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Background: Supraclavicular block is a popular technique for upper limb surgeries. It can be performed with landmark, nerve stimulator (NS), ultrasound (US) guidance or a combination of techniques. NS can be an invaluable tool even in low resource set up. There are limited studies to compare NS guided supraclavicular block with (dual technique; Group NS+US) and without (Group NS) US guidance. Although US is gaining popularity, its availability at all times can be limited. Whenever available, the combination of two technique can improve the success rate. Material and Methods: Thirty patients (n=30) were included each in group NS and NS+US in the study. Both groups received 30 ml of 1:1 mixture of 2% adrenalized lignocaine and 0.5% bupivacaine. Both techniques were assessed in terms of ease of block execution (block execution time, number of skin punctures and needle redirections), block success rates and patient satisfaction. Onset and duration of block as well as complications were noted. Results: Both the groups were comparable in terms of age, gender, and mean weight. The block execution times were comparable but the dual technique group had significantly lower number of skin punctures and needle redirections. Both groups had similar success rates. The dual technique group had significantly earlier onset of motor and sensory blockade. No statistically significant difference in the incidence of complications was noted. The dual technique group had better patient satisfaction. Conclusion: A successful supraclavicular block can be performed with NS with or without US safely. The combination of two techniques eases the block execution, hastens the onset and provides better patient satisfaction.

Simple Summary: Local anaesthetic nerve blocks can be used to provide pain relief during and after surgery. While specific local anaesthetic techniques are commonplace in humans and some species, it is a relatively new field of research in rabbits. Rabbits are prey species that hide pain well but may express changes in behaviour, food intake, and production of faeces as a result of pain, making them challenging to study. This study aimed to investigate a specific local anaesthetic technique in rabbits undergoing orthopaedic surgery on a front leg. Its effectiveness was investigated by comparing the requirement for extra pain relief during and after surgery and comparing changes in food intake, faeces production, and behaviour after surgery. Both remote filming and direct observation were used. The rabbits who received the block required no additional pain relief during surgery, whereas every rabbit who received intravenous pain relief did require additional pain relief. However, after surgery, the severity of pain and the requirement for extra pain relief were the same, and there was no difference in behaviour between the groups. In conclusion, this local anaesthetic nerve block was easy to administer and provided effective pain relief during surgery, reducing the need for additional drug therapy. Locoregional anaesthetic techniques are invaluable for providing multimodal analgesia for painful surgical procedures. This prospective, randomised study describes a nerve stimulator-guided brachial plexus blockade (BPB) in rabbits undergoing orthopaedic surgery in comparison to systemic lidocaine. Premedication was provided with intramuscular (IM) medetomidine, fentanyl, and midazolam. Anaesthesia was induced (propofol IV) and maintained with isoflurane. Nine rabbits received a lidocaine BPB (2%; 0.3 mL kg−1), and eight received a lidocaine constant rate infusion (CRI) (2 mg kg−1 IV, followed by 100 µg kg−1 min−1). Rescue analgesia was provided with fentanyl IV. Carprofen was administered at the end of the surgery. Postoperative pain was determined using the Rabbit Grimace Scale (RGS) and a composite pain scale. Buprenorphine was administered according to the pain score for two hours after extubation. Rabbits were filmed during the first two hours to measure distance travelled and behaviours. Food intake and faeces output were compared. Every rabbit in CRI required intraoperative rescue analgesia compared to none in BPB. However, rabbits in both groups had similar pain scores, and there was no difference in the administration of postoperative analgesia. There were no significant differences in food intake or faeces production over 18 h, and no significant differences in distance travelled or behaviours examined during the first two hours. BPB seems superior for intraoperative analgesia. Postoperatively, both groups were comparable. [ABSTRACT FROM AUTHOR]

Background: Supraclavicular block is a popular technique for upper limb surgeries. It can be performed with landmark, nerve stimulator (NS), ultrasound (US) guidance or a combination of techniques. NS can be an invaluable tool even in low resource set up. There are limited studies to compare NS guided supraclavicular block with (dual technique; Group NS+US) and without (Group NS) US guidance. Although US is gaining popularity, its availability at all times can be limited. Whenever available, the combination of two technique can improve the success rate. Material and Methods: Thirty patients (n=30) were included each in group NS and NS+US in the study. Both groups received 30 ml of 1:1 mixture of 2% adrenalized lignocaine and 0.5% bupivacaine. Both techniques were assessed in terms of ease of block execution (block execution time, number of skin punctures and needle redirections), block success rates and patient satisfaction. Onset and duration of block as well as complications were noted. Results: Both the groups were comparable in terms of age, gender, and mean weight. The block execution times were comparable but the dual technique group had significantly lower number of skin punctures and needle redirections. Both groups had similar success rates. The dual technique group had significantly earlier onset of motor and sensory blockade. No statistically significant difference in the incidence of complications was noted. The dual technique group had better patient satisfaction. Conclusion: Asuccessful supraclavicular block can be performed with NS with or without US safely. The combination of two techniques eases the block execution, hastens the onset and provides better patient satisfaction. [ABSTRACT FROM AUTHOR]

Locoregional anaesthetic techniques are invaluable for providing multimodal analgesia for painful surgical procedures. This prospective, randomised study describes a nerve stimulator-guided brachial plexus blockade (BPB) in rabbits undergoing orthopaedic surgery in comparison to systemic lidocaine. Premedication was provided with intramuscular (IM) medetomidine, fentanyl, and midazolam. Anaesthesia was induced (propofol IV) and maintained with isoflurane. Nine rabbits received a lidocaine BPB (2%; 0.3 mL kg−1), and eight received a lidocaine constant rate infusion (CRI) (2 mg kg−1 IV, followed by 100 µg kg−1 min−1). Rescue analgesia was provided with fentanyl IV. Carprofen was administered at the end of the surgery. Postoperative pain was determined using the Rabbit Grimace Scale (RGS) and a composite pain scale. Buprenorphine was administered according to the pain score for two hours after extubation. Rabbits were filmed during the first two hours to measure distance travelled and behaviours. Food intake and faeces output were compared. Every rabbit in CRI required intraoperative rescue analgesia compared to none in BPB. However, rabbits in both groups had similar pain scores, and there was no difference in the administration of postoperative analgesia. There were no significant differences in food intake or faeces production over 18 h, and no significant differences in distance travelled or behaviours examined during the first two hours. BPB seems superior for intraoperative analgesia. Postoperatively, both groups were comparable.

Interscalene block is usually performed using either ultrasound (US) or nerve stimulator (NS) guidance. This single-blinded, prospective, randomised study was performed to find out whether US was able to offer distinct advantages over conventional NS guidance. 100 patients in the American Society of Anaesthesiology (ASA) physical status I to III, aged 18–70 years were randomised into US guided or NS guided group for interscalene block with 15 ml 0.5% bupivacaine and 5 ml 2% lignocaine. Patients were premedicated with midazolam 0.03 mg/kg (maximum 2 mg) and fentanyl 2 mcg/kg (max 100 mcg) was used as rescue analgesia. Mean time of onset of sensory block in the NS group was 6.2 min (3.1), the US group 4.7 min (1.1), p value (<0.001). Mean duration of post-operative analgesia in NS group 323.6 min (98.6), US group 558.6 min (144.3), (p < 0.001). Mean time for performance of block NS Group 7.3 min (2.0), and in the US group 4.9 min (1.3), (p < 0.001). Number of needle passes NS group 1.7(0.9), US group 1.3 (1.0), (p < 0.005). Total cost per surgery with NS was Rs 363.10 less than in the US-guided block. Incremental cost effectiveness ratio for ultrasound group for onset of block was Rs −242.07, Rs 92.0 for duration of block and Rs −151.29 for time for performance of block. No incident of post-operative neurological complications seen in either group. Ultrasound use offers faster onset, longer duration of block, reduces time for performance of blocks with comparable complication rates. For most of the measured parameters it was superior but more costly than nerve stimulator for directly measured costs. [ABSTRACT FROM AUTHOR]

Abstract Objectives To compare the duration of regional anesthesia of the pelvic limb using bupivacaine with and without a temperature‐responsive hydrogel (TRH) in dogs. Methods Under anesthesia using medetomidine (10 μg·kg−1), alfaxalone (2 mg·kg−1), and isoflurane, seven healthy male Beagles received four injections of 0.5% bupivacaine (1 mg·kg−1 with 5 μg·ml−1 epinephrine) to block the femoral and sciatic nerves bilaterally via ultrasound with nerve stimulation guidance. Bupivacaine was used on one pelvic limb (Bup treatment), and bupivacaine with TRH was used on the contralateral limb (Bup‐TRH treatment). The nerve block was considered successful upon the absence of responses to pinching the digital pads and mid‐tibial skin of both pelvic limbs with mosquito forceps; the pinch, proprioception, and locomotion tests were performed before (baseline) and at each hour after the nerve block until sensory and motor functions returned to baseline. The effect of TRH on nerve blocks was analyzed using a linear mixed model. Results The duration of the sensory nerve block at the digital pads and mid‐tibial skin was longer with Bup‐TRH (8.0 ± 1.6 h and 10.9 ± 1.6 h, respectively) than with Bup treatment (3.7 ± 2.0 h and 8.0 ± 1.6 h, respectively). Motor block times of proprioception and locomotion were longer with Bup‐TRH (9.3 ± 1.6 and 12.7 ± 1.5 h, respectively) than with Bup treatment (4.6 ± 1.9 and 9.6 ± 1.5 h, respectively). No complications were observed. Clinical significance TRH extended the duration of regional anesthesia of the pelvic limb using bupivacaine.

Objectives: To compare the duration of regional anesthesia of the pelvic limb using bupivacaine with and without a temperature‐responsive hydrogel (TRH) in dogs. Methods: Under anesthesia using medetomidine (10 μg·kg−1), alfaxalone (2 mg·kg−1), and isoflurane, seven healthy male Beagles received four injections of 0.5% bupivacaine (1 mg·kg−1 with 5 μg·ml−1 epinephrine) to block the femoral and sciatic nerves bilaterally via ultrasound with nerve stimulation guidance. Bupivacaine was used on one pelvic limb (Bup treatment), and bupivacaine with TRH was used on the contralateral limb (Bup‐TRH treatment). The nerve block was considered successful upon the absence of responses to pinching the digital pads and mid‐tibial skin of both pelvic limbs with mosquito forceps; the pinch, proprioception, and locomotion tests were performed before (baseline) and at each hour after the nerve block until sensory and motor functions returned to baseline. The effect of TRH on nerve blocks was analyzed using a linear mixed model. Results: The duration of the sensory nerve block at the digital pads and mid‐tibial skin was longer with Bup‐TRH (8.0 ± 1.6 h and 10.9 ± 1.6 h, respectively) than with Bup treatment (3.7 ± 2.0 h and 8.0 ± 1.6 h, respectively). Motor block times of proprioception and locomotion were longer with Bup‐TRH (9.3 ± 1.6 and 12.7 ± 1.5 h, respectively) than with Bup treatment (4.6 ± 1.9 and 9.6 ± 1.5 h, respectively). No complications were observed. Clinical significance: TRH extended the duration of regional anesthesia of the pelvic limb using bupivacaine. [ABSTRACT FROM AUTHOR]

Precise nerve fascicle identification is important in certain peripheral nerve procedures. Although we believe bipolar nerve stimulation with intraoperative neuromonitoring is a superior method, many rely on clinical response evoked by handheld monopolar nerve stimulators. We present a modification in the use of the latter for a more precise fascicle stimulation. A 55-year-old man with a right high brachial plexus injury and a 47-year-old woman with a left median nerve schwannoma were scheduled for exploration and ulnar-to-musculocutaneous nerve transfer, and for surgical excision respectively. Intraoperatively, we used a disposable handheld monopolar nerve stimulator in an unorthodox way, placing the anode right next to the cathode (both touching the same nerve fascicle). In the first case, a fascicle that showed flexor carpi ulnaris (FCU) and intrinsic hand muscle contraction with standard stimulation (anode placed on patient's skin), showed only FCU activation with our modified method, and was chosen as donor. A BMC grade M4 elbow flexion was achieved 9 months after surgery. In the second case, safe schwannoma excision was performed after our modified stimulation technique caused thenar muscle activation in a single, unaffected fascicle, while standard monopolar stimulation showed activation in several fascicles. No unexpected motor/sensory deficits were noted during follow-up. This report shows an easy modification in the use of handheld nerve stimulators that improves selectiveness when looking for nerve fascicles., (© 2024 Wiley Periodicals LLC.)

The supraclavicular block is effective in providing surgical anesthesia for upper limb surgery. The safety profile is improved with the use of a nerve stimulator to locate the brachial plexus. Above-elbow amputation in infants is commonly done under general anesthesia, however, the presence of certain comorbid conditions may increase the risk of mortality. We report the use of a nerve stimulator-guided supraclavicular block with sedation, to carry out transhumeral amputation for an 11-week-old female infant who had gangrene of her left forearm. The subclavian perivascular approach was used to perform the block. A mixture of 0.5% bupivacaine and 2% lidocaine in adrenaline was administered to achieve surgical anesthesia. The onset of the block was 5 min. A total of 2 mg of midazolam was used for sedation. The infant had a successful block. There was no block-related complication. We suggest that nerve stimulator-guided supraclavicular block in infants is feasible and safe.

Abstract Sugammadex is a new selective relaxant binding drug that provides a rapid decrease in free rocuronium in the plasma and also at the nicotinic receptor that helps in proper awakening of patients, which is extremely helpful for minimizing postoperative respiratory complications. The aim of this study is to compare the recovery profile of sugammadex versus neostigmine in asthmatic patients undergoing open cholecystectomy. Methods This study included 60 patients of ASA physical status II, aged 45–55 years with controlled bronchial asthma undergoing open cholecystectomy. General anesthesia was induced with propofol (2–3 mg/kg), fentanyl 1 μg/kg, and then rocuronium 0.6 mg/kg was administered to facilitate tracheal intubation (train of four (TOF) guarded). Muscle relaxation was maintained throughout the procedure with additional bolus doses of rocuronium 0.15 mg/kg which were administered upon appearance of the second twitch in TOF to maintain neuromuscular block during surgery. Patients were allocated randomly into two equal groups: (group I) received sugammadex 4 mg/kg, and (group II) received neostigmine 0.05 mg/kg and atropine 0.02 mg/kg (group II) as a reversal agent. Assessment of pulmonary function tests on the day before and 30 min after extubation was made. In addition capillary hemoglobin oxygen saturation was measured as well as the reversal time. Results The reversal time showed highly significant differences between the two groups: 2.5–3 min in group I versus 21–25.3 min in group II. Pulmonary function tests (PFT) and number of patients unable to perform sustained head elevation for 5 s showed non-significant differences between the two groups. Conclusion This study showed that the benefits of sugammadex are superior to those of neostigmine in reversing rocuronium-induced neuromuscular blockade in asthmatic patients undergoing open cholecystectomy.

Aim: To describe the successful treatment of atypical occipital neuralgia (ON) using a unilateral dual-lead occipital nerve stimulator. Setting: Outpatient clinic/operating room. Patient: A 53-year-old male with atypical ON. Case description: Patient was previously diagnosed with treatment-refractory left-sided trigeminal neuralgia with atypical occipital distribution. On presentation, his symptoms were consistent with ON with distribution to the left fronto-orbital area. He received a left-sided nerve stimulator implant targeting both the greater and lesser occipital nerves. Results: Patient reported pain relief from a numerical rating scale 10/10 to 3-4/10. Conclusion: ON with referred ipsilateral trigeminal distribution should be considered when patients present with simultaneous facial and occipital pain. Further, a dual-lead unilateral stimulator approach may be a viable treatment.

Objective: This study aims to compare stimulator-guided peripheral nerve block with and without ultrasonography techniques to investigate the block procedure time, sensory and motor block onset time, pain related to the block procedure-related pain, and anesthesia-related complications. Methods: Patients were randomized into two groups: The nerve stimulator (NS)-guided technique group (n=30) and the NS with ultrasound (NU)-guided technique group (n=30). One-quarter of the solution prepared with prilocaine 2% and lidocaine 2% with the height/5 formula was injected around each nerve after receiving a motor response between 0.3-0.5 mA. The block procedure time, sensory and motor block onset time, the number of skin punctures, procedure-related preoperative complications, procedure-related postoperative complications, and visual analog scale (VAS) (0-10) scores were recorded. The heart rate, systolic arterial pressure, diastolic arterial pressure, mean arterial pressure, and peripheral oxygen saturation values were noted at 0, 5, 10, 15, 30, 45, 60, 120, and 180 minutes. Results: The block procedure time was similar between them (p>0.05). The number of skin punctures (p=0.001) and VAS (p<0.045) were significantly higher in the NS group. The sensory and motor block onset times were significantly similar (p>0.05) except for the motor block of musculocutaneous nerve onset time (p<0.05). Although the success rate was higher in the NU group, there was no statistically significant difference between the groups (p>0.05). The number of complications was significantly higher in the NS group (p<0.05). Conclusion: Using ultrasonography with the NS in the axillary approach to brachial block improves the success rate with a lower incidence rate of complications. [ABSTRACT FROM AUTHOR]

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Background and Aims: Transverse Abdominis Plane (TAP) block was originally described as a landmark-based technique. Peripheral nerve stimulator (PNS) guided blocks are still widely performed, where ultrasound is unavailable. Methods: Cadaveric dissections were performed which showed the subcostal nerve following a predictable course at the lateral abdominal wall in the TAP. The subcostal nerve was identified by ultrasound in three volunteers. Stimulation of the subcostal nerve was performed using PNS and landmarks as guidance in and 20 patients. Twitches of the anterior abdominal wall muscles were elicited, and needle position and drug dispersion were confirmed using ultrasound. Results: Out of 32 attempts made, the drug dispersion was appropriate in 24, not appropriate on four insertions and twitches were not elicited in 4 attempts. Conclusion: Nerve stimulator can be used as a guidance for TAP blocks where the availability of ultrasound is limited.

To determine the intraoperative and early postoperative opioid requirement after ultrasound-guided sciatic and/or femoral nerve block or epidural anaesthesia in dogs undergoing tibial plateau levelling osteotomy (TPLO). Prospective, masked, pilot, randomized, clinical trial. A total of 40 client-owned dogs undergoing TPLO. Each dog was randomly assigned to group SF (combined sciatic and femoral nerve block), group S (sciatic nerve block), group F (femoral nerve block) or group E (epidural anaesthesia). A total of 0.3 mL kg–1 of ropivacaine 0.5% was administered to each nerve or in the epidural space. Intraoperatively, fentanyl (2 μg kg–1) was administered intravenously when heart rate, mean arterial pressure or respiratory rate increased by >30% compared with baseline values. Postoperatively, a visual analogue scale (VAS) and a modified German version of the French pain scale (4AVet) were used to assess pain every 30 minutes for 150 minutes and again once the morning after surgery. Methadone (0.1 mg kg–1) was administered intravenously if the VAS was ≥ 4 cm [maximal value 10 cm; median (interquartile range)] or the composite pain score was ≥5 [maximal value 15; median (interquartile range)]. Significance was defined as p ≤ 0.05. Groups SF and E required less total intraoperative and early postoperative opioid doses compared with groups S and F (p = 0.031). No dogs in group SF had a block failure or required postoperative methadone. A reduced methadone requirement was found in group SF compared with all the other groups up to 150 minutes after recovery (p = 0.041). Combined sciatic and femoral nerve block and epidural anaesthesia lead to less cumulative consumption of perioperative opioids than single nerve blockade. Sciatic or femoral nerve block alone might be insufficient to control nociception and early postoperative pain in dogs undergoing TPLO. [ABSTRACT FROM AUTHOR]

Purpose To identify factors associated with successful sacral nerve stimulator (SNS) trial after SNS implantation for the treatment of medication refractory overactive bladder (OAB). Methods Patients undergoing treatment for OAB at Lahey Hospital and Medical Center between 2004 and 2016 were identified. Patients undergoing SNS placement were identified; SNS success was defined as permanent implantation of the SNS. Demographic, clinical and treatment data were extracted from patient charts; uni- and multivariate analyses were conducted to identify factors associated with SNS treatment success. Results A total of 128 patients were included. On univariate analysis, male sex, prior diagnosis of benign prostatic hyperplasia, and lower volume at first urge on urodynamics (UDS) were associated with unsuccessful SNS trial. On multivariate analysis, male sex (odds ratio [OR], 0.145; 95% confidence interval [CI], 0.036–0.530) and lower volume at first urge on UDS (OR, 0.982; 95% CI, 0.967–0.995) were associated with unsuccessful SNS trial. A threshold value of 100 mL at first urge during preoperative UDS had a specificity of 0.86 in predicting SNS success in men. Conclusions SNS is frequently successful at relieving OAB symptoms. Male patients and those with lower volumes at first urge on UDS, particularly below 100 mL, are more likely to have an unsuccessful SNS trial. Patients in these groups should be counseled on the lower likelihood of SNS success.

Aim: To compare our experiences of the brachial plexus block (BPB) using nerve stimulator (NS) and ultrasonography (US) for upper limb surgery. Methods: This retrospective study was designed in 186 American Society of Anesthesiologists I-II-III patients undergoing upper extremity surgery under BPB (supraclavicular, interscalene and infraclavicular block) by US guidance and NS. The patients were divided into two groups as US group (n=118) and NS group (n=68). Data on demographical characteristics, premedication, position, regional block approach, number of stimulator needles, dose of local anesthetics, and success rate were recorded. Results: Demographic data were similar and no statistically difference was recorded between the groups in nerve block method (interscalene, supraclavicular, infraclavicular) (p>0.05). 20 mL 0.5% bupivacaine + 10 mL 2% lidocaine were administered. Blocks were performed with a sedation regimen (1-3 mg midazolam). There was a significant difference in success rates between US (94.1%) and NS groups (80.9%) (p

The aim of the present study was to evaluate the effect of adding tramadol to lidocaine for brachial plexus block in sheep. Six healthy, adult ewes weighing 41.7 ± 3.82 kg were used. Using an electrical stimulator, brachial plexus block was performed with lidocaine (4 mg/kg) (LID), lidocaine (4 mg/kg)-tramadol (2 mg/kg) (LTL), and lidocaine (4 mg/kg)-tramadol (4 mg/kg) (LTH). All sheep received the three treatments with one-week interval. The final volume of administered solutions was adjusted to 0.3 mL/kg. Time to the onset and duration of anesthesia as well as changes in heart rate, respiratory rate, and rectal temperature were determined. Time to the onset of sensory blockade and motor blockade was not significantly different among groups. The duration of sensory blockade and motor blockade were significantly longer in LTH (128.3 ± 9.7 and 151.5 ± 21.5 min, respectively) compared with those of LID (88.6 ± 6.5 and 110.5 ± 21 min, respectively) and LTL (51.6 ± 11.8 and 89.6 ± 22.7 min, respectively). Although the onset of sensory blockade was longer than that of motor blockade in the three treatments, the difference was only significant in LTL. No significant differences were observed in heart rate, respiratory rate and rectal temperature among and within treatments. It was concluded that addition of tramadol (4 mg/kg) to lidocaine, without altering the onset, can provide more prolonged anesthesia than that of lidocaine in brachial plexus block in sheep.

Peripheral nerve blocks have been part of anaesthetic techniques used for upper and lower extremity surgery for decades. The introduction of the nerve stimulator and the ultrasound guidance, during last decade, made a marked change in everyday practice. Ultrasound guided nerve blocks are now becoming the standard practice in regional anaesthesia as more effective technique requires less volume of local anaesthetic and reduces the incidence of complications. Ultrasound guidance enables better assessment of local anaesthetic placement and dosage required, rendering it the safest and most reliable technique in regional anesthesia at present.

Background The external branch of the superior laryngeal nerve (EBSLN) injury is an important and not uncommon, though frequently overlooked, complication of thyroid surgery. The rate of EBSLN injury has been reported to vary from 0 to 58%, depending on different postoperative assessment methods. Injury to the EBSLN during thyroid operation can paralyze ipsilateral cricothyroid muscle, and the clinical symptoms mainly include vocal fatigue and diminished vocal frequency range, especially with respect to raising pitch, which may result in decreased quality of life, particularly for voice professionals. Patients and methods This prospective study included 22 patients with goiter. They were divided into two groups: group 1 (G1) included all cases in whom nerve stimulator was used and group 2 (G2) included all cases in whom trial of visual identification of the EBSLN was done. Results It was found that patients with short obese neck, large gland size, large gland weight, and retrosternal extension showed difficulty in EBSLN identification and had high risk of nerve injury (P<0.042, 0.04, 0.03, and 0.041, respectively). Nerve stimulator has improved identification of EBSLN (P<0.036) with less voice affection postoperatively (P<0.04), with no statistical difference between both groups regarding operative time. Conclusion It was concluded that routine use of nerve stimulator in surgical interventions on the thyroid gland will be beneficial for more secure identification and prevention of EBSLN injury and preservation of voice quality postoperatively. [ABSTRACT FROM AUTHOR]

Background: Meralgia paresthetica is a mononeuropathy of the lateral femoral cutaneous nerve. A common therapy is injection with corticosteroids. The goal of this study was to analyze the effect of injection with methylprednisolone/lidocaine vs placebo.Methods: After randomization, 10 patients received a nerve stimulator-guided injection with methylprednisolone/lidocaine, and 10 patients received saline. The primary outcome measure was pain (visual analogue scale, VAS).Results: In the placebo group, there was a significant pain reduction (baseline VAS, 6.8; VAS week 12, 4.3; P = .014). The VAS score in the methylprednisolone group did not show a significant reduction (baseline VAS, 7.4; VAS week 12, 4.8; P = .053). There was no significant difference in pain reduction between the groups.Conclusions: We found no objective evidence for benefit from nerve stimulator-guided injection with corticosteroids in meralgia paresthetica, although this study is limited by a small sample size. Future placebo-controlled studies using ultrasound-guided injection are warranted. [ABSTRACT FROM AUTHOR]

To compare the nerve stimulation test (group NS) with the running-drip method (group RUN) for successful identification of the sacrococcygeal (SCo) epidural space prior to drug administration in dogs. A total of 62 dogs. A randomized clinical study. Dogs requiring an epidural anaesthetic as part of the multimodal anaesthetic plan were randomly allocated to one of the two study groups. In group NS, the epidural space was located using an insulated needle connected to a nerve stimulator; in group RUN, the epidural space was identified using a Tuohy needle connected to a fluid bag elevated 60 cm above the spine via an administration set. The success of the technique was assessed 5 minutes after epidural injection by the disappearance of the patella reflex. Data were checked for normality, nonparametric data was analysed using a Mann–Whitney U test and success rate was analysed using a Fisher's exact test. The significance level was set at p < 0.05, and the results are presented in absolute values, percentage (95% confident interval) and median (range). The success in identification of the epidural space did not differ between groups NS and RUN [87.1% (70.2%–96.4%) versus 90.3% (74.2%–98%); p = 1.000]. The time required for identification of the epidural space was shorter in group RUN [26 (15–53) seconds] than in group NS [40 (19–137) seconds] (p = 0.0225). No other differences were found in any studied variables. and clinical relevance In this study, both RUN and NS techniques were successful in identifying the epidural space at the SCo intervertebral space. RUN requires no specialised equipment, can be performed rapidly and offers an alternative to the NS for use in general veterinary practice. [ABSTRACT FROM AUTHOR]

Objective: The Checkpoint nerve stimulator (Checkpoint Surgical, Cleveland, OH) is a U.S. Food and Drug Administration-approved device for neural localization and monitoring during surgery. Its safety, efficacy, and reliability for neural monitoring during thyroid and parathyroid surgery have not been compared to more standard formats of neural monitoring.Study Design: Retrospective review.Methods: Vagal, recurrent, and superior laryngeal nerve monitoring were performed using both the Checkpoint stimulator and Medtronic NIM 3.0 laryngeal electromyography endotracheal tube (Medtronic, Jacksonville, FL) during thyroid and parathyroid surgery. A total of 21 operated sides in 15 patients were included for analysis. Latency and amplitude data for the Checkpoint stimulator were recorded using the NIM monitor and compared to normative endotracheal tube surface electrode data.Results: Mean amplitude using the Checkpoint stimulator was 574.6 microvolts (μV), 1060.6 μV, and 182.8 μV for the vagus, recurrent laryngeal, and superior laryngeal nerves, respectively. Mean amplitude using standard laryngeal electromyography was 709 μV, 1077.0 μV, and 183.7 μV for the same nerves. Mean latency was significantly shorter with stimulation of the recurrent laryngeal nerve compared to the vagus nerve with both stimulators (P < 0.001). No neural injuries occurred during the study.Conclusion: The Checkpoint stimulator is a safe and reliable alternative to traditional laryngeal electromyography providing equivalent induced electromyography of the vocalis for neural monitoring during thyroid and parathyroid surgery.Level Of Evidence: 4 Laryngoscope, 130:561-565, 2020. [ABSTRACT FROM AUTHOR]

Sugammadex is a new selective relaxant binding drug that provides a rapid decrease in free rocuronium in the plasma and also at the nicotinic receptor that helps in proper awakening of patients, which is extremely helpful for minimizing postoperative respiratory complications. The aim of this study is to compare the recovery profile of sugammadex versus neostigmine in asthmatic patients undergoing open cholecystectomy. Methods: This study included 60 patients of ASA physical status II, aged 45–55 years with controlled bronchial asthma undergoing open cholecystectomy. General anesthesia was induced with propofol (2–3 mg/kg), fentanyl 1 μg/kg, and then rocuronium 0.6 mg/kg was administered to facilitate tracheal intubation (train of four (TOF) guarded). Muscle relaxation was maintained throughout the procedure with additional bolus doses of rocuronium 0.15 mg/kg which were administered upon appearance of the second twitch in TOF to maintain neuromuscular block during surgery. Patients were allocated randomly into two equal groups: (group I) received sugammadex 4 mg/kg, and (group II) received neostigmine 0.05 mg/kg and atropine 0.02 mg/kg (group II) as a reversal agent. Assessment of pulmonary function tests on the day before and 30 min after extubation was made. In addition capillary hemoglobin oxygen saturation was measured as well as the reversal time. Results: The reversal time showed highly significant differences between the two groups: 2.5–3 min in group I versus 21–25.3 min in group II. Pulmonary function tests (PFT) and number of patients unable to perform sustained head elevation for 5 s showed non-significant differences between the two groups. Conclusion: This study showed that the benefits of sugammadex are superior to those of neostigmine in reversing rocuronium-induced neuromuscular blockade in asthmatic patients undergoing open cholecystectomy. [ABSTRACT FROM AUTHOR]

Background and Aims: The supraclavicular and infraclavicular brachial plexus blocks have a similar distribution of anaesthesia, and both can be used effectively for surgeries of the upper limb. This study aimed to compare the supraclavicular and infraclavicular approaches of brachial plexus blocks, guided by ultrasound and neurostimulation. Methods: Sixty adult patients scheduled for elective upper limb surgery of the elbow and/or below were randomly divided into two groups: infraclavicular Group (I) and supraclavicular Group (S). All the blocks were performed with the aid of ultrasound-guided nerve stimulator confirmation. The two groups were compared with respect to block performance time, onset of sensory and motor blockade, readiness for surgery, success rate and complications. The statistical analysis was performed with Student t-test and Chi-square test. Results: The block performance time for the infraclavicular group was 9.57 ± 3.19 min, whereas for supraclavicular group, it was 11.53 ± 2.90 min with similar success rates (93.3%). Onset of sensory blockade was achieved earlier (6.43 ± 2.61 min) in Group I than Group S (8.45 ± 2.87 min, P = 0.006). The onset of motor blockade was similar in Group I (7.32 ± 2.90 min) and Group S (8.68 ± 3.50 min, P = 0.121). The patient satisfaction was similar in both the groups. One patient had a pneumothorax, three patients developed Horner syndrome and another had clinically symptomatic diaphragmatic paresis in Group S. Conclusion: The infraclavicular block is more rapidly executed compared to supraclavicular block with similar success rates and fewer complications in the presence of ultrasound and nerve stimulator and hence should be preferred.

Persistent hiccups that occur after abdominal surgery seriously affect postoperative rehabilitation. Phrenic nerve block therapy has been recommended after failure of medication or physical maneuvers. However, the phrenic nerve is often difficult to accurately identify because of its small diameter and anatomic variations. We combined ultrasound with the use of a nerve stimulator to quickly and accurately identify and block the phrenic nerve in a patient with postoperative persistent hiccups. The ongoing hiccups were immediately terminated with no adverse effects. The patient reported no recurrence during the 2-week follow-up period. We conclude that the combined use of real-time ultrasound guidance and a nerve stimulator for singular phrenic nerve block might be an effective intervention for terminating postoperative persistent hiccups, although further studies are needed to evaluate the safety and efficacy of this technique. The findings in this case suggest a potential clinical application for this technique in managing persistent hiccups, thereby contributing to improved patient care and outcomes., Competing Interests: Declaration of conflicting interestsThe authors declare that there is no conflict of interest.

Highlights • The ReStore system is an implantable nerve stimulator with no battery or leads. • It is constructed using commercial components and processes for manufacturability. • Results from bench and in vivo testing demonstrate biocompatibility and reliability. Abstract Background The growing use of neuromodulation techniques to treat neurological disorders has motivated efforts to improve on the safety and reliability of implantable nerve stimulators. New method The present study describes the ReStore system, a miniature, implantable wireless nerve stimulator system that has no battery or leads and is constructed using commercial components and processes. The implant can be programmed wirelessly to deliver charge-balanced, biphasic current pulses of varying amplitudes, pulse widths, frequencies, and train durations. Here, we describe bench and in vivo testing to evaluate the operational performance and efficacy of nerve recruitment. Additionally, we also provide results from a large-animal chronic active stimulation study assessing the long-term biocompatibility of the device. Results The results show that the system can reliably deliver accurate stimulation pulses through a range of different loads. Tests of nerve recruitment demonstrate that the implant can effectively activate peripheral nerves, even after accelerated aging and post-chronic implantation. Biocompatibility and hermeticity tests provide an initial indication that the implant will be safe for use in humans. Comparison with existing method(s) Most commercially available nerve stimulators include a battery and wire leads which often require subsequent surgeries to address failures in these components. Though miniaturized battery-less stimulators have been prototyped in academic labs, they are often constructed using custom components and processes that hinder clinical translation. Conclusions The results from testing the performance and safety of the ReStore system establish its potential to advance the field of peripheral neuromodulation. [ABSTRACT FROM AUTHOR]

Background and Aims: Transverse Abdominis Plane (TAP) block was originally described as a landmark-based technique. Peripheral nerve stimulator (PNS) guided blocks are still widely performed, where ultrasound is unavailable. Methods: Cadaveric dissections were performed which showed the subcostal nerve following a predictable course at the lateral abdominal wall in the TAP. The subcostal nerve was identified by ultrasound in three volunteers. Stimulation of the subcostal nerve was performed using PNS and landmarks as guidance in and 20 patients. Twitches of the anterior abdominal wall muscles were elicited, and needle position and drug dispersion were confirmed using ultrasound. Results: Out of 32 attempts made, the drug dispersion was appropriate in 24, not appropriate on four insertions and twitches were not elicited in 4 attempts. Conclusion: Nerve stimulator can be used as a guidance for TAP blocks where the availability of ultrasound is limited. [ABSTRACT FROM AUTHOR]

It is important to develop a feasible animal model of regional anesthesia other than sciatic nerve blockade for pharmacokinetic investigations of new local anesthetics or analgesia in upper extremity surgery. Herein, we explored a nerve stimulator (NS)-guided brachial plexus block (BPB) in a rat model. The anatomy of the brachial plexus in rats was delineated in cadavers, and various BPBs were examined. The puncture point was located 0.5–1.0 cm below the lateral one-third of the clavicle. The efficacy and safety of the NS-guided BPB were evaluated using an injection of 2% lidocaine or 0.5% bupivacaine in 16 live animals; saline injection was used as a control. Both sides of the brachial plexus were located successfully using the NS-guided technique. Sensory blockade (nociception assessment) and motor blockade (grasping and straightening tests) appeared after application of the two classical local anesthetics, but not normal saline. The motor and sensory blockade induced by bupivacaine exhibited a longer duration than that induced by lidocaine (p < 0.05). All rats recovered uneventfully from general anesthesia and BPB. No abnormal results were found in pathological studies or behavioral observations. Thus, a rat model of NS-guided BPB was established, and BPB induced an overall reversible sensory and motor blockade in the thoracic limbs. Evaluation of the efficacy and safety demonstrated that this rat BPB model was feasible, reproducible, and safe. [ABSTRACT FROM AUTHOR]

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Purpose: Obturator nerve block (ONB) has been performed in surgeries of transurethral resection of bladder tumors (TUR-BT) for the prevention of the development of obturator muscle contraction. Currently, classic and inguinal approaches are frequently being used. In the present study, we aimed to compare the success rate, performance speed, and complication risks of both approaches. Materials and Methods: Sixty-six patients who underwent TUR-BT under spinal anesthesia were randomly selected, and ONB was performed on the tumor location side using classic (n = 33) or inguinal (n = 33) approaches. Ten milliliters of 0.25% bupivacaine were administered using a peripheral nerve stimulator in both approaches. Two endpoints were defined in the study: Primary endpoint; the duration of the determination of the obturator nerve and number of interventions when each participant is assessed in at the end of the ONB procedure. Secondary endpoint; development of contractions, and complications each participant is assessed during the TUR-BT and 24 hours after ONB. Result: General anesthesia was applied to the five patients in the classic ONB group who detected diffuse or bilateral tumors. These patients were excluded from the study. Contractions developed in 4 patients in each group, no statistically significant difference was detected between the groups (14.3%, n = 4 versus 12.1%, n = 4) (P = 1.00). No complications were detected in both groups during the TUR-BT and 24 hours after ONB. We found that the inguinal approach provided a statistically significant advantage regarding the number of punctures (1.9 ± 0.9 versus 1.5 ± 0.7) (P = .036), and duration of the procedure (99.1 ± 48.4 seconds versus 76.0 ± 31.9 seconds) (P=.029) compared with the classic approach. Conclusion: Although complications and success rates were similar in both groups, the inguinal method may be a better approach because it is faster and requires fewer punctures. [ABSTRACT FROM AUTHOR]

Introduction: Given the high prevalence of upper extremity fractures and increasing need to perform painless reduction in the emergency departments, the use of analgesic methods with fewer complications and more satisfaction appears to be essential. The aim of this study is comparison the nerve stimulator guided axillary block (NSAB) with intravenous sedation in induction of analgesia for painless reduction of distal radius fractures. Methods: In the present randomized clinical trial, 60 patients (18-70 years of age) suffered from distal radius fractures, were divided into two equal groups. One group received axillary nerve block by nerve stimulator guidance and the other procedural sedation and analgesia (PSA) using midazolam/fentanyl. Onset of analgesia, duration of analgesic effect, total procedure time and pain scores were recorded using visual analogue scale (VAS) and the outcomes were compared. Chi-squared and student t test were performed to evaluate differences between two groups. Results: Sixty patients were randomly divided into two groups (83.3% male). The mean age of patients was 31 ±0.7 years. While the onset of analgesia was significantly longer in the NSAB group, the mean total time of procedure was shorter than PSA (p0.05). Conclusion: It seems that shorter post-operative monitoring time and consequently lesser total time of procedure, make nerve stimulator guided axillary block as an appropriate alternative for procedural sedation and analgesia in painless reduction of distal radius fractures in emergency department.

An adult male jungle cat (Felis chaus) weighing 6 kg with the history of inability to bearing weight on its left forelimb was presented. Physical examination and radiography revealed transverse radio-ulna fracture and carpal subluxation. Internal fixation with plate was chosen for treatment. On the day of surgery, anesthesia was induced with intramuscular ketamine (10 mg/kg) and midazolam (0.3 mg/kg). Brachial plexus block (BPB) was performed using lidocaine (3 mg/kg) and bupivacaine (0.75 mg/kg) mixture guided by an electrical nerve stimulator. During the surgery, anesthesia was maintained with isoflurane 0.5–1% in 100% oxygen. Heart rate, respiratory rate, rectal temperature, hemoglobin oxygen saturation, and end-tidal carbon dioxide tension remained stable during surgical procedure. The outcome of the present case suggests that combination of BPB and general anesthesia can be used to provide balanced anesthesia in wild felids. Reducing the isoflurane requirement and providing sufficient anti-nociception during surgery without any adverse effect are the main advantages of this protocol. [ABSTRACT FROM AUTHOR]

Peripheral nerve stimulators have widespread among anaesthesiologists and remain a popular technique. However, in commercial devices, the user has to manually adjust stimulus intensity. Thus, the aim of this study is to propose a method that allows automating the current intensity control. An earlier nerve stimulator prototype was modified to add an accelerometer and an sEMG module. The choice of these two sensors is aimed at the possibility of observing the mechanical and electrical responses of the muscle contraction evoked by the stimulation. The tests were performed in two steps. The first step was to observe how the sensors behave during stimulation and muscle contraction. The second step was to implement a control algorithm and to validate the automation technique. Comparing the two methods, no significant differences were found on procedure time (manual: 12.5 ± 2.3; automatic: 11.6 ± 1.9; ρ =0.380) and blockade latency time (manual: 11.6 ± 1.1; automatic: 11.9 ± 1.2; ρ =0.524). Comparing needle-nerve distance in manual or automatic mode, no significant differences were found for 1.0 mA, 0.8 mA, 0.5 mA and 0.3 mA. We conclude that the technique for automating the current intensity update, using accelerometer and/or electromyography, is satisfactory. Furthermore, we conclude that the use of the accelerometer alone is sufficient for detection of muscle contraction. [ABSTRACT FROM AUTHOR]

Purpose: To identify factors associated with successful sacral nerve stimulator (SNS) trial after SNS implantation for the treatment of medication refractory overactive bladder (OAB). Methods: Patients undergoing treatment for OAB at Lahey Hospital and Medical Center between 2004 and 2016 were identified. Patients undergoing SNS placement were identified; SNS success was defined as permanent implantation of the SNS. Demographic, clinical and treatment data were extracted from patient charts; uni- and multivariate analyses were conducted to identify factors associated with SNS treatment success. Results: A total of 128 patients were included. On univariate analysis, male sex, prior diagnosis of benign prostatic hyperplasia, and lower volume at first urge on urodynamics (UDS) were associated with unsuccessful SNS trial. On multivariate analysis, male sex (odds ratio [OR], 0.145; 95% confidence interval [CI], 0.036-0.530) and lower volume at first urge on UDS (OR, 0.982; 95% CI, 0.967-0.995) were associated with unsuccessful SNS trial. A threshold value of 100 mL at first urge during preoperative UDS had a specificity of 0.86 in predicting SNS success in men. Conclusions: SNS is frequently successful at relieving OAB symptoms. Male patients and those with lower volumes at first urge on UDS, particularly below 100 mL, are more likely to have an unsuccessful SNS trial. Patients in these groups should be counseled on the lower likelihood of SNS success. [ABSTRACT FROM AUTHOR]

Aim: To compare our experiences of the brachial plexus block (BPB) using nerve stimulator (NS) and ultrasonography (US) for upper limb surgery. Methods: This retrospective study was designed in 186 American Society of Anesthesiologists I-II-III patients undergoing upper extremity surgery under BPB (supraclavicular, interscalene and infraclavicular block) by US guidance and NS. The patients were divided into two groups as US group (n=118) and NS group (n=68). Data on demographical characteristics, premedication, position, regional block approach, number of stimulator needles, dose of local anesthetics, and success rate were recorded. Results: Demographic data were similar and no statistically difference was recorded between the groups in nerve block method (interscalene, supraclavicular, infraclavicular) (p>0.05). 20 mL 0.5% bupivacaine + 10 mL 2% lidocaine were administered. Blocks were performed with a sedation regimen (1-3 mg midazolam). There was a significant difference in success rates between US (94.1%) and NS groups (80.9%) (p<0.005). Horner's syndrome was observed in three patients in NS group (4.4%), and four patients in US group (4.2). In addition, hematoma, local anesthetic toxicity and pneumothorax were observed in 3.1 and one patients, respectively, in NS group. Conclusion: Ultrasonographic guidance improves the success of regional anesthesia and causes less complication compared to block using NS. [ABSTRACT FROM AUTHOR]

Objective: The aim of the study was to investigate the application of nerve stimulator-guided thoracic paravertebral nerve block (TPVB) plus general anesthesia (GA) in small-incision lung cancer surgery.Methods: Forty patients scheduled for small-incision lung cancer surgery, the American Society of Anesthesiologists Grade I-II, were randomized into a TPVB-GA group (Group P) and a GA group (Group G), with 20 cases in each group. The dosage of general anesthetic, mean arterial pressure (MAP) at each time point, and heart rate (HR) of the two groups were recorded. The postoperative respiration recovery time, extubation time, incidence of adverse reactions, and postoperative visual analog scale (VAS) scores of the two groups were also observed.Results: Group P showed stable hemodynamics, and lower MAP and HR at each time point than Group G (P < 0.05). The intraoperative dosage of general anesthetic in Group P was lower than that in Group G (P < 0.05). The respiration recovery time and extubation time in Group P were significantly shorter than those in Group G (P < 0.05); the incidence of agitation was significantly lower than that in Group G (P < 0.05). The VAS scores of Group P under quiet and cough status were also better than Group G (P < 0.05).Conclusions: Nerve stimulator-guided TPVB-GA is suitable for small-incision lung cancer surgery. [ABSTRACT FROM AUTHOR]

Background: The supraclavicular approach is considered to be the easiest and most effective approach to block the brachial plexus for upper limb surgeries. The classical approach using the anatomical landmark technique was associated with higher failure rates and complications. Ultrasonography (USG) guidance and peripheral nerve stimulator (PNS) have improved the success rates and safety margin. Aims: The aim of the present study is to compare USG with PNS in supraclavicular brachial plexus block for upper limb surgeries with respect to the onset of motor and sensory blockade, total duration of blockade, procedure time, and complications. Settings and Design: Prospective, randomized controlled study. Subject and Methods: Sixty patients aged above 18 years scheduled for elective upper limb surgery were randomly allocated into two groups. Group A patients received supraclavicular brachial plexus block under ultrasound guidance and in Group B patients, PNS was used. In both groups, local anesthetic mixture consisting of 15 ml of 0.5% bupivacaine and 10 ml of 2% lignocaine with 1:200,000 adrenaline were used. Statistical Analysis: Independent t-test used to compare mean between groups; Chi-square test for categorical variables. Results: The procedure time was shorter with USG (11.57 ± 2.75 min) compared to PNS (21.73 ± 4.84). The onset time of sensory block (12.83 ± 3.64 min vs. 16 ± 3.57 min) and onset of motor block (23 ± 4.27 min vs. 27 ± 3.85 min) were significantly shorter in Group A compared to Group B (P < 0.05). The duration of sensory block was significantly prolonged in Group A (8.00 ± 0.891 h) compared to Group B (7.25 ± 1.418 h). None of the patients in either groups developed any complications. Conclusion: The ultrasound-guided supraclavicular brachial plexus block can be done quicker, with a faster onset of sensory and motor block compared to nerve stimulator technique. [ABSTRACT FROM AUTHOR]

Background: Recently, several energy-based devices (EBDs) have been developed and applied in the context of thyroid surgery. EBDs can reduce operation time, blood loss, and postoperative pain. Compared to conventional electrocautery, EBDs operate at a relatively lower temperature and produce minimal lateral tissue damage. Yet, during device operation, the tip of the EBD is hot enough to cause thermal nerve damage, increasing the need for surgeons to be cautious about EBD application. To increase the safety of EBDs, we attached nerve stimulators to the tips of two EBDs and compared them to conventional monopolar nerve stimulation using a porcine model.Methods: Three piglets (30-40 kg) underwent total thyroidectomy after orotracheal intubation with a nerve integrity monitor (NIM) electromyography (EMG) endotracheal tube. Nerve stimulators were attached to two EBDs (Harmonic Focus®+ and LigaSure™). After dissection and identification of six recurrent laryngeal nerves in the three piglets, both of the EBDs with attached nerve stimulators and a conventional monopolar nerve stimulator were applied near the nerve and EMG parameters were recorded using the NIM 3.0 system. The stimulus intensity was varied from 5 mA to 1 mA and the maximum distance and amplitude at which nerve detection was achieved were measured.Results: There were no statistically significant differences between the maximum distance or mean amplitude obtained from nerve stimulators attached to EBDs and those obtained from the conventional nerve stimulator. Additionally, there were no adverse EMG events related to the use of nerve stimulators attached to EBDs.Conclusions: Attachment of a nerve stimulator to an EBD for nerve detection during thyroidectomy was as safe and effective as attachment of a conventional nerve stimulator. Use of a nerve stimulator attachment may reduce the likelihood of EBD-associated nerve damage during thyroid surgery. [ABSTRACT FROM AUTHOR]