Cervical Spine Injury: Immobilisation and Airway Management

This is a copy of the slides I used during a talk I gave at the Grand Rounds Presentation of the Department of Anesthesia, Pain Management and Perioperative Medicine, Halifax, Nova Scotia.

This (updated) talk was designed to provide an update for anaesthetists in the management of acute spinal cord injury, with a particular focus on cervical spine trauma. I have focused particularly on the evidence (or lack of it) relating to spinal immobilisation techniques and how to safely undertake tracheal intubation in the patient who has proven, or suspected, cervical spine instability.

The pdf of my presentation can be downloaded by clicking the link below:

SCI Canada 2017

 

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Traumatic Brain Injury Management in the ED

This is a handout designed to supplement a talk I gave at the NACCSGBI ASM in London, 2017. The full programme of the meeting can be found here.

This talk was designed to provide an update for anaesthetists in the management of traumatic brain injury with a particular focus on management within the emergency department.

The pdf of my summary document can be downloaded by clicking the link below:

NACCS TBI Summary

This summary of an earlier talk may also be of value and it discusses the value of spinal immobilisation in trauma.

NACCS SCI Update 2016

STH Breakfast Club: Perineural dexamethasone in peripheral nerve blocks

April 19th, 2017. Jake Drinkwater

A copy of the full presentation is available at the following link (Perineural Dexamethasone), with a summary shown below.

Background:

Additives to local anaesthetic (LA) have long been used in an attempt to prolong the duration, reduce the onset time and improve the safety profile of LA’s. Recently there has been much interest in the addition of dexamethasone to LA used for peripheral nerve blockade with the aim of prolonging the duration of the block. As with any new technique there are often undesirable consequences, side effects and often a degree of risk. As ever, the clinical benefit of the technique must be weighed against the risks and against alternative techniques. In this presentation we look at the current evidence for the use of Dexamethasone to prolong to duration of peripheral nerve blockade.

Main question/ issues discussed:

  1. Does dexamethasone increase duration analgesia of nerve blocks?
  2. Is perineural dexamethasone better than systemic administration?
  3. Is perineural dexamethasone safe?

Take home messages:

Perineural dexamethasone significantly prolongs the duration of peripheral nerve blocks, with greater effect when added to longer acting local anaesthetics. However, a statistically similar prolongation of the duration of peripheral nerve blocks can be achieved with systemically administered dexamethasone. Owing to uncertainty regarding the neurotoxic effects of dexamethasone and in the absence of a clear benefit of perineural administration, current evidence points towards the systemic administration to prolong the duration of peripheral nerve blockade.

References

  1. Abdallah FW, Brull R. Facilitatory effects of perineural dexmedetomidine on neuraxial and peripheral nerve block: a systematic review and meta-analysis. British Journal of Anaesthesia. 2013 May 19;110(6):915–25.
  2. Abdallah FW, Johnson J, Chan V, Murgatroyd H, Ghafari M, Ami N, et al. Intravenous Dexamethasone and Perineural Dexamethasone Similarly Prolong the Duration of Analgesia After Supraclavicular Brachial Plexus Block. Regional Anesthesia and Pain Medicine. 2015;40(2):125–32.
  3. Albrecht E, Kern C, Kirkham KR. Perineural vs intravenous administration of dexamethasone: more data are available. British Journal of Anaesthesia. 2014 Dec 11;114(1):160–0.
  4. Aliste J, Leurcharusmee P, Engsusophon P, Gordon A, Michelagnoli G, Sriparkdee C, et al. Comparaison randomisée entre la dexaméthasone intraveineuse et périneurale pour réaliser un bloc axillaire échoguidé. Canadian Journal of Anesthesia/Journal canadien d’anesthésie. 2016 Sep 23;64(1):29–36.
  5. Bjørn S, Linde F, Nielsen KK, Børglum J, Hauritz RW, Bendtsen TF. Effect of Perineural Dexamethasone on the Duration of Single Injection Saphenous Nerve Block for Analgesia After Major Ankle Surgery. Regional Anesthesia and Pain Medicine. 2017;42(2):210–6.
  6. Chisholm MF, Cheng J, Fields KG, Marx RG, Maalouf DB, Liguori GA, et al. Perineural dexamethasone with subsartorial saphenous nerve blocks in ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2016 Apr 13;40(2):125–2.
  7. Choi S, Rodseth R, McCartney CJL. Effects of dexamethasone as a local anaesthetic adjuvant for brachial plexus block: a systematic review and meta-analysis of randomized trials. British Journal of Anaesthesia. 2014 Feb 17;112(3):427–39.
  8. Chun EH, Kim YJ, Woo JH. Which is your choice for prolonging the analgesic duration of single-shot interscalene brachial blocks for arthroscopic shoulder surgery? intravenous dexamethasone 5 mg vs. perineural dexamethasone 5 mg randomized, controlled, clinical trial. Medicine. 2016 Jun;95(23):e3828–8.
  9. Dawson RL, McLeod DH, Koerber JP, Plummer JL, Dracopoulos GC. A randomised controlled trial of perineural vs intravenous dexamethasone for foot surgery. Anaesthesia. 4 ed. 2015 Dec 18;71(3):285–90.
  10. Desmet M, Braems H, Reynvoet M, Plasschaert S, Van Cauwelaert J, Pottel H, et al. I.V. and perineural dexamethasone are equivalent in increasing the analgesic duration of a single-shot interscalene block with ropivacaine for shoulder surgery: a prospective, randomized, placebo-controlled study. British Journal of Anaesthesia. 2013 Aug 14;111(3):445–52.
  11. Fredrickson FANZCA MJ, Danesh-Clough TK, White R. Adjuvant Dexamethasone for Bupivacaine Sciatic and Ankle Blocks. Regional Anesthesia and Pain Medicine. 2013;38(4):300–7.
  12. Jæger P, Grevstad U, Koscielniak-Nielsen ZJ, Sauter AR, Sørensen JK, Dahl JB. Does dexamethasone have a perineural mechanism of action? A paired, blinded, randomized, controlled study in healthy volunteers. British Journal of Anaesthesia. 2016 Oct 31;117(5):635–41.
  13. Tanaka K, Kawanishi R, Tsutsumi YM, Takeda Y, Yamamoto K, Nomura K, et al. Perineural but not systemic low-dose dexamethasone prolongs the duration of interscalene block with ropivacaine: a prospective randomized trial. LRA. 2014 Apr;:5–5.
  14. Leurcharusmee P, Aliste J, Van Zundert TCRV, Engsusophon P, Arnuntasupakul V, Tiyaprasertkul W, et al. A Multicenter Randomized Comparison Between Intravenous and Perineural Dexamethasone for Ultrasound-Guided Infraclavicular Block. Regional Anesthesia and Pain Medicine. 2016;41(3):328–33.
  15. Maher DP, Serna-Gallegos D, Mardirosian R, Thomas OJ, Zhang X, McKenna R, et al. The Combination of IV and Perineural Dexamethasone Prolongs the Analgesic Duration of Intercostal Nerve Blocks Compared with IV Dexamethasone Alone. Pain Med. 2016 Jul 29;:pnw149–2.
  16. Marty P, Bennis M, Legaillard B, Cavaignac E, Ferre F, Lebon J, et al. A New Step Toward Evidence of In Vivo Perineural Dexamethasone Safety. Regional Anesthesia and Pain Medicine. 2017 Apr;:1–2.
  17. Morales-Muñoz C, Sánchez-Ramos JL, Díaz-Lara MD, González-González J, Gallego-Alonso I, Hernández-del-Castillo MS. Eficacia analgésica de una dosis única de dexametasona perineural en el bloqueo ecoguiado del nervio femoral en cirugía de prótesis total de rodilla. Revista Española de Anestesiología y Reanimación. 2017 Jan;64(1):19–26.
  18. De Oliveira GS, Almeida MD, Benzon HT, McCarthy RJ. Perioperative Single Dose Systemic Dexamethasone for Postoperative PainA Meta-analysis of Randomized Controlled Trials. Anesthesiology. The American Society of Anesthesiologists; 2011 Sep 1;115(3):575–88.
  19. Rahangdale R, Kendall MC, McCarthy RJ, Tureanu L, Doty R Jr, Weingart A, et al. The Effects of Perineural Versus Intravenous Dexamethasone on Sciatic Nerve Blockade Outcomes. Anesth Analg. 2014 May;118(5):1113–9.
  20. Rosenfeld DM, Ivancic MG, Hattrup SJ, Renfree KJ, Watkins AR, Hentz JG, et al. Perineural versus intravenous dexamethasone as adjuncts to local anaesthetic brachial plexus block for shoulder surgery. Anaesthesia. 4 ed. 2016 Feb 22;71(4):380–8.
  21. Tandoc MN, Fan L, Kolesnikov S, Kruglov A, Nader ND. Adjuvant dexamethasone with bupivacaine prolongs the duration of interscalene block: a prospective randomized trial. Journal of Anesthesia. 2011 Jun 17;25(5):704–9.
  22. Tomar GS, Ganguly S, Cherian G. Effect of Perineural Dexamethasone With Bupivacaine in Single Space Paravertebral Block for Postoperative Analgesia in Elective Nephrectomy Cases. American Journal of Therapeutics. 2016 Jan;:1–2.
  23. Williams BA, Hough KA, Tsui BYK, Ibinson JW, Gold MS, Gebhart GF. Neurotoxicity of Adjuvants Used in Perineural Anesthesia and Analgesia in Comparison With Ropivacaine. Regional Anesthesia and Pain Medicine. 2011 May;36(3):225–30.
  24. Yilmaz-Rastoder E, Gold MS, Hough KA, Gebhart GF, Williams BA. Effect of Adjuvant Drugs on the Action of Local Anesthetics in Isolated Rat Sciatic Nerves. Regional Anesthesia and Pain Medicine. 2012;37(4):403–9.