|Year : 2020 | Volume
| Issue : 1 | Page : 8-14
Peripheral nerve blocks in trauma patients: Recent updates and improving patient outcomes: A narrative review
G. V. Krishna Prasad, Sangeeta Khanna, Vipin Sharma
Department of Anaesthesiology, Military Hospital Kirkee, Pune, Maharashtra, India
|Date of Submission||15-Sep-2019|
|Date of Acceptance||11-Mar-2020|
|Date of Web Publication||16-Apr-2020|
Dr. G. V. Krishna Prasad
Military Hospital Kirkee, Pune - 411 020, Maharashtra
Source of Support: None, Conflict of Interest: None
Trauma is a significant health problem and a leading cause of death in all age groups. Pain related to trauma is severe, but is often undertreated in trauma population. Opioids are widely used to treat pain in trauma patients but being associated with undesirable effects. In contrast, regional analgesia confers excellent site-specific pain relief that is free from major side effects, reduces opioid requirement and is safe and easy to perform. Specific populations that have shown benefits (including decreased morbidity and mortality) with regional analgesic techniques include those with fractured ribs and femur and hip fractures and patients undergoing digital replantation. The use of regional anesthesia in patients at risk for compartment syndrome is controversial; although the data is sparse, there is no evidence that peripheral nerve blocks delay the diagnosis. The benefit of regional analgesia is most evident when it is initiated as early as possible. The performance of nerve blocks both in the emergency room and in the field has been shown to provide quality pain relief with an excellent safety profile.
Keywords: Nerve block, regional anesthesia, trauma, outcomes
|How to cite this article:|
Prasad GV, Khanna S, Sharma V. Peripheral nerve blocks in trauma patients: Recent updates and improving patient outcomes: A narrative review. Indian J Pain 2020;34:8-14
|How to cite this URL:|
Prasad GV, Khanna S, Sharma V. Peripheral nerve blocks in trauma patients: Recent updates and improving patient outcomes: A narrative review. Indian J Pain [serial online] 2020 [cited 2020 May 29];34:8-14. Available from: http://www.indianjpain.org/text.asp?2020/34/1/8/282556
| Introduction|| |
Severe trauma induces stress response by increasing the morbidity and mortality through the activation of neuroendocrine and immune systems. The generation of systemic inflammatory response elevates the catabolic rate and oxygen consumption. Unstabilized patients develop sepsis and multiple organ failure. Pain remains untreated during the initial part of resuscitation, but should be a priority. Untreated pain aggravates stress response and increases oxygen demand and myocardial ischemia. Chronic pain and posttraumatic stress disorder may lead to long-term complications. Opioids are the mainstay for pain relief but are associated with mounting adverse effects.
Trauma patients demand special medical care. Life-threatening conditions (e.g. hemorrhage shock, neurotrauma, and severe blunt or crush injury) demand emergency treatment, and in the early phase of trauma, resuscitation and life-saving measure take priority. However, traumatic injury produces severe stress response and pain that have major impact on the morbidity and mortality. Stress response and pain, activates the neuroendocrine and immune systems producing systemic inflammatory response increasing oxygen consumption and catabolic state., On the other hand, our body develops counteracting systemic response that attenuates first hit, or activation of the neuroendocrine and immune systems., If those reactions are severe, patients will develop complications such as sepsis and multiple organ failure. Multiple organ dysfunctions occur in 11%–50% of trauma patients with high mortality rate (27%–100%). As a pain estimation and treatment takes no priority in the early phase of trauma, pain is frequently undertreated., Sometimes, pain is undertreated purposefully because response to pain stimuli is used as an important physical sign in patient assessment (e.g. in abdominal trauma or as a sign of consciousness in neurotrauma). Other reasons for inadequate pain treatment include lack of knowledge, fear of addiction, and inappropriate pain estimation by medical staff. The consequences of inappropriate pain treatment could aggravate stress response, increase oxygen demand, and lead to myocardial ischemia., In addition, patients with inadequate pain therapy could develop chronic pain and posttraumatic stress disorder. The mainstays of pain treatment in trauma patients are opioids intravenous (IV), especially in the emergency department. The adverse effects of opioid therapy are respiratory depression, nausea and hypotension especially if used in high doses., Beside systemic analgesics' administration, pain could be treated with regional anesthesia (RA) techniques. Currently, RA is a wellestablished method for analgesia in surgical patients for intraoperative and postoperative pain relief., Neuroaxial and peripheral nerve blocks are effective procedures for acute pain treatment. Use of nerve stimulation and advances in ultrasound guided nerve blocks make those procedures safer and even more desirable., Advantages of RA over systemic analgesia in trauma patients are numerous. Application of nerve blocks produces excellent pain control with decreased stress response and minimal systemic effects if applied properly. Mounting literatures showed that RA hastens recovery, decreases intensive care unit and hospital length of stay, improves cardiac and pulmonary function, decreases infection rates, decreases sympathetic activation, and promotes earlier return of bowel function., Absence systemic effects of parenteral opioids and influence on mental status and hemodynamic stability is especially important for trauma patients., Continuous RA techniques with catheter placement and newer local anesthetic and opioid drugs enable frequent adjustment of analgesia intensity according to patients' needs and therefore decreased that risk of masking pain as it is important signs of surgical disease. Another advantage of RA is that simple peripheral nerve blocks could be done in the early phase of trauma in prehospital setting or in the emergency department, decreasing pain and stress to trauma that improves patients' comfort and decreases the probability for chronic pain development., Several RA techniques are optional for trauma patients. Neuroaxial techniques such as continuous epidural catheter are suggested for bilateral rib fractures but are not the best choice if the patient is in shock with multiple extremity fractures., Meanwhile, peripheral nerve blocks are easy to perform for single-extremity fracture in stable patients with low risk of adverse effects. Standard contraindication and measure of precaution with application of epidural analgesia and peripheral nerve blocks to minimize side effects also refers to trauma patients as well., RA must not jeopardize patient safety, and a survey of block quality and duration, especially if continuous techniques are applied, must be assured.
Thus, the present review article was designed to present a weighted summary of the available outcome data in the field of peripheral RA.
| Regional Anesthesia for Rib Fractures|| |
Rib fractures are common in thoracic blunt trauma and are associated with increased morbidity and mortality (up to 16%) if more than three ribs are involved., The mainstay of therapy is good pain control with chest physiotherapy and mobilization., Optional RA techniques for rib fractures include thoracic epidural block, paravertebral block, and intercostal block. The method of choice for rib fractures, especially bilateral, is thoracic epidural analgesia with the possibility of continuous application through catheter placements. Studies show that thoracic epidural block doubles vital capacity, reduces paradox chest movements, and avoids the side effects of systemic opioids for analgesia., There is also six times lower risk of pneumonia with the use of thoracic epidural block in contrast to the use of systemic opioids for pain relief., The percentage of patients treated with thoracic epidural is only about 22% because frequently other factors such as lack of expertise, threat of infection, coagulopathy, spinal fractures, hemodynamic instability, and patient compliance disable its application. There is also concern of placement of epidural catheters in patients with risk of elevated intracranial pressure such as neurotrauma. Thoracic paravertebral block, either as a bolus injection of local anesthetics or as a continuous catheter blocks, represents a valuable alternative when indicated., Few studies found no advantages of thoracic epidural over thoracic paravertebral catheterization for the treatment of rib fracture pain., Although paravertebral blocks are effective modality for pain treatment, their drawbacks include possible side effect of unintentional epidural spread of local anesthetic and need for bilateral block. One level paravertebral blockade produces reliable analgesia for five dermatomes, and some authors recommended paravertebral catheters with fractures of more than four ribs., Techniques for paravertebral blocks include advancing needle to pre-determined distance (1–1.5 cm) beyond the transversus process, loss of resistance, peripheral nerve stimulation, or ultrasound-guided techniques. Application of paravertebral block in trauma patients could be difficult even under the guidance of nerve stimulator or ultrasound because subcutaneous emphysema and hematoma could disrupt orientation. Additional information about the best place and depth of paravertebral blocks could be obtained from computed tomography scan, improving the margin of safety. Another technique for pain relief in patients with rib fractures includes intercostal block, a simple and effective method for initial pain therapy but with limited duration of maximally 4–6 h. Insertion of catheters may prolong analgesic effects but also increase the danger of side effect of systemic absorptions of local anesthetics.
Blanco et al. in 2013 described ultrasound-guided serratus anterior plane (SAP) block as an alternative to other regional anesthetic techniques in patients undergoing breast surgeries identifying two potential spaces: superficial and deep to serratus anterior (SA) muscle at the level of the fifth rib in the mid-axillary line. However, Fajardo et al. gave preference to the deeper block, between the SA and external intercostal muscles.
The erector spinae plane block (ESP block) is a novel ultrasound-guided technique that has recently been described for the management of acute and chronic thoracic pain. ESP block is a RA technique in which local anesthetic (LA) is injected between the erector spinae muscle and transverse process under ultrasound guidance, blocking the dorsal and ventral rami of the thoracic and abdominal spinal nerves.[Figure 1] (a, b) shows, sonoanatomy for ESP block & (c, d) shows, Ultrasound guided ESP block showing location of needle and local anaesthetic deposited deep to the erector spinae muscle developing visual linear pattern of LA spread.
|Figure 1: (a and b) Sonographic anatomy for erector spinae plane block. Tm: Trapezius muscle, Rm: Rhomboid major muscle, Es: Erector spinae muscle, TV4 and TV5: Transverse process of the fourth and fifth thoracic vertebrae, respectively. (c and d) Ultrasound-guided erector spinae plane block showing the location of needle (arrows) and local anesthetic (LA) deposited deep to the erector spinae muscle (Adapted from Hamilton et al. Br J Anaesth 2017)|
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Luftig et al. reported that in the ESP bloc the posterior rami are better targeted in comparison to SAP block. In addition, injection in this region shows evidence of cephalocaudal and paravertebral LA spread that reaches the origin of the intercostal nerves, resulting in dense hemithorax anesthesia. The author suggested that ESP block is highly effective for acutely injured patients with posterior rib fractures.
ESPB is a recently introduced myofascial plane block by Forero et al. in 2016 for chronic postthoracic neuropathic pain poorly responsive to oral pharmacotherapy. The exact mechanism by which ESPB provides analgesia is still unclear. One mechanism that is widely accepted is the diffusion of LA into PVB space, which blocks both the dorsal and ventral rami of spinal nerves and rami communicants that transmit sympathetic fibers to provide anesthesia and analgesia. However, a recent cadaveric study by Ivanusic et al. demonstrated extensive craniocaudal and mediolateral dye spread superficial and deep to the erector spinae muscle, but there was lack of spread of the dye anteriorly to PVB space. Adhikary et al. used magnetic resonance imaging to compare ESPB and retrolaminar block in cadavers. They noted the spread of dye to intercostal spaces, neuroforaminal areas, and epidural space in ESPB. Chin et al. have proposed differential block theory which may help to reconcile the disputing results between the clinical effects and cadaveric study. According to this theory, fascial plane blocks, where LA is deposited away from the target nerves; the volume of LA is so small that detection by conventional means is difficult.
An intercostal nerve blockade at only one segment provides anesthesia or analgesia in a limited area. Blockade of several nerves could be used as the primary anesthetic technique in a variety of surgical procedures on the thoracic and abdominal wall. The extent of the blockade, however, is determined not only by the site of the blockade, but also by the volume of local anesthetic rejected. The spread of the local anesthetic has been carefully studied by several investigators and has been demonstrated both anatomically and radiologically.
Further, rib fracture scores also affect the anesthetic administration. Easter created a formula to find adult patients who are at higher risk and are therefore in need of a higher level of care.
Rib fracture score = (breaks × sides) + age factor
“Breaks” is the total number of fractures to the ribs and not the number of ribs fractured, for example, two fractures in one rib score 2. For “sides,” unilateral fractures score 1 and bilateral 2. Age is factored into the equation due to the aforementioned increased risk of complications, with different age groups scoring between 0 and 4.
One of the recently described approaches is mid-point transverse process to pleura (MTP) block by Costache et al. In this, the anesthetic drug is deposited at the mid-point between the transverse process and pleura, and it reaches the paravertebral space by diffusion. With this technique, even if superior costal transverse ligament (SCTL) is not visible, effective block can be achieved. In addition, the needle is placed far away from the pleura, minimizing the rate of pneumothorax. Previous studies have reported the presence of gap between the medial and lateral parts of the SCTL, the intermingling of lateral fibers with internal costal membrane, and the fenestrated nature of SCTL., These probably explain the diffusion of drug in MTP block, to reach the nerve roots in the paravertebral space. This block is reported to be successful in unilateral mastectomy and mammoplasty surgeries where drug is injected at multiple levels.
| Hip and Lower Extremity Bone Fractures|| |
Long bone fractures are associated with severe pain that is frequently left undertreated in the emergency department., Several studies described better pain control, decreased incidence of deep-vein thrombosis (DVT), decreased postoperative confusion, and decreased incidence of postoperative pneumonia in patients with femur and hip fractures treated with RA. Proximal femur is predominately innervated by femoral nerve with contribution of sciatic nerve and obturator nerve that also should be blocked if total analgesia for surgery is needed. The types of RA used for hip and proximal femoral fractures include femoral nerve block and fascia iliaca compartment block (FICB)., Femoral nerve is blocked either by bolus dose or continuously with the placement of a catheter. Femoral nerve could be easily visualized on ultrasound and obvious local anesthetics spread could be followed, thus avoiding unpleasant nerve stimulation. The following landmarks are used to determine the site of needle insertion: inguinal ligament, inguinal crease, and femoral artery. Femoral nerve block reduces parenteral analgesics, improves analgesia and help to optimize patients positioning for neuroaxial block if surgery is planned., FICB is performed by a single blunt needle puncture 1 cm bellow point between the distal and medial parts of a line drawn between the spine iliaca anterior superior and pubic bone. While advancing the needle, two pops should be felt and local anesthetics is injected after confirmation of no intravascular injection. Volume of local anesthetics of about 20 ml has been used successfully. Sciatic nerve block is indicated for more distal femur fracture and fractures of the leg and ankle. Sciatic nerve block technique for femur fracture includes classic Labat or supragluteal approach. Sciatic nerve identification is done using ultrasound or nerve stimulation techniques. For successful analgesia and surgical repair of proximal tibia and fibula fracture, femoral and sciatic nerve blocks are beneficial. For fibula fracture, sciatic nerve block should be complemented with saphenous nerve block depending on the medial cutaneous involvement. For lower leg and ankle fractures, a popliteal block is indicated, and ultrasound visualization of nerve poses a great margin of safety with high efficiency.,
Continuous block techniques are utilized because of severe pain after surgical stabilization. Due to the erector spinae muscle extension to the lumbosacral level, it is conceivable that LA may spread to lumbosacral levels during ESP block at lower lumbar levels. In fact, the ESP block has been described as part of multimodal analgesia after spine surgery of lumbar stenosis or prolapsed lumbar disc. The paraspinal muscles and posterior bony elements of the spine are innervated by the dorsal rami of the spinal nerves. These originate shortly after the spinal nerves exit the vertebral foramina and travel posteriorly through the intertransverse connective tissues and the paraspinal muscles to reach the superficial tissues. In the ESP block, LA spreads within the musculofascial plane and acts on the dorsal rami of spinal nerves. Melvin et al. reported the usefulness of continuous bilateral ESP block performed at the T10/T12 level for perioperative analgesia in lumbrosacral spine surgery in a case series. At lumbar level, the ESP block has been also applied as part of multimodal analgesia in a case of transverse process fracture. Tulgar and Sentruk also suggested that ESP block performed at L4 level could be as effective as epidural analgesia in total hip arthroplasty. Even though the lumbar approach has been demonstrated reliable and effective, the lumbar ESP block placement can be more challenging due to the increased thickness in the erector spinae muscle and the corresponding depth of the intermuscular plane in the lumbar levels, as compared to the thoracic region.
FICB is a technique of injecting a local anesthetic immediately beneath the iliac fascia into the compartment between this fascia and the underlying iliac muscle. This technique has been reported in this article previously. The FICB is thought to block the proximal femoral and lateral cutaneous nerves, both contributing to sensory innervation of the hip. Acute pain management with a traditional FICB in the emergency department is superior to systemic analgesics and possibly several other regional pain strategies in adult patients with hip fractures.,, In a cadaver study, Hebbard et al. described a modified, suprainguinal approach with a theoretical advantage of more dorsal and proximal spread of local anesthetic fluid in the iliac fossa, with a potentially increased success rate. Stevens et al. in a perioperative clinical study on patients undergoing hip arthroplasty concluded that a supra-inguinal technique has significant opioid-sparing effects compared to a sham block.
Adductor canal block (ACB) has been introduced as a pure sensory nerve block for postoperative analgesia following knee surgery. The rationale behind the ACB is that that injecting LA in the canal will block saphenous nerve and part of the obturator nerve travelling through the adductor canal of thigh. A single shot of ACB provides pain relief comparable to femoral nerve catheter and facilitates discharge of patients after total knee arthroplasty. In a small randomized controlled trial, Sztain et al. showed that there is no statistically significant difference between continuous ACB and continuous FNB regarding the median number of hours to overall discharge readiness following unicompartment knee arthroplasty, however, ACB was associated with a lower number of discrete days until discharge. Machi et al. also found that continuous ACB compared to continuous FNB decreases the time until adequate mobilization but not the overall time to discharge readiness.
| Upper Extremity Fracture|| |
Innervations received by humerus from brachial plexus could be blocked at several places, namely, supraclavicular, infraclavicular, and in the interscalene grove. Ultrasound and nerve stimulation techniques are both used successfully, minimizing the risk of nerve injury, intravascular injection, pneumothorax, and inadequate block. Direct visualization of local anesthetics injections enables using low dose of LA thus reducing the risk of side effects., Catheter positioning with continuous approach is recommended because humerus fracture is very painful even after surgical stabilization. The most important point to be kept in mind prior to performing RA is to determine if there is nerve injury that should be documented. A valuable option for shoulder displacement represents interscalene block that offers excellent pain relief and muscle relaxation. For clavicle fracture, nerve blocks of C5/C6 nerve roots are utilized for distal fracture and C4 root for more medial fracture. In patients with clavicle fracture, there is risk for injury of supraclavicular nerve and brachial plexus that should be investigated before RA. RA techniques for the repair of forearm bone fractures (radial/ulnar bones) include brachial and axillary plexus blocks. Patients on ultrasound-guided blocks have excellent analgesia, reduction in parenteral opioids, shorter recovery room times, and earlier hospital discharge than those on general anesthesia, which makes RA a technique of choice., Both blocks can be performed easily and safely with ultrasound visualization, ensuring adequate pain control and blockade of all branches of brachial and axillary plexus blocks for successful pain control.
| Concerns of Regional Anesthesia Techniques in Trauma Patients|| |
Like any medicine procedure, RA has its own risk and limitations. The main disadvantages are technical complexity of procedure and training to achieve and maintain proficiency in RA procedures. As an invasive procedure, RA poses risks of infection, nerve injury, vascular injury, pneumothorax, and local anesthetic toxicity. Anesthesiologists must be aware of all drawbacks of RA, such as need of appropriate environment for block performance (compliant patient, compliant surgeon, quite environment, and enough time). Thorough knowledge of local anesthetics pharmacology is crucial enabling the block to be effective when surgery starts. It is prudent to choose general anesthesia over RA when multiple blocks and catheters are needed. Examples are patients with multiple fractures and extensive trauma when patients life is priority. In such situation, RA could be introduced after surgery for analgesia. Anesthesiologists performing RA must have thorough knowledge of pathophysiology changes in trauma patients, especially addressing compartment syndrome and coagulation abnormalities. Compartment syndrome is of primary concern because patients with forearm or leg injuries are especially prone to the development of that syndrome that, if left untreated, could result in amputation of extremity or in multiple organ failure with lethal outcome. The disadvantages of RA are that complete analgesia could mask pain and paraesthesia, early symptoms of compartment syndrome, or nerve injury. There are several reports of delayed diagnosis of nerve injury and compartment syndrome in literature, especially with subarachnoidal and epidural blocks., Patients at greatest risk for compartment syndrome includes fracture of forearm bones, tibiae plateau fracture, crush injuries and prolonged immobilization. Patients with hip and femoral fractures are less prone to compartment syndrome. Early diagnosis is sine qua non for the management of compartment syndrome with extensive fasciotomy. A high index of suspicion, frequent evaluation of pain and RA quality and patient assessment, and compartment pressure measurement are crucial for the successful diagnosis of compartment syndrome. The risk of masking compartment syndrome is decreased by using continuous RA techniques, with lower local anesthetic concentrations and using newer local anesthetic drugs with short duration of action., When performing RA in trauma patients, practitioners must be aware of the increased chance for coagulation abnormalities. Recommendations for performing RA should be devised according to the latest American Society of RA and pain medicine guidelines. The best way is to individually weigh the risks against the benefits of RA in trauma patients with coagulation abnormalities. If RA is chosen for patients with coagulation abnormalities, extreme vigilance and monitoring for eventual side effects is mandatory.
Continuous peripheral nerve catheters
Continuous peripheral nerve blocks (CPNBs) are also known as continuous perineural blocks. CPNBs offer tremendous advantage in the perioperative period. These techniques offer the possibility of prolonging intraoperative anesthesia while avoiding the risks and side effects of general anesthesia and central neuraxial block. Continuous perineural blocks are site specific and offer superior analgesia than parenteral opioid and also are not associated with the possible side effects of opioid analgesia including nausea, vomiting, sedation, and respiratory depression. The quality of analgesia mimics that of epidural analgesia, but it is devoid of certain complications associated with epidural anesthesia such as hypotension, urinary retention, and pruritus. There is increasing evidence to indicate that CPNBs aid in early mobilization, decrease the incidence of DVT in the perioperative period, aid in better sleep pattern, and decrease the incidence of cognitive dysfunction in the perioperative period.[Figure 2], illustrates a continuous peripheral nerve block involving the femoral nerve.
|Figure 2: Illustration of a continuous peripheral nerve block involving the femoral nerve. This particular perineural catheter insertion technique employs electrical stimulation alone via a stimulating catheter (Adapted from Ilfed et al. Anesth Analg. 2011.)|
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Benefits of CPNB are better pain control, reduced opioid consumption and related side effects, and increasing patient satisfaction, as in shoulder and elbow procedures. Potent analgesia is achieved and maintained perineural infusion of local anesthetics.
Ilfeld et al. reported in a retrospective study that a continuous interscalene block using ropivacaine 0.2% was associated with increased range of shoulder motion following shoulder arthroplasty.
The dramatic decrease in supplemental opioids, opioid-related side effects, and sleep disturbances, while simultaneously increasing patient satisfaction, are important benefits of the CPNB. Moreover, a an early ambulation with additional optimization of daily activities after CPNB compared with IV opioids has been described. For continuous RA following shoulder and knee arthroplasty, an accelerated improvement of passive joint range of motion potentially leading to shorter hospitalization has been described.
The possible complications include catheter tip placement too far from the target nerve and therefore lacking analgesia, or misplacements such as intravascular, intrapleural, intraneural, epidural, or even intrathecal. However, whether catheter migration is possible after correct placement remains unclear.
| Newer Applications; On-Arrival Block|| |
The chemical sympathectomy produced by CPNBs is ideal after microvascular surgery, reimplantation, and free flap procedures. They are also of great use in treating patients with chronic pain syndromes and those requiring palliation for terminal illness. It also helps to provide immediate pain relief in major trauma just after the initial stabilization of the patient. This could be termed as “on-arrival block.” It is also becoming evident that it not only provides immediate pain relief to the trauma victim but also considerably attenuates the stress response to tissue trauma. The stress response to tissue injury is mediated through neurohormonal, metabolic, and immunological responses, which, in turn, result in the release of a plethora of chemical mediators such as bradykinin, substance P, leukotrienes, and interleukin. These chemical mediators in turn produce changes in the end organs and if unabated might lead to systemic inflammatory response syndrome (SIRS) and occasionally even to multiple organ dysfunction syndromes. Effective and early analgesia is thought to attenuate this stress response and possibly could prevent the development of SIRS.
| Conclusion|| |
Advances in the techniques and technologies pertaining to regional anesthesia offer entirely a new spectrum of anesthesia delivery system to the patients. Site-specific analgesia would be probably the most preferred anesthetic technique of the present decade. The development of stimulating catheters has significantly improved the precision of catheter placement close to the peripheral nerves and plexuses, thus increasing the success rate. It offers a promise for future as these continuous perineural catheters might greatly influence the perioperative outcome.
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Conflicts of interest
There are no conflicts of interest.
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