Intercostal nerve blockade for children

A modified technique of intercostal nerve blockade is described which is suitable for use in children. Ten patients received intercostal nerve blockade on a total of 29 occasions in order to provide analgesia following liver transplantation and to facilitate weaning from artificial ventilation of the lungs. The opioid requirement of patients who received intercostal nerve blockade was considerably lower than that of those who did not; 56% of the children who received intercostal nerve blockade required no additional analgesia. One child, the first to receive intercostal nerve blockade, developed a pneumothorax following the procedure. The technique has proved to be safe in skilled hands. It is an acceptable method of postoperative analgesia in children after liver transplantation and may be a useful technique in the management of other paediatric patients.     

Upper limb sympathetic blockade following intercostal nerve blocks

A case of transient sympathetic block of the arm following percutaneous intercostal nerve injections is described and the possible aetiology discussed.     

Low volume intercostal injection. A comparative study in patients and cadavers

This study compared the spread of 3 ml of a solution of bupivacaine-methylene blue in the intercostal space of patients and cadavers. There were 51 successful injections in each group which demonstrated in 86% of patient injections and 84% of cadaver injections that spread was confined to one intercostal space. Spread was more extensive in cadavers, probably as a result of autolysis. It would therefore still appear necessary, when low volumes of local anaesthetic are used, to block each intercostal nerve individually.     

Intercostal neuralgia following stellate ganglion block

The case is described of a 78-year-old female patient who experienced temporary but severe chest wall pain following stellate ganglion block. The possible mechanisms and treatment of this complication are discussed.     

The effects of volume and speed of injection in peribulbar anaesthesia

We have evaluated the effects of the volume and speed of administration of local anaesthetic during peribulbar anaesthesia. One hundred and forty patients scheduled for cataract surgery were randomly allocated to one of four groups of 35. Each patient received an injection of the same mixture of lignocaine, bupivacaine and hyaluronidase. Patients in group A were given 9 ml at a speed of 5 mlmin⁻¹, group B were given the same volume at 12 mlmin⁻¹, group C were given 13.5 ml at 5 mlmin⁻¹ and group D were given 13.5 ml at 12 mlmin⁻¹. A significantly higher incidence of satisfactory akinesia was found in group D, whose pain score at injection was no higher than for the other groups. Large volumes of local anaesthetic significantly affected intra-ocular pressure. The incidences of early and late ptosis or diplopia were not affected by either the rate of injection or the volume of local anaesthetic.     

Perineuronal morphine in intercostal block

In a double-blind, randomised study the potential benefits of combining low-dose morphine with bupivacaine for intercostal nerve blocks for analgesia after biliary surgery were investigated. There was no significant improvement in pain scores or consumption of supplementary analgesics when morphine was added to bupivacaine. This investigation supports the findings of other workers who showed that perineural morphine was ineffective for postoperative pain relief.     

Use of a low-power nerve stimulator during sciatic nerve block

The use of a low-power nerve stimulator to aid nerve location during the performance of sciatic nerve block was compared with a conventional anatomically based technique. The success rate, both in terms of the production of an effective block and the duration of postoperative analgesia, was significantly higher in the stimulator groups than in the non-stimulator groups. The implications of the study for both clinical and teaching practice are discussed.     

Enhanced brachial plexus blockade. Effect of pain and muscular exercises on the efficiency of brachial plexus blockade

Three groups each of 20 patients scheduled to undergo operations on hand or forearm, received supraclavicular brachial plexus blocks with 25 ml lignocaine 1.5%. Patients in the control group did not suffer from pain and were not asked to do muscular exercise. Patients with acute trauma of the upper limb formed the pain group and showed significantly decreased latency for onset of analgesia, partial and complete muscle paralysis. Patients in the muscle exercise group were free of pain and were asked to do muscular exercise for 5 minutes after injection of the lignocaine. Onset of analgesia, partial and complete muscle paralysis was significantly more rapid than in both control and pain groups. Changes in the duration of block were not significant. It is concluded that pain and muscular exercise enhance the onset of brachial plexus blockade.     

Accidental spinal anaesthesia following intrathoracic intercostal nerve blockade

A case of high spinal anaesthesia following intrathoracic intercostal nerve blockade is described and the possible causative mechanisms are discussed.     

The alkalinisation of bupivacaine for intercostal nerve blockade

A double-blind randomised study was performed to investigate the effect of pH adjustment of bupivacaine, with adrenaline 1:200,000, on the duration of block and pain relief after intercostal nerve blockade following thoracotomy. One group (n = 10) received bupivacaine with adrenaline 1:200,000 (pH = 4.1) and the other (n = 10) received alkalinised bupivacaine with adrenaline 1:200,000 (pH = 6.9). There was no significant difference in block duration (mean 23.9 and 26.4 hours respectively) visual analogue pain scores or morphine usage. Patients were more likely to have a block during the first 12 hours if they received alkalinised bupivacaine (p less than 0.01, Chi-squared test). A progressive regression of block, not previously described, was observed, explicable by means of spread of local anaesthesia to adjacent intercostal nerves. Alkalinisation of bupivacaine with adrenaline for intercostal nerve blockade has little clinical benefit.     

Multiple rib fractures and head injury—an indication for intercostal catheterisation and infusion of local anaesthetics

A case is presented which demonstrates the advantages of continuous intercostal analgesia in a patient with a head injury and multiple rib fractures.     

Possible inadvertent subdural block following attempted stellate ganglion blockade

A case is reported of suspected inadvertent subdural block following attempted stellate ganglion blockade for relief of cervicobrachial pain in a patient suffering from reflex sympathetic dystrophy. Possible complications due to neuraxial spread of local anaesthetics while performing a cervicothoracic ganglion blockade are considered.     

Sciatic nerve palsy following uneventful sciatic nerve block

We describe the loss of function in the sciatic nerve after an uneventful sciatic nerve block using 25 ml of lignocaine 1% with adrenaline 1 in 200 000 in a patient receiving β blocker drugs. Lack of pain on injection and complete regeneration of the nerve after 12 months in a patient with severe peripheral vascular disease led us to postulate ischaemic nerve damage as a mechanism of injury. Adrenaline-induced unopposed α-mediated vasoconstriction in a β-blocked patient is suggested as a possible mechanism of peripheral nerve injury worthy of further investigation.     

Unilateral subarachnoid anaesthesia

The development of a unilateral block after subarachnoid anaesthesia is described. Other reported cases are discussed and the anatomy of subarachnoid space summarised.