD Department of Anesthesiology and Intensive Care Airedale General Hospital Steeton, United Kingdom
The author declares no conflict of interest. REFERENCES 1. Taenzer AH, Walker BJ, Bosenberg AT, et al. Asleep vs. awake—does it matter? Pediatric regional block complications by patient state. A report from the Pediatric Regional Anesthesia Network (PRAN). Reg Anesth Pain Med. 2014; 39:279–283. 2. Cohen JM, Gray AT. Functional deficits after intraneural injection during interscalene block. Reg Anesth Pain Med. 2010;35:397–399. 3. Bigeleisen PE. Nerve puncture and apparent intraneural injection during ultrasound-guided axillary block does not invariably result in neurologic injury. Anesthesiology. 2006;105: 779–783. 4. Patil JJ, Ford S, Egeler C, Williams DJ. The effect of needle dimensions and infusion rates on injection pressures in regional anaesthesia needles: a bench-top study. Anaesthesia. 2015;70:183–189. 5. Dalens B, Albert N. Asleep or awake: rethinking “safety.” Reg Anesth Pain Med. 2014;39:267–268. 6. Boyd G. Clinical judgement and the emotions. Intern Med J. 2014;44:704–706.
Wrong-Side Nerve Blocks Can Be Avoided Accepted for publication: December 9, 2014. To the Editor: n response to the letter by Lie and Letheren,1 I would like to draw readers’ attention to a care bundle developed at our hospital to reduce wrong-side nerve blocks. In recent years, many new safety initiatives have been introduced in the United Kingdom including the World Health Organization Surgical Safety checklist, the “Stop Before You Block” (SBYB) campaign, and a national incident reporting system.2,3 Despite this, wrong-side blocks continue to occur.
I
Although specifically excluded from the UK list of “never events,”4 a wrongside nerve block should be considered a significant incident, warranting a thorough investigation. They expose the patient to increased risk of adverse effects and complications. When combined with a correctside procedure, there is a higher risk of local anesthetic toxicity from the combined dosage. There is added risk of prolonged immobility, inadequate physiotherapy and mobilization, and longer inpatient stay. Such incidents also suggest system failure and the need to enhance existing safeguards. A number of case reports have described the root causes of such events.5,6 Following this incident, we have introduced a bundle of measures: • Minimize position change during the anaesthetic process. • Perform block prior to a spinal anaesthetic where possible. • Place stimulator electrode on the surgical marking arrow as a further visual confirmation to the side of block. This should happen routinely whether nerve stimulator is to be used or not. • Introduce a “block box.” This consists of an “up-cycled”’ HNS11/12 nerve stimulator plastic box, from which the foam inserts have been removed to allow sterilization. The cover of the block box has an SBYB A4 laminate on it. Any equipment related to the performance of a regional anesthetic is placed in this box before the patient’s arrival. This has the added advantage of ensuring that syringes of clear local anesthetic solution are not in the same location as syringes meant for intravenous administration. At performance of the block, the SBYB check is completed before the box is opened, and the block performed. • Adapt and increase presence of the SBYB campaign poster. Laminated A6 size copies have been attached to the nerve stimulators. Laminated A4 copies have also been attached to front of our ultrasound machines, and the front of the block boxes.
We believe that this bundle adds further barriers to recurrence of wrong-sided blocks, “blinding” the holes in the Swisscheese model. We welcome further discussion.
Priti Kamath, MBBS, BSc, FRCA James Stimpson, FRCA, MRCP Alistair Steel, FRCA, MRCP Anaesthesia Department The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Norfolk, United Kingdom
© 2014 American Society of Regional Anesthesia and Pain Medicine
Copyright © 2015 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine • Volume 40, Number 2, March-April 2015
Letters to the Editor
Benjamin Fox, FRCA Anaesthesia Department Norfolk and Norwich University Hospital Norwich, United Kingdom
The authors declare no conflict of interest.
REFERENCES 1. Lie J, Letheren M. “Wrong side” sticker/dressing to help reduce wrong-sided nerve blocks. Reg Anesth Pain Med. 2014;39:441–442. 2. The Royal College of Anaesthetists, 2010. Stop Before You Block. Available at: http://www.rcoa. ac.uk/standards-of-clinical-practice/wrong-siteblock. Accessed April 25, 2014. 3. Safe Anaesthesia Liaison Group, 2010. Wrong Site Blocks During Surgery. Available at: http://www.aagbi.org/sites/default/files/ SALG_statement_WSB_10_11_10.pdf. Accessed April 25, 2014. 4. NHS England. Never Events Update 2013/14. Available at: http://www.england.nhs.uk/wpcontent/uploads/2013/12/nev-ev-list-1314-clar. pdf. Accessed April 27, 2014. 5. Al-Nasser B. Unintentional side error for continuous sciatic nerve block at the popliteal fossa. Acta Anaesthesiol Belg. 2011;62:213–215. 6. Cohen SP, Hayek SM, Datta S, et al. Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study. Anesthesiology. 2010;112:711–718.
Thoracic Paravertebral Block and Its Effects on Chronic Pain and Health-Related Quality of Life After Modified Radical Mastectomy Accepted for publication: October 30, 2014. To the Editor: e congratulate Karmakar and colleagues1 for their thoughtful study about the importance of postoperative pain relief and chronic pain prevention after breast cancer surgery. Women undergoing breast cancer surgery may benefit from increased attention to protocols promoting enhanced recover after surgery.2 Our department is also striving to improve regional techniques to provide analgesia quality after breast cancer surgery. We think the serratus-intercostal plane block3 could become an effective alternative to paravertebral block. Although clinical trials are needed, preliminary published studies are promising.
W
FIGURE 1. The picture shows a 100 mm 21G needle inserted with an in‐plane approaching the mid-axillary line in a woman during the serrato‐intercostal ultrasound block performance and corresponding ultrasound image.
In our experience, this new block offers advantages. It can be safely performed under general anesthesia, helping us decrease patients’ anxiety. In contrast to the paravertebral block, these interfascial thoracic blocks can be safely used in the presence of coagulation disorders and have fewer complications, promoting hospital discharge and decreased costs. We can use a single-shot technique or in conjunction with a continuous infuser pump. A remarkable point is how useful the serratusintercostal plane block single shot can be when the axillary area is included in the surgery. We have noticed that if we administer the local anesthetic between the anterior serratus muscle (ASM) and the external intercostal muscle, at the level of the fourth to sixth rib in the midaxillary line in the long axis of the body with an in-plane approach from caudal to cranial direction, instead of the double injection suggested by Blanco et al,4 there is a greater likelihood of good
© 2014 American Society of Regional Anesthesia and Pain Medicine
analgesia in the axillary region and we avoid blocking the long thoracic nerve. The block’s effectiveness in the axillary region is also better than the modified Pecs block because the 3-headed form of the ASM prohibits the correct local anesthetic distribution when administered below the minor pectoral muscle. At this level, in the midaxillary line, the ultrasound image is simple to recognize (Fig. 1): We see subcutaneous tissue, ASM, the ribs with the intercostal muscles, and pleura. The serratus-intercostal plane block is of moderate complexity, reducing performance time. This block helps ensure the distribution of the local anesthetic along the hemithoracic wall in every direction along the interfascial plane, blocking the lateral cutaneous intercostal nerve branches responsible for innervation of the mammary glands. Although paravertebral block is a widely studied regional technique block, we must remain open to new techniques that may be useful when a paravertebral block has failed, is
177
Copyright © 2015 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Letters to the Editor 4. Ishiguro S, Yokochi A, Yoshioka K, et al. Technical communication: anatomy and clinical implications of ultrasound-guided selective femoral nerve block. Anesth Analg. 2012;115: 1467–1470. 5. Jaeger P, Zaric D, Fomsgaard JS, et al. Adductor canal block versus femoral nerve block for analgesia after total knee arthroplasty: a randomized, double-blind study. Reg Anesth Pain Med. 2013; 38:526–532. 6. Hanson NA, Allen CJ, Hostetter LS, et al. Continuous ultrasound-guided adductor canal block for total knee arthroplasty: a randomized, double-blind trial. Anesth Analg. 2014;118: 1370–1377.
Block Awake or Asleep Still a Conundrum? Accepted for publication: December 9, 2014. To the Editor: read with interest the report from the Pediatric Regional Anesthesia Network by Taenzer et al1 regarding pediatric regional block complications. Performance of regional blocks in the awake versus anesthetized or heavily sedated state is a controversial topic in regional anesthesia. This report supports the safety of regional blocks in anesthetized children, which all pediatric anesthesiologists will agree with and in fact is paramount for the safe performance of pediatric regional anesthesia. Concerns of neural damage in anesthetized adults cannot be warranted. Currently, there are no specific or sensitive indicators of nerve injury. Subjective symptoms of neural injury such as pain and paresthesia are unreliable even in awake patients.2 Evidence shows that intraneural injection occurs quite frequently even in experienced hands, not invariably resulting in nerve damage.3 Perception of high injection pressures, too, is unreliable and can be confounded by needle make and design.4 With the use of ultrasound, high injection pressures should prompt the clinician to refocus on needle tip position. I suggest that block performance in adults should be individualized to the particular patient with emphasis on the risk-benefit ratio. Heavy sedation/anesthesia should be offered to anxious patients as well as for procedures near critical structures to prevent unintentional movement. Trainee anesthesiologists, too, would benefit from block performance in such patients by the provision of precious time and a still target, thereby improving relative safety.
I
176
I do not entirely agree with the comments in the related editorial by Dalens and Albert5 that “individual perception of sound decisions is no longer deemed appropriate.” The human-factors movement recognizes the importance of “gut feeling” borne out of years of experience in the medical field, suggesting that it is something that should be valued.6 Jayaprakash J. Patil, MD Department of Anesthesiology and Intensive Care Airedale General Hospital Steeton, United Kingdom
The author declares no conflict of interest. REFERENCES 1. Taenzer AH, Walker BJ, Bosenberg AT, et al. Asleep vs. awake—does it matter? Pediatric regional block complications by patient state. A report from the Pediatric Regional Anesthesia Network (PRAN). Reg Anesth Pain Med. 2014; 39:279–283. 2. Cohen JM, Gray AT. Functional deficits after intraneural injection during interscalene block. Reg Anesth Pain Med. 2010;35:397–399. 3. Bigeleisen PE. Nerve puncture and apparent intraneural injection during ultrasound-guided axillary block does not invariably result in neurologic injury. Anesthesiology. 2006;105: 779–783. 4. Patil JJ, Ford S, Egeler C, Williams DJ. The effect of needle dimensions and infusion rates on injection pressures in regional anaesthesia needles: a bench-top study. Anaesthesia. 2015;70:183–189. 5. Dalens B, Albert N. Asleep or awake: rethinking “safety.” Reg Anesth Pain Med. 2014;39:267–268. 6. Boyd G. Clinical judgement and the emotions. Intern Med J. 2014;44:704–706.
Wrong-Side Nerve Blocks Can Be Avoided Accepted for publication: December 9, 2014. To the Editor: n response to the letter by Lie and Letheren,1 I would like to draw readers’ attention to a care bundle developed at our hospital to reduce wrong-side nerve blocks. In recent years, many new safety initiatives have been introduced in the United Kingdom including the World Health Organization Surgical Safety checklist, the “Stop Before You Block” (SBYB) campaign, and a national incident reporting system.2,3 Despite this, wrong-side blocks continue to occur.
I
Although specifically excluded from the UK list of “never events,”4 a wrongside nerve block should be considered a significant incident, warranting a thorough investigation. They expose the patient to increased risk of adverse effects and complications. When combined with a correctside procedure, there is a higher risk of local anesthetic toxicity from the combined dosage. There is added risk of prolonged immobility, inadequate physiotherapy and mobilization, and longer inpatient stay. Such incidents also suggest system failure and the need to enhance existing safeguards. A number of case reports have described the root causes of such events.5,6 Following this incident, we have introduced a bundle of measures: • Minimize position change during the anaesthetic process. • Perform block prior to a spinal anaesthetic where possible. • Place stimulator electrode on the surgical marking arrow as a further visual confirmation to the side of block. This should happen routinely whether nerve stimulator is to be used or not. • Introduce a “block box.” This consists of an “up-cycled”’ HNS11/12 nerve stimulator plastic box, from which the foam inserts have been removed to allow sterilization. The cover of the block box has an SBYB A4 laminate on it. Any equipment related to the performance of a regional anesthetic is placed in this box before the patient’s arrival. This has the added advantage of ensuring that syringes of clear local anesthetic solution are not in the same location as syringes meant for intravenous administration. At performance of the block, the SBYB check is completed before the box is opened, and the block performed. • Adapt and increase presence of the SBYB campaign poster. Laminated A6 size copies have been attached to the nerve stimulators. Laminated A4 copies have also been attached to front of our ultrasound machines, and the front of the block boxes.
We believe that this bundle adds further barriers to recurrence of wrong-sided blocks, “blinding” the holes in the Swisscheese model. We welcome further discussion.
Priti Kamath, MBBS, BSc, FRCA James Stimpson, FRCA, MRCP Alistair Steel, FRCA, MRCP Anaesthesia Department The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Norfolk, United Kingdom
© 2014 American Society of Regional Anesthesia and Pain Medicine
Copyright © 2015 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine • Volume 40, Number 2, March-April 2015
Letters to the Editor
Benjamin Fox, FRCA Anaesthesia Department Norfolk and Norwich University Hospital Norwich, United Kingdom
The authors declare no conflict of interest.
REFERENCES 1. Lie J, Letheren M. “Wrong side” sticker/dressing to help reduce wrong-sided nerve blocks. Reg Anesth Pain Med. 2014;39:441–442. 2. The Royal College of Anaesthetists, 2010. Stop Before You Block. Available at: http://www.rcoa. ac.uk/standards-of-clinical-practice/wrong-siteblock. Accessed April 25, 2014. 3. Safe Anaesthesia Liaison Group, 2010. Wrong Site Blocks During Surgery. Available at: http://www.aagbi.org/sites/default/files/ SALG_statement_WSB_10_11_10.pdf. Accessed April 25, 2014. 4. NHS England. Never Events Update 2013/14. Available at: http://www.england.nhs.uk/wpcontent/uploads/2013/12/nev-ev-list-1314-clar. pdf. Accessed April 27, 2014. 5. Al-Nasser B. Unintentional side error for continuous sciatic nerve block at the popliteal fossa. Acta Anaesthesiol Belg. 2011;62:213–215. 6. Cohen SP, Hayek SM, Datta S, et al. Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study. Anesthesiology. 2010;112:711–718.
Thoracic Paravertebral Block and Its Effects on Chronic Pain and Health-Related Quality of Life After Modified Radical Mastectomy Accepted for publication: October 30, 2014. To the Editor: e congratulate Karmakar and colleagues1 for their thoughtful study about the importance of postoperative pain relief and chronic pain prevention after breast cancer surgery. Women undergoing breast cancer surgery may benefit from increased attention to protocols promoting enhanced recover after surgery.2 Our department is also striving to improve regional techniques to provide analgesia quality after breast cancer surgery. We think the serratus-intercostal plane block3 could become an effective alternative to paravertebral block. Although clinical trials are needed, preliminary published studies are promising.
W
FIGURE 1. The picture shows a 100 mm 21G needle inserted with an in‐plane approaching the mid-axillary line in a woman during the serrato‐intercostal ultrasound block performance and corresponding ultrasound image.
In our experience, this new block offers advantages. It can be safely performed under general anesthesia, helping us decrease patients’ anxiety. In contrast to the paravertebral block, these interfascial thoracic blocks can be safely used in the presence of coagulation disorders and have fewer complications, promoting hospital discharge and decreased costs. We can use a single-shot technique or in conjunction with a continuous infuser pump. A remarkable point is how useful the serratusintercostal plane block single shot can be when the axillary area is included in the surgery. We have noticed that if we administer the local anesthetic between the anterior serratus muscle (ASM) and the external intercostal muscle, at the level of the fourth to sixth rib in the midaxillary line in the long axis of the body with an in-plane approach from caudal to cranial direction, instead of the double injection suggested by Blanco et al,4 there is a greater likelihood of good
© 2014 American Society of Regional Anesthesia and Pain Medicine
analgesia in the axillary region and we avoid blocking the long thoracic nerve. The block’s effectiveness in the axillary region is also better than the modified Pecs block because the 3-headed form of the ASM prohibits the correct local anesthetic distribution when administered below the minor pectoral muscle. At this level, in the midaxillary line, the ultrasound image is simple to recognize (Fig. 1): We see subcutaneous tissue, ASM, the ribs with the intercostal muscles, and pleura. The serratus-intercostal plane block is of moderate complexity, reducing performance time. This block helps ensure the distribution of the local anesthetic along the hemithoracic wall in every direction along the interfascial plane, blocking the lateral cutaneous intercostal nerve branches responsible for innervation of the mammary glands. Although paravertebral block is a widely studied regional technique block, we must remain open to new techniques that may be useful when a paravertebral block has failed, is
177
Copyright © 2015 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
