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• W2897193663 abstract "No medical intervention is without risk, and even though generally considered safe, this also holds true for peripheral nerve blocks. Despite their clinical benefits in a variety of settings of acute and chronic pain 1, clinicians continue to be rightfully wary of nerve damage, which is thought to occur in less than 1 in 2000 patients 2. Commonly accepted aetiologies for peri-operative nerve injury include nerve ischaemia, intraneural bleeding, compression, direct trauma and stretch 3. When nerve blocks are specifically considered, mechanical needle and injection trauma, local anaesthetic neurotoxicity, and injection pressure can contribute 4, 5. Preclinical evidence has suggested that increased injection pressure might indicate intraneural or even intrafascicular (dangerous) needle-tip position 6. In bench studies, where injection force was measured using an in-line manometer, Claudio et al. reported that anaesthetists were prone to use more force during injection than considered safe and that the syringe-feel method of detecting might be unreliable 7. This has led to the market introduction of and evaluation of devices designed to detect or avoid high injection pressures 8, 9. In past issues 10, 11 and this issue of Anaesthesia 12, a group of Swiss and French colleagues share with us their findings following a series of in-vitro and ex-vivo investigations on injection pressure measurement in needles and injection assemblies used for peripheral regional anaesthesia. The authors first described and validated a novel system for real-time continuous monitoring of injection pressure at the needle tip using an optical fibre pressure sensor, as compared with conventional in-line monitors 10. The most important conclusion from a clinical viewpoint was that “injection pressure values measured in the injection line cannot be assumed to be a reliable indicator of the injection pressure at the needle tip”. In a second experiment, the authors demonstrated that in cadavers, their system was able to discriminate, based on injection pressure, between perineural and intraneural sciatic nerve injections 11. In the third experiment published this month, the authors demonstrate in keeping with the physical laws of fluid mechanics, that under different injection conditions, the pressure measured in-line was greater than that measured at the needle tip. This difference was especially striking when the rates of injection were increased. In contrast, the pressure measured at the needle tip was not influenced by the speed of injection 12. Saporito et al. are to be commended for their new and fresh look at injection pressure monitoring. Their findings suggest that, if we want to take injection pressure measurements to a more reliable level, we need to substantially change the way we assess this parameter. If we follow the authors’ reasoning, we would need to redesign regional anaesthesia needles to allow for direct pressure measurement at the tip, and have a pressure monitor at bed-side. If we accept additional data by Vermeylen et al. obtained in cadavers, we might also need to interpret the slope and shape of pressure curves on injection, and measure opening injection pressure 13. The use of monitors and technologies to localise nerves and guide local anaesthetic injection is central to our current practice of peripheral nerve blockade. Ultrasound guidance is the primary needle-localising technique and monitor of peripheral nerve blockade. However, even when an ultrasound transducer is in expert hands, adequate images of the outer border of the nerve (epineurium) and the needle tip may not be obtained in all patients. Therefore, ultrasound imaging will not be able to prevent needle-nerve contact or needle trauma in all cases. One way to approach this problem would be to use complementary methods to ensure safe needle guidance. Theoretically, the more tools could be implemented, the safer regional anaesthesia would become. Before introducing and implementing any new techniques we need to diligently weigh its risks, benefits and costs. Before recommending a therapy for any disease (in this case block-related postoperative peripheral nerve injury) we need to consider its biology, mechanisms and natural history. The functional units of the peripheral nerve, the axons, are tightly embedded in a specialised connective tissue matrix called the endoneurium to form fascicles, which are enclosed by perineurium. The perineurium is the highly specialised protective layer of the peripheral nerve complex and is responsible for mechanical stability and protecting the nerve fibres (axons) from both mechanical and chemical injury. There is little ambiguity that intraneural, in particular intrafascicular, injection exposes axons to both mechanical injury and the cytotoxic effects of local anaesthetics. Intrafascicular injection results in severe histological abnormalities 14-17 and functional deficits 6 and should be avoided 5. The exact site of injection is critical, intrafascicular local anaesthetics cause marked histological abnormalities 15, whereas extrafascicular and extraneural (external to the epineurium) injections cause milder histological abnormalities. Even in the absence of injection, nerve-needle trauma can lead to electrophysiological evidence of neuronal injury 18. According to the above biological and anatomical reasoning, avoiding intraneural injection is a sensible safety precaution during regional anaesthesia. Selander et al. in rabbits 19, and Hadzic et al. in dogs 6 found that injection of local anaesthetics into the fascicle resulted in high injection pressures (> 100 kPa) whereas intraneural, extrafascicular injection led to relatively low pressures (typically < 20 kPa). Injection of local anaesthetic into the intrafascicular compartment (deep to the perineurium) in animals is associated with higher opening injection pressures 19 and histological and functional evidence of severe nerve injury 6, 20. Of important note, in one porcine study, intraneural injection resulted in low-pressure measurement, but this was still associated with histological evidence of median nerve injury in 7 out of 10 specimens 16. In cadavers, injection pressure is higher in the intraneural compared with perineural compartments varying according to anatomical location 13, 21, 22. Regrettably, we have no full understanding of the incidence and evolution of nerve injury as a result of peripheral nerve blocks. The body of evidence supporting a low incidence of severe or permanent nerve injury is not comprehensive, but rather, it is confounded by different definitions for the key outcome (nerve injury), variable methods used to detect potential nerve injuries, and duration of follow-up. We cannot estimate how many of the 1 in 2000 patients 2 who suffer severe nerve injury, do so because excessive pressure was created in the fascicular compartment, and which share is attributable to other aetiologies 23. In humans, injection pressure monitoring has been shown to give a positive (pathological) signal upon needle-nerve contact 8 injection against fascial planes 9, or injection at high speed 24, suggesting good sensitivity but low specificity for intraneural injection. Following a review of factors associated with the risk of nerve injury after peripheral nerve block, Sondekoppam et al. concluded that there is inadequate evidence (low quality) supporting the use of injection pressure monitoring for preventing nerve injury 23. However, we should remind ourselves that assessment of the quality of evidence and formulating a practice guideline recommendation are separate processes. In certain circumstances, a strong recommendation can be based on low-quality evidence, and low-quality evidence can still be influenced by new evidence. In our view, in 2018, the added value of injection pressure monitors in scenarios reflecting current state-of-the-art clinical practice and existing procedural standards has not been demonstrated sufficiently to recommend widespread implementation. We advocate for a Bayesian, gradual approach and wait for more evidence to support introducing injection pressure monitoring into routine practice. Questions to be answered include the reproducibility of the various authors’ findings in different tissues, using different types of needles and accessories, and the practicality of visualising and integrating injection pressure measurement with existing procedural standards. It may be relatively easy to popularise and embed a new intuitive technology into routine practice but impossible to determine decisively if any one new device will improve patient safety after peripheral nerve blockade. Observing some clinically applicable advantage of pressure sensing when used in realistic scenarios would seem like a strong precondition for its introduction. The experimental setups by Claudio et al. 7 and Patil et al. 24 which seemed to suggest that physicians are bad at detecting high injection pressures cannot be simply translated to the clinical situation, where dynamic sonographic information on needle-tip localisation is combined with visual and tactile information during incremental injection of small fluid volumes to confirm needle-tip location. Whether active measurement of injection pressure curves (or opening injection pressure 13) has the potential to elevate patient safety above the level provided by expert use of ultrasound guidance combined with tactile cues and situational awareness (hopefully today's scenario) remains unclear. Saporito et al. describe and validate a novel system for continuous monitoring of injection pressure at the needle tip and demonstrate that to accurately monitor the injection pressure required to overcome tissue compliance, independent from operator, equipment and injection parameters, measurement at the needle tip is necessary. Their results highlight that even seemingly simple challenges such as measuring actual injection pressure are more complex when looked at in greater detail, and form a good basis for continued research into the relationship between needle position, injection pressure, and neurologic outcome. Regardless of how sophisticated and intuitive our assembled monitors appear, patient safety will continue to rely on meticulous attention to indication (anatomical, patient), anatomy, technique and equipment. The importance of provider education and core skills development, situational awareness, adequate organisation, preparation, non-technical skills, standardised processes such as safety checklists, and routine patient follow-up will remain paramount 25. The use of technical aids in an effort to compensate for insufficient education or situational awareness of providers should be strongly discouraged." @default.
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• W2897193663 title "Reducing the risk of neurological complications after peripheral nerve block: what is the role of pressure monitoring?" @default.
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