Combination of intraneural injection and high injection pressure leads to fascicular injury and neurologic deficits in dogs

Hadžić, Admir; Dilberović, Faruk; Shah, Shruti; Kulenović, Amela; Kapur, Eldan; Začiragić, Asija; Ćosović, Esad; Vučković, Ilvana; Divanović, Kučuk-Alija; Mornjaković, Zakira; Thys, Daniel M.; Santos, Alan C.

doi:10.1097/00115550-200409000-00005

Cited by 192 publications

(113 citation statements)

References 28 publications

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“…The cutoff of 15 psi was chosen based on data from a previous study of OIP in brachial plexus block as well as on research conducted on animals and fresh human cadavers. 4,5,14,15 Because OIPs of more than 20 psi have been associated with intrafascicular injection, a cutoff pressure was chosen 5 psi lower than the lowest reported value that resulted in neurological injury. 14,15 Our results are similar to a previous study performed at the interscalene brachial plexus.…”

Section: Discussionmentioning

confidence: 99%

“…4,5,14,15 Because OIPs of more than 20 psi have been associated with intrafascicular injection, a cutoff pressure was chosen 5 psi lower than the lowest reported value that resulted in neurological injury. 14,15 Our results are similar to a previous study performed at the interscalene brachial plexus. 4 However, the neural architecture of the femoral nerve is unlike that of brachial plexus roots.…”

Section: Discussionmentioning

confidence: 99%

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High Opening Injection Pressure Is Associated With Needle-Nerve and Needle-Fascia Contact During Femoral Nerve Block

Gadsden

Latmore

Levine

et al. 2016

Regional Anesthesia and Pain Medicine

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

High Opening Injection Pressure Is Associated With Needle-Nerve and Needle-Fascia Contact During Femoral Nerve Block

Gadsden

Latmore

Levine

et al. 2016

Regional Anesthesia and Pain Medicine

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“…11 Monitoring injection pressures may also aid in preventing intrafascicular injection, but this modality has been studied only in animals and, like other tools, is neither completely sensitive nor predictive of injury. 12,13 Conversely, ultrasound is a sensitive tool for demonstrating intraneural injection in porcine models, as manifested by consistent nerve expansion observed with 1-mL injectate or less. 13Y15 However, although nerve expansion was correlated with histologic injury, concomitant functional injury was not observed.…”

Section: Peripheral Nerve Injurymentioning

confidence: 90%

Ultrasound-Guided Regional Anesthesia and Patient Safety

Neal¹

2010

Regional Anesthesia and Pain Medicine

205

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The role of ultrasound-guided regional anesthesia (UGRA) in reducing the frequency of regional anesthetic-related complications is difficult to ascertain from analyzing the limited literature on the topic. This evidence-based review critically evaluates the contributions of UGRA to improved patient safety, particularly as compared with standard nerve localization tools. Randomized controlled trials that compared UGRA with another form of neural localization and case series of more than 500 patients were used to compare safety parameters. The quality of studies and strength of evidence were graded. Of those randomized controlled trials identified by our search techniques, 22 compared the incidence of postoperative nerve symptoms, 17 assessed local anesthetic systemic toxicity parameters, and 3 studied hemidiaphragmatic paresis. Statistical proof for meaningful reduction in the frequency of extremely rare complications, such as permanent peripheral nerve injury, is likely unattainable. Although there is evidence for UGRA reducing the occurrence of vascular puncture and the frequency of hemidiaphragmatic paresis, as yet there is at best inconclusive scientific proof that these surrogate outcomes are linked to actual reduction of their associated complications, such as local anesthetic systemic toxicity or predictable diaphragmatic impairment in at-risk individuals. This evidence-based review thus strives to summarize both the power and the limitations of UGRA as a tool for improving patient safety.

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“…While the exact mechanism leading to nerve injury is still controversial, there is strong evidence from animal experiments that intrafascicular injections, resulting in high injection pressures, have the potential to rupture nerve fascicles and may place patients at risk for permanent nerve injury and neurological deficits 3. As the needle traverses through connective and neural tissues, injection pressure fluctuates, such that perineural injection pressures (≤4 psi) are lower than intrafascicular injection pressures (>25 psi) 4. Some authors suggest that injection pressures less than 25 psi should be considered acceptable for peripheral nerve block injections5 while injection pressures greater than 25 psi may be associated with persistent motor deficits as a result of mechanical injury and pressure ischemia 4.…”

mentioning

confidence: 99%

“…As the needle traverses through connective and neural tissues, injection pressure fluctuates, such that perineural injection pressures (≤4 psi) are lower than intrafascicular injection pressures (>25 psi) 4. Some authors suggest that injection pressures less than 25 psi should be considered acceptable for peripheral nerve block injections5 while injection pressures greater than 25 psi may be associated with persistent motor deficits as a result of mechanical injury and pressure ischemia 4. Other authors have found that high opening pressure as low as ≥15 psi can detect needle-to-nerve contact6 and forceful needle-to-nerve contact alone is capable of causing histologic damage to nerves in animals 7…”

mentioning

confidence: 99%

Evaluation of the B-Smart manometer and the CompuFlo computerized injection pump technology for accurate needle-tip injection pressure measurement during peripheral nerve blockade

Weisman

Bhavsar

Schuster

et al. 2019

Regional Anesthesia &Amp; Pain Medicine

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Background and ObjectivesThe exact mechanism of peripheral nerve blocks causing/leading to nerve injury remains controversial. Evidence from animal experiments suggests that intrafascicular injection resulting in high injection pressure has the potential to rupture nerve fascicles and may consequently cause permanent nerve injury and neurological deficits. The B-Smart (BS) in-line manometer and the CompuFlo (CF) computerized injection pump technology are two modalities used for monitoring pressure during regional anesthesia. This study sought to explore the accuracy of these two technologies in measuring needle-tip pressures in a simulated environment.MethodsIn seven simulated needle–syringe combinations, the BS and the CF devices were connected in series through a closed system and attached to a digital manometer at the tip of various needles. The pressures were evaluated in three trials per needle-syringe combination. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy (F1 Score) were determined for each needle type and overall.ResultsFor pressures ≥15 psi and ≥20 psi, respectively, the CF device demonstrated a sensitivity of 100%, 100%; specificity of 96%, 98%; positive predictive value 93%, 93%; and negative predictive value of 100%, 100%. The BS device demonstrated a sensitivity of 60%, 100%; specificity of 99%, 95%; positive predictive value of 96%, 85%; and negative predictive value of 85%, 100%. Accuracy, as measured by the F1 Score, for detecting a pressure of ≥15 psi was 0.96 for the CF and 0.74 for the BS.ConclusionsFuture research is needed to explore in-vivo performance and evaluate whether either of these devices can impact on clinical outcomes.

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Combination of intraneural injection and high injection pressure leads to fascicular injury and neurologic deficits in dogs

Cited by 192 publications

References 28 publications

High Opening Injection Pressure Is Associated With Needle-Nerve and Needle-Fascia Contact During Femoral Nerve Block

High Opening Injection Pressure Is Associated With Needle-Nerve and Needle-Fascia Contact During Femoral Nerve Block

Ultrasound-Guided Regional Anesthesia and Patient Safety

Evaluation of the B-Smart manometer and the CompuFlo computerized injection pump technology for accurate needle-tip injection pressure measurement during peripheral nerve blockade

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