Hadzic A, Dilberovic F, Shah S, Kulenovic A, Kapur E, Zaciragic A, Cosovic E, Vuckovic I, Divanovic KA, Mornjakovic Z, Thys DM, Santos AC. Combination of intraneural injection and high injection pressure leads to fascicular injury and neurological deficits in dogs
Unintentional intraneural injection of local anesthetics may cause mechanical injury and pressure ischemia of the nerve fascicles. One study in small animals showed that intraneural injection may be associated with higher injection pressures. However, the pressure heralding an intraneural injection and the clinical consequences of such injections remain controversial. Our hypothesis is that an intraneural injection is associated with higher pressures and an increase in the risk of neurologic injury as compared with perineural injection.
Seven dogs of mixed breed (15-18 kg) were studied. After general endotracheal anesthesia, the sciatic nerves were exposed bilaterally. Under direct microscopic guidance, a 25-gauge needle was placed either perineurally (into the epineurium) or intraneurally (within the perineurium), and 4 mL of lidocaine 2% (1:250,000 epinephrine) was injected by using an automated infusion pump (4 mL/min). Injection pressure data were acquired by using an in-line manometer coupled to a computer via an analog digital conversion board. After injection, the animals were awakened and subjected to serial neurologic examinations. On the 7th day, the dogs were killed, the sciatic nerves were excised, and histologic examination was performed by pathologists blinded to the purpose of the study.
Whereas all perineural injections resulted in pressures < or =4 psi, the majority of intraneural injections were associated with high pressures (25-45 psi) at the beginning of the injection. Normal motor function returned 3 hours after all injections associated with low injection pressures (< or =11 psi), whereas persistent motor deficits were observed in all 4 animals having high injection pressures (> or =25 psi). Histologic examination showed destruction of neural architecture and degeneration of axons in all 4 sciatic nerves receiving high-pressure injections.
High injection pressures at the onset of injection may indicate an intraneural needle placement and lead to severe fascicular injury and persistent neurologic deficits. If these results are applicable to clinical practice, avoiding excessive injection pressure during nerve block administration may help to reduce the risk of neurologic injury.
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- "As previously discussed, local pressure effects and intraneural injection may explain some of the reports of prolonged response to local anesthetics seen in patients with SSc. Animal studies have shown that injection pressures of greater than 20 psi71 may be associated with intraneural injection, and the development of regional anesthesia block needles capable of monitoring injection pressure may provide an additional safeguard when performing regional anesthesia in patients with SSc. "
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ABSTRACT: Systemic sclerosis (SSc), previously known as progressive systemic sclerosis, is a form of scleroderma and a multisystem connective tissue disease which can impact on every aspect of anesthetic care, especially airway management. In this review we outline clinical manifestations and current medical treatment of the disease, and general principles of anesthetizing these patients. We focus on the role of regional anesthesia, including neuroaxial anesthesia, which may serve as a safe alternative to general anesthesia but can be technically challenging. We address concerns regarding abnormal responses to local anesthesia which have previously been reported in patients with SSc, and explore future developments in technology and pharmacology, which may enable regional anesthesia to be performed more successfully and with fewer complications.
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