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Ultrasonography and stimulating perineural catheters for nerve blocks: a review of the evidence

L’échographie et les cathéters périneuraux stimulants pour les blocs nerveux : une synthèse des données probantes

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Abstract

Purpose: This narrative review summarizes the evidence derived from randomized controlled trials (RCTs) offering blinded assessment and sample size justification, in order to determine the benefits associated with adjunctive ultrasonography (US) and stimulating perineural catheters for nerve blocks.

Source: The literature search for this review was conducted during the second week of December 2007 using the MEDLINE (January 1950 to November 2007) and EMBASE (January 1980 to November 2007) databases. For US-guided peripheral and neuraxial blocks, the following medical subject heading (MeSH) terms were searched: “nerve block”, “epidural anesthesia”, “epidural analgesia”, “epidural injection”, “epidural space”, “spinal anesthesia”, and “spinal injection”, the results were combined with “ultrasonography” (MeSH term) and “ultrasound” (key word). For stimulating perineural catheters, the following MeSH terms were cross referenced with the MeSH term, “nerve block”: “peripheral catheterization”, “indwelling catheterization”, “catheterization”, and keywords, “nerve catheter” and “continuous”. Subsequently, the result of this search was combined to “stimulating” (key word). Fifteen RCTs, offering blinded assessment and sample size justification, were retained for analysis.

Principal findings: For axillary blocks, US guidance yields a higher success rate than a double-injection, transarterial and a triple-injection, neurostimulation-guided technique. Compared to a quadruple-stimulation technique, no major differences can be found. The addition of nerve stimulation to US guidance offers no clear benefits for axillary blocks. For femoral blocks, compared to neurostimulation, echoguidance is associated with a local anesthetic (LA) sparing effect (up to 42%). In children, US guidance yields a LA sparing effect and a longer duration of action for lower extremity nerve blocks. Compared to their blind counterparts, stimulating catheters seem to offer limited clinical benefits. Despite providing a sparing effect on LA and opioid consumption, stimulating catheters are not associated with a decrease in side effects or analgesia-related expenditures.

Conclusions: Published reports of RCTs provide evidence to formulate limited recommendations regarding the use of adjunctive US and stimulating perineural catheters. Further well-designed and meticulously executed RCTs are warranted.

Résumé

Objectif: Cette synthèse narrative résume les données probantes tirées d’études randomisées contrôlées (ERC) disposant d’une évaluation en aveugle et de justification de la taille de l’échantillon afin d’identifier les bienfaits associés à une utilisation conjointe de l’échographie et de cathéters périneuraux stimulants lors de blocs nerveux.

Sources: La recherche de littérature pour cet article de synthèse a été menée la deuxième semaine de décembre 2007 dans les bases de données MEDLINE (janvier 1950 à novembre 2007) et EMBASE (janvier 1980 à novembre 2007). Pour les blocs périphériques et neuraxiaux échoguidés, les termes MeSH suivants ont été recherchés : « nerve block », « epidural anesthesia », « epidural analgesia », « epidural injection », « epidural space », « spinal anesthesia » et « spinal injection », et ont été associés à « ultrasonography » (terme MeSH) et « ultrasound » (mot clé). Pour les cathéters périneuraux stimulants, les termes MeSH suivants ont été croisés avec le terme MeSH « nerve block » : « peripheral catheterization », « indwelling catheterization », « catheterization », et les mots clés « nerve catheter » et « continuous ». Ensuite, les résultats de cette recherche ont été combinés avec le mot clé « stimulating ». Quinze ERC disposant d’une évaluation en aveugle et de justification de la taille de l’échantillon ont été retenues pour être analysées.

Constatations principales: Dans le cas de blocs axillaires, l’échoguidage offre un meilleur taux de réussite qu’une technique de double injection transartérielle et qu’une technique de triple injection guidée par neurostimulation. Si on compare l’échoguidage à une technique de quadruple stimulation, aucune différence majeure n’apparaît. L’ajout de stimulation nerveuse à l’échoguidage ne procure pas de bienfaits clairs dans le cas des blocs axillaires. Lorsqu’un bloc fémoral est réalisé, l’échoguidage est associé à un besoin moindre en anesthésique local (AL) (jusqu’à 42 %) par rapport à la neurostimulation. Chez les enfants, l’échoguidage résulte en un besoin moindre en anesthésique local et une durée prolongée d’action pour les blocs nerveux des membres inférieurs. Par rapport à leurs pendants aveugles, les cathéters stimulants semblent n’offrir que des bienfaits cliniques limités. Malgré le fait qu’ils génèrent un besoin moins important en anesthésiques locaux et réduisent la consommation d’opioïdes, les cathéters stimulants ne sont pas associés à une réduction des effets secondaires ou des coûts liés à l’analgésie.

Conclusion: Les comptes-rendus publiés d’ERC fournissent des données probantes qui peuvent encourager la formulation de recommandations limitées quant à l’utilisation conjointe d’échoguidage et de cathéters périneuraux stimulants. D’autres ERC bien conçues et menées avec soin sont justifiées.

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Correspondence to Q. H. Tran MD FRCPC.

Additional information

Competing interests: None declared.

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Tran, Q.H., Muñoz, L., Russo, G. et al. Ultrasonography and stimulating perineural catheters for nerve blocks: a review of the evidence. Can J Anesth 55, 447 (2008). https://doi.org/10.1007/BF03016312

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Keywords

  • Nerve Block
  • Ropivacaine
  • Total Knee Replacement
  • Levobupivacaine
  • Femoral Nerve Block