Regional anesthesia has been used by anesthetists for decades. Anesthesiologist perform central neuroaxial block, peripheral nerve block and interventional pain injection as a procedure for anesthesia or acute or chronic pain control. Traditional regional anesthetic techniques usually is done by help of the anatomical landmarks and clinical judgment . Anatomic landmarks are usually an anatomic sign on the skin of injection site which identified by palpation on the bony prominence or arterial pulse. It could be near bony prominence or arterial pulse or a few centimeters away from it, based on the passage of a nerve or nearby organ-specific. But many disadvantages like anatomical differences, small adjacent nerves and blood vessels, lungs, …show more content…
and other vital organs that lead to the failure of the injections and side effects and complications and also inaccuracy of epidural steroid injections performed with surface landmarks put the success of the landmark technique into question. ( 1-3) With introduction of ultrasound (US) in medicine by Dr. Karl Theo Dussik, an Austrian neurologist as a medical diagnostic tool (4), anesthetists tried to use it to increase the quality of injections. US is the first widely used imaging instrument in regional anesthetia practice because it is mobile, free of radiation risk and relatively inexpensive when compared with other imaging modalities(e.g. magnetic resonance and computed tomography). Moreover It is noninvasive, safe, easy to use, and can be quickly performed. So USG became a promising alternative to traditional landmark-based techniques.(5-6) But anesthesiologist were slow adopters of USG largely because they had a culture of using surface landmarks to help the performance of nerve blocks .(7) Like any scientific work, the experts were looking for sonoanatomy, they tried to find evidence for injections with ultrasound and measure the distance from the skin to the injection site to know how and how many centimeters of the body must needles pass to reach the maximum block. Milestones that must be met during injection with the help of ultrasounds are familiarity with sonoanatomy and correct diagnosis of bony acoustic shadow, muscle layers, vessels and deposition of the local anesthetic in correct site for example into the appropriate interfascial planes. US provide cross-sectional view of anatomical structures and providing instantaneous visual guidance or real-time imaging that can help define individual regional anatomy, guide needle advancement carefully and ensure spread of local anesthesia, potentially optimizing nerve block efficacy and safety.(8) Bogin and Stulin were the first to report the use of US for central neuraxial block in 1971.(9) Porter et al in 1978 used US to image the sonoanatomy of lumbar spine.(10) Cork et al use US to locate the landmarks relevant for epidural anesthesia in 1984.(11) Ultrasound imaging has transformed the practice of regional anesthesia in the last 10 years.USG has been associated with higher block success rates and lower volumes of local anesthetic solution required compared to landmark techniques.
Studies have demonstrated that ultrasound guidance leads to faster and denser blocks, as well as a reduction in local anesthetic requirements, when compared to nerve stimulation guidance.(1,2,6,12-14) Recent data suggest that ultrasound guidance reduces the number of needle passes required to perform interscalene block and that more consistent anesthesia of the lower trunk is possible with USG techniques.(15-16) Ultrasound guidance is emerging as a reliable, effective technique for perineural catheter insertion too. USG help to placed catheters in the vicinity of peripheral nerves for continuous infusion of drugs (17) but not improve the ease of insertion of labour epidural catheters in patients with easily palpable lumbar spines (18 ). Pain medicine practice guidelines recommend that almost all procedures perform by image guidance to enhance the accuracy, precision, safety, and diagnostic information derived from the procedure.(19) Evidence suggests that USG epidural puncture …show more content…
improves the success rate of epidural access on the first attempt (20),decrease the number of attempts(21) and improves patient comfort during the procedure.(22) Especially in patients with difficult epidural access like obesity or in patients with a history of difficult epidural access, and kyphosis or scoliosis .(21) USG obstetric epidural anesthesia decrease side effects and increase the quality of analgesia and patient satisfaction.(23) Ultrasound is extraordinarily common in acute pain block procedures, and chronic pain practitioners for both a diagnostic and therapeutic block .
USG use for doing many procedures for example; nerve blocks (e.g. the brachial or lumbar plexus, more distal branches of the plexus, or at less common locations such as proximal to sites of trauma or entrapment or neuroma formation), blockade of various small sensory or mixed nerves, such as the suprascapular(24), pudendal(25), intercostal(26), genitofemoral(27), ilioinguinal &iliohyoigasteric(28), lateral femoral cutaneous( LFCN)(29) , greater occipital and third occipital nerve blocks(31) and various other sites. As well as spinal procedures including epidurals, selective spinal nerve blocks(31) facet joint, medial branch blocks(33,34) could be done by US, further sympathetic blocks like stellate ganglion(34), celiac plexus block(35), superior hypogasteric plexus block(36) and impare ganglion block(37) is done by US, also injection into interfascial planes like transverse abdominal plane block (38), rectus sheet block(39) plus myofacial injection(40) , joint injection(41) and bursitis ,tendonitis injection (42) is perform by US, although the outcome of intra-articular procedures is not specifically known.(43) Finally, there are possible to place peripheral neuromodulation electrode with ultrasound guidance( 44) or fill interathecal pump by US.(45)
US faces many challenges such as difficulty in visualization
of thin needles, poor image quality in obese patients, and the need to invest time and money in training . However, the advantages makes ultrasound a very attractive option, and with further research and training, ultrasound may well become a standard of care. Although superiority of USG to landmark injection is obvious, however landmark techniques are sometimes the base of USG techniques, for example LFCN injection is at 2 cm medial and 2 cm inferior to the anterior superior iliac spine ( ASIS) and this site is just the same site where you put the linear probe for USG injection(29) or in sacroiliac joint (SIJ) injection which its landmark for injection is one thumb under posterior superior iliac spine( PSIS), where is the same site you put the curve probe for USG injection(46-47) or in caudal block which enter needle according to landmark by palpation and identification of sacral hiatus and put the curve probe at the same site for USG injection (48-49). However in some injection landmark are different from USG, for example in illioinguinal & iliohypogasteric block landmarks are 2 inch medial and 2 inch inferior to the ASIS and 1 inch medial and 1 inch inferior to the ASIS respectively where the site of injection in USG block is between internal abdominal muscles and transverse abdominal muscle and linear probe must put in the distance of ASIS and umbilicus and block both nerve simultaneously(28) or the site of injection for transverse abdominal plane block (TAPB) according to landmark is at the ilio-lumbar triangle of Petit, a small triangle above iliac crest, but USG help you to do injection on many site of anterior abdominal wall between internal abdominal muscles and transverse abdominal muscle(38). For novice practitioner learning of landmarks are useful because the basics of every ultrasound injection is; familiarity with anatomy of injection site, identification of the landmark and study of the sonoanatomy , and finally injection technique. So, landmark help the novice to put their probe correctly at the site of injection. The author predicts that as ultrasound technology continues to improve and as anesthesiologists and pain specialist interested on technology and skills necessary to perform USG injection, USG will undoubtedly progress and may become the standard care in the future. It is undeniable that landmark technique opens the door to the emergence of USG and should not be forgotten that USG injection is update of landmark or clinical judgment in regional anesthesia
Prior to intubation for a surgical procedure, the anesthesiologist administered a single dose of the neuromuscular blocking agent, succinylcholine, to a 23-year-old female to provide muscular relaxation during surgery and to facilitate the insertion of the endotracheal tube. Following this, the inhalation anesthetic was administered and the surgical procedure completed.
The first activity was isolating the gastrocnemius muscle. A cut between the thigh and hip was made so the skin can be pulled down past the lower leg. Then the tendon was cut away from the bone of the heel and one end of the nine-inch string was tied to the tendon. This led to the isolation of the sciatic nerve, found between the hamstring and heel on the lateral side of the thigh. Using fingers, the seams along the quadriceps and hamstring underwent a blunt dissection. In doing so, the glass-dissecting probe was used to free the sciatic nerve embedded in the tissues. A four-inch string was inserted between the nerve and the tissues. Then the transducer was calibrated using a fifty-gram block under the “Frog Muscle” program. Parameter of CAL 1 was changed to zero grams and CAL 2 was changed
Brody, Michael, and Donald Martin. “The Role of Anesthesiologists.” Physicians Protecting Patients. N.p. N.d. Web. October 21, 2015. An anesthesiologist is a physician who has received at least 8 years of schooling and has completed a residency program dealing with anesthesiology. Now, a licensed physician, an anesthesiologist deals with the administration of anesthesia during many medical procedures, including surgical or obstetric procedures, and pain management for acute and chronic illnesses, or cancer related pain. Anesthesiologists are also in charge of “anesthesia care teams” that include the anesthesiologist, an anesthesia assistant, certified registered nurse anesthetist, and an anesthesia technician. As the leader of the care team, the anesthesiologist is responsible for assessing the patient before, during, and after medical procedures, as well as developing and monitoring performance and quality of practices and standards in regards to administering anesthesia. The entirety of
In order to be completely informed a mother needs to know what exactly an epidural is and how it works. An epidural is the most popular form of pain relief during labor. An epidural is a regional pain reducer. An epidural is analgesia, which is meant for pain relief. This is much different than an anesthesia, which provides total lack of feeling to a region of the body. Epidurals are giving intravenously. There are two types of epidurals a woman can get. The first method is a regular epidural. In a regular epidural, after the catheter is in place, a combination of narcotic and anesthesia is administered either by a pump or by periodic injections into the epidural space. The second type of epidural is a combined spinal-epidural, these are often called the “”walking epidural”. In this type of epidural, an initial dose of narcotic, anesthetic or a combination of the two is injected beneath the outermost membrane covering the spinal cord.
The practice of patient-controlled analgesia (PCA) has been around for approximately four decades now. During this time there have been improvements to the technology and the understanding of how to use this form of patient pain control; however, there continues to be concern related to the safety and efficacy of PCA. As this analysis proceeds it will briefly explain what PCA is and how it is used, then delve into the benefits and the safety issues surrounding PCA use as it pertains to the patient and the nurse. Some of the benefits of PCA include improved pain management, improved use of nursing resources, increased patient satisfaction, and reduced pulmonary issues (Hicks, Sikirica, Nelson, Schein & Cousins, 2008). Some of the safety issues surrounding PCA use include infusion pump programing errors, basal infusion dosing, and proxy errors when using PCA by proxy (Ladak, Chan, Easty, & Chagpar, 2007). Therefore, the purpose of this report is to examine the benefits and risks of patient-controlled analgesia and how it relates to nursing practice.
Other basic cases happen when managed weight has been connected over a nerve, hindering/fortifying its capacity. Evacuating the weight ordinarily brings about continuous help of these paresthesias. (Paresthesia 1)
This book has a detailed account of the discovery and controversy over anesthesia. I used this book mostly for its primary documents. It was extremely useful.
Development of protocols that restrict catheter placement can serve as a constant reminder for providers about the correct use of catheters and provide alternatives to indwelling catheter use (Meddings et al. 2013). The 'Secondary' of the 'Secondary' of the 'Secondary' of the 'Secondary' of the 'Secondary' of the 'Secondary' of the 'Secon Alternatives to indwelling catheter include condom catheter, or intermittent straight catheterization. One of the protocols used in this study is urinary retention protocols. This protocol integrates the use of a portable bladder ultrasound to verify urinary retention prior to catheterization. In addition, it recommends using intermittent catheterization to solve temporary issues rather than using indwelling catheters.
This could be due to the particular patient's situation or to the type of medical procedure being done. If the surgeon uses a local anesthetic, no modifier is required. If the surgeon uses a general or regional anesthetic, Modifier 47 is used to distinguish this difference.
...ure anesthesia, auricular needling is often used. By stimulating sensory receptors at auricular points, signals inputted into the body are transmitted through the trigeminal lemniscuses instead of the spinal cord. There were studies demonstrated anterior and posterior portions of the nucleus of spinal tract of trigeminal nerve had similar feedback effects to the gate system in the posterior horn of spinal cord, which could be used to modulate transmissions of pain impulses. This might be able to explain why auricular acupuncture has analgesia effects on surgical or painful irritation on the head and face. However, anesthesia effects of auricular acupuncture during thoracic and abdominal surgeries cannot be explained by any hypotheses about the gate control occurring at either posterior horns of the spinal cord or the nucleus of spinal tract of trigeminal nerve [27].
"Chapter 37." Operative Techniques in Orthopaedic Surgery. Ed. Sam Wiesel. 4th ed. Vol. 2. Lippincott Williams & Wilkins, 2011. eBook.
Volles, D. F. (2011, April 11). University of Virginia Health System Adult and Geriatric Sedation/Analgesia for Diagnostic and Therapeutic Procedures. Retrieved May 12, 2011, from University of Virgina Health System: University of Virginia Health System Adult and Geriatric Sedation/Analgesia for Diagnostic and Therapeutic Procedures
Today scientist found a way to create 3-D organ prints, physicians have a large variety of options to use as medication such as antibiotics. Also, many surgical procedures have been discovered throughout the years. An improvement toward surgery has bee anesthesia. “Modern surgery is possible because of the development of anesthesia” ("Anesthesia & Types of Anesthesia”). There has been developed three types of anesthesia: local, regional, and general. “The type of anesthesia used for a surgical procedure is determined by several factors: type and length of the surgery, patient health, and preference of the patient and physician.” (“Anesthesia & Types of Anesthesia”). Local anesthesia is used for minor surgeries in a very specific region, it can come as a spray or a cream. Regional anesthesia numbs a whole body region, usually done on the lower part of the body. This anesthesia is used for intensive surgeries. General anesthesia makes you completely unconscious. It is inhaled by a mask through the patient, but it is only used if regional or local anesthesia could not be utilized. The advancement of anaesthesia makes more surgical procedures possible. Today's surgery pain is not as cruel as it used to be during the civil war. If a person got wounded due to a bullet they most likely would not need amputation because of the medical advancements. Amputation is not as painful as before and
Unlike vaginal birth delivery, the process of a cesarean delivery is quite different, but just as safe as giving vaginal birth (Taylor, 1). When delivering a baby using the cesarean method, there are two ways anesthetic can be used. The women can be put into an unconscious state using the anesthetic, therefore she will be asleep during the entire operation and her coach may not be present. The other way for the anesthetic to be used would be in an epidural or spinal block to temporarily numb the woman from her waist down. In this case the mother will be awake and her coach may be present to give her extra support. Once the anesthetic is working, an incision is made in the abdomen either horizontally or vertically, depending on the reason for the cesarean delivery. A vertical incision is made when the baby is in trouble and needs to be out as quickly as possible, when there is more time the horizontal incision is used. The baby is then lifted out of the uterus and gone for the APGAP procedure. The placenta is then removed and the mother’s reproductive organs are examined before closing the incision (Taylor, 1).
Neurological procedures can lead to significant postoperative deficits. It is important for physicians to assess nervous system function intraoperatively so that any deficits can be corrected before they become permanent. The oldest method of assessing spinal cord function is with the Stagnara wake up test where patients are awoken in the middle of surgery in order to assess motor function(1). Once the neurological status of the patient is evaluated, the patient would be reanesthetized and the surgery would resume. The wake up test is limited in that it only provides a brief assessment of motor function. It fails to detect ischemia and sensory function(2). Now, intraoperative neurophysiological monitoring with motor evoked potentials (MEPs), somatosensory evoked potentials (SEPs), electromyography (EMG), electrocorticography (ECoG), and cortical mapping has become the new standard of care. It allows physicians to examine the nervous system function without waking the patient. It has become an essential intraoperative tool to improve safety in surgical procedures and helping minimize postoperative deficits. It has allowed surgeons to accept high-risk patients who might have been otherwise denied for a surgical procedure. There are many intraoperative monitoring modalities used to assess different part of brain, spinal cord, and the peripheral nervous system. The strength of each modality is able to offset the limitations of other monitoring modalities, and when combined together, they provide a comprehensive picture on the complex spinal cord function.