Nerve injury monitoring: too much ain’t enough

Sala‐Blanch, Xavier; Mejia, Jorge

doi:10.1136/rapm-2021-103293

Cited by 4 publications

(2 citation statements)

References 4 publications

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“…We would like to thank Costa et al 1 for their interest in our study 2. We fully agree, as previously outlined, that pressure monitoring plays an important role in the prevention of nerve injury, and our results should not discourage from progressing in this direction 3. However, we also feel we should not overestimate the information that these instruments provide.…”

supporting

confidence: 80%

Response to Dr Costa

Mejia

Sala‐Blanch

2022

Reg Anesth Pain Med

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supporting

confidence: 80%

Response to Dr Costa

Mejia

Sala‐Blanch

2022

Reg Anesth Pain Med

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“…The test dose concept has been extensively used in neuraxial regional anesthesia, particularly in epidural techniques. Though not widely used in peripheral nerve blocks, the concept has been previously described (better known as hydrolocation) and included in nerve block safety/efficacy algorithms 14–16. Certainly, though US guidance allows real-time vision of nerve and needle, it is often difficult to avoid needle puncture or injection beyond the epineurial barrier.…”

Section: Discussionmentioning

confidence: 99%

Ultrasound is better than injection pressure monitoring detecting the low-volume intraneural injection

Goffin

Mejia

Prats‐Galino

et al. 2022

Reg Anesth Pain Med

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IntroductionInadvertent intraneural injection is not infrequent during peripheral nerve blocks. For this reason, injection pressure monitoring has been suggested as a safeguard method that warns the clinician of a potentially hazardous needle tip location. However, doubts remain whether it is superior to the sonographic nerve swelling in terms of earlier detection of the intraneural injection.MethodsAn observational cadaveric study was designed to assess injection pressures during an ultrasound-guided intraneural injection of the median nerve. We hypothesized that the evidence of nerve swelling occurred prior to an elevated injection pressure (>15 pound per square inch) measured with a portable in-line monitor. 33 ultrasound-guided intraneural injections of 11 median nerves from unembalmed human cadavers were performed at proximal, mid and distal forearm. 1 mL of a mixture of local anesthetic and methylene blue was injected intraneurally at a rate of 10 mL/min. Following injections, specimens were dissected to assess spread location. Video recordings of the procedures including ultrasound images were blindly analyzed to evaluate nerve swelling and injection pressures.Results31 injections were considered for analysis (two were excluded due to uncertainty regarding needle tip position). >15 pound per square inch was reached in six injections (19%) following a median injected volume of 0.6 mL. Nerve swelling was evident in all 31 injections (100%) with a median injected volume of 0.4 mL. On dissection, spread location was confirmed intraneural in all injections.DiscussionUltrasound is a more sensitive and earlier indicator of the low-volume intraneural injection than injection pressure monitoring.

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