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Phantom position under upper limb block and assessment of success
Letters to the Editor References 1. Wu CL, Perkins FM. Oral anticoagulant prophylaxis and epidural catheter removal. Reg Anesth 1996;21:517-524. 2. Horlocker TT, Wedel DJ, Schlichting JL. Postoperative epidural analgesia and oral anticoagulant therapy. Anesth Analg 1994;79:89-93. 3. Enneking FK, Benzon H. Oral anticoagulants and regional anesthesia: A perspective. Reg Anesth Pain Med 1998; 23(suppl 2):140-145.
Accepted for publication August 21, 2001. doi:10.1053/rapm.2002.29129
Phantom Position Under Upper Limb Block and Assessment of Success To the Editor: During regional block, patients commonly report an erroneous position sense in the anesthetized limb, which seems to be associated with more dense neural blocks.1 We conducted a study to evaluate a link between this phenomenon and the block success. After local ethical committee approval and patients’ informed consent, American Society of Anesthesiologists stage I-II patients scheduled for upper limb surgery under axillary block (AB; n ⫽ 75) or intravenous regional block (IVRA; n ⫽ 47) were enrolled. In patients unaware of study design, lying supine with the operated arm in abduction during the whole study duration, AB was performed with stimulations of 2 brachial plexus nerves (radial and median or ulnar nerves). Then 40 mL 1.5% plain lidocaine was injected. A tourniquet was inflated to 250 mm Hg. IVRA was performed with a double tourniquet inflated to 250 mm Hg, and 40 mL plain 0.5% lidocaine was injected. Sensory and motor blocks were evaluated 20 minutes later by pinprick2 in the C5-D1 dermatomes and Bromage’s test3 quoted from 0 (no block) to 3 (complete block). Patients were questioned about tourniquet sensation (0 to 1) or pain (0 to 1) and phantom limb perception from complete abduction to complete flexion (0 to 4). The quality of motor block was estimated by using the sum of each motor block score. Chi-square, Mann-Whitney U-test, and Spearman correlation were used with P ⬍ .05. General anesthesia was required in 4 cases (1 AB, 3 IVRA), and in none of these patients was phantom sensation reported. All other patients had effective blocks and phantom position. Forty-one patients (34%) had tourniquet sensation (13% and 47%, respectively, in IVRA and AB groups; P ⬍ .001), and 116 patients (95%) had tourniquet pain (94% and 97% in IVRA and AB groups, respectively; not significant). The motor block was significantly better in the AB group for all muscular territories except for the musculo-cutaneous territory, whereas the phantom positions were similar in most of the patients describing their limb in incomplete abduction (43% and 37% in IVRA and AB groups, respectively) or in complete flexion (51% and 55% in IVRA and AB groups). In the IVRA group, the phantom was correlated with the intensity of motor block in all territories except the musculo-cutaneous territory. This was not observed in the AB group.
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Our results agree with a previous study1 and suggest a statistical link between phantom position sense and the success of regional blocks. In the study by Bromage and Melzack,1 the rate of phantom sensation (86%) with brachial plexus block contrasts slightly with our results (98.6%) in the AB group performed with a double nerve stimulation; no results concerning the sensory and motor blocks were given.1 Pinprick3 and cold tests4 are the main tests to assess the sensory blocks in regional anesthesia; they activate predominantly A␦ fibers, though they differ from surgical stimulation and do not imply the block of nociception5 when phantom position sense implicates complete deafferentation.1 In our study, tourniquet sensation or pain despite effective blocks were reported as similar to previous studies.6,7 Marc E. Gentili, RD, RSc Francis Bonnet, RD Jean-Marc Bernard, MD, PhD Jean-Xavier Maxoit, MD, PhD Centre Me´dicoChirurgical Saint-Vincent Saint-Gre´goire, France Laboratory of Anesthesiology University-Hospital Biceˆtre Le Kremlin Biceˆtre, France References 1. Bromage PR, Melzack R. Phantom limbs and the bodyschema. Can J Anaesth Soc J 1974;21:267-274. 2. Curatolo M, Petersen-Felix S, Arendt –Nielsen L, Zbinden AM. Epidural epinephrine and clonidine: Segmental analgesia and effects on different pain modalities. Anesthesiology 1997;87:785-794. 3. Bromage PR. A comparison of the hydrochloride and carbon dioxyde solutions of lidocaine and prilocaine in epidural analgesia. Acta Anaesthesiol Scand Suppl 1965;16:55-69. 4. Liu S, Kopacz DJ,Carpenter RI. Quantitative assessment of differential sensory nerve block after lidocaine spinal anesthesia. Anesthesiology 1995;82:60-63. 5. Curatolo M, Kaufmann R, Petersen-Felix S, Arendt-Nielsen L, Scaramozzino P, Zbinden AM. Block of pinprick and cold sensation pooorly correlate with relief of postoperative pain during epidural analgesia. Clin J Pain 1999;15:6-12. 6. Tezlaff JE,Walsh M, Yoon HJ. pH adjustment of mepivacaine decreases the incidence of tourniquet pain during axillary brachial plexus anaesthesia. Can J Anaesth 1993;40:133136. 7. Estebe JP, Le Naoures A, Chemaly L, Ecoffey C. Tourniquet pain in a volunteer study: Effect of changes in cuff width and pressure. Anaesthesia 2000;55:21-26.
Accepted for publication August 21, 2001. doi:10.1053/rapm.2002.29133
Walking Spinal Anesthesia for Cesarean Delivery—Have We Walked Too Far? To the Editor: We would like to report a new spinal anesthesia technique for cesarean delivery. In many institutions, spinal anesthesia for cesarean delivery has once again become the norm. Newer versions of spinal anesthesia have been
Accepted for publication August 21, 2001. doi:10.1053/rapm.2002.29129
Phantom Position Under Upper Limb Block and Assessment of Success To the Editor: During regional block, patients commonly report an erroneous position sense in the anesthetized limb, which seems to be associated with more dense neural blocks.1 We conducted a study to evaluate a link between this phenomenon and the block success. After local ethical committee approval and patients’ informed consent, American Society of Anesthesiologists stage I-II patients scheduled for upper limb surgery under axillary block (AB; n ⫽ 75) or intravenous regional block (IVRA; n ⫽ 47) were enrolled. In patients unaware of study design, lying supine with the operated arm in abduction during the whole study duration, AB was performed with stimulations of 2 brachial plexus nerves (radial and median or ulnar nerves). Then 40 mL 1.5% plain lidocaine was injected. A tourniquet was inflated to 250 mm Hg. IVRA was performed with a double tourniquet inflated to 250 mm Hg, and 40 mL plain 0.5% lidocaine was injected. Sensory and motor blocks were evaluated 20 minutes later by pinprick2 in the C5-D1 dermatomes and Bromage’s test3 quoted from 0 (no block) to 3 (complete block). Patients were questioned about tourniquet sensation (0 to 1) or pain (0 to 1) and phantom limb perception from complete abduction to complete flexion (0 to 4). The quality of motor block was estimated by using the sum of each motor block score. Chi-square, Mann-Whitney U-test, and Spearman correlation were used with P ⬍ .05. General anesthesia was required in 4 cases (1 AB, 3 IVRA), and in none of these patients was phantom sensation reported. All other patients had effective blocks and phantom position. Forty-one patients (34%) had tourniquet sensation (13% and 47%, respectively, in IVRA and AB groups; P ⬍ .001), and 116 patients (95%) had tourniquet pain (94% and 97% in IVRA and AB groups, respectively; not significant). The motor block was significantly better in the AB group for all muscular territories except for the musculo-cutaneous territory, whereas the phantom positions were similar in most of the patients describing their limb in incomplete abduction (43% and 37% in IVRA and AB groups, respectively) or in complete flexion (51% and 55% in IVRA and AB groups). In the IVRA group, the phantom was correlated with the intensity of motor block in all territories except the musculo-cutaneous territory. This was not observed in the AB group.
113
Our results agree with a previous study1 and suggest a statistical link between phantom position sense and the success of regional blocks. In the study by Bromage and Melzack,1 the rate of phantom sensation (86%) with brachial plexus block contrasts slightly with our results (98.6%) in the AB group performed with a double nerve stimulation; no results concerning the sensory and motor blocks were given.1 Pinprick3 and cold tests4 are the main tests to assess the sensory blocks in regional anesthesia; they activate predominantly A␦ fibers, though they differ from surgical stimulation and do not imply the block of nociception5 when phantom position sense implicates complete deafferentation.1 In our study, tourniquet sensation or pain despite effective blocks were reported as similar to previous studies.6,7 Marc E. Gentili, RD, RSc Francis Bonnet, RD Jean-Marc Bernard, MD, PhD Jean-Xavier Maxoit, MD, PhD Centre Me´dicoChirurgical Saint-Vincent Saint-Gre´goire, France Laboratory of Anesthesiology University-Hospital Biceˆtre Le Kremlin Biceˆtre, France References 1. Bromage PR, Melzack R. Phantom limbs and the bodyschema. Can J Anaesth Soc J 1974;21:267-274. 2. Curatolo M, Petersen-Felix S, Arendt –Nielsen L, Zbinden AM. Epidural epinephrine and clonidine: Segmental analgesia and effects on different pain modalities. Anesthesiology 1997;87:785-794. 3. Bromage PR. A comparison of the hydrochloride and carbon dioxyde solutions of lidocaine and prilocaine in epidural analgesia. Acta Anaesthesiol Scand Suppl 1965;16:55-69. 4. Liu S, Kopacz DJ,Carpenter RI. Quantitative assessment of differential sensory nerve block after lidocaine spinal anesthesia. Anesthesiology 1995;82:60-63. 5. Curatolo M, Kaufmann R, Petersen-Felix S, Arendt-Nielsen L, Scaramozzino P, Zbinden AM. Block of pinprick and cold sensation pooorly correlate with relief of postoperative pain during epidural analgesia. Clin J Pain 1999;15:6-12. 6. Tezlaff JE,Walsh M, Yoon HJ. pH adjustment of mepivacaine decreases the incidence of tourniquet pain during axillary brachial plexus anaesthesia. Can J Anaesth 1993;40:133136. 7. Estebe JP, Le Naoures A, Chemaly L, Ecoffey C. Tourniquet pain in a volunteer study: Effect of changes in cuff width and pressure. Anaesthesia 2000;55:21-26.
Accepted for publication August 21, 2001. doi:10.1053/rapm.2002.29133
Walking Spinal Anesthesia for Cesarean Delivery—Have We Walked Too Far? To the Editor: We would like to report a new spinal anesthesia technique for cesarean delivery. In many institutions, spinal anesthesia for cesarean delivery has once again become the norm. Newer versions of spinal anesthesia have been