Brachial plexus block (BPB) techniques provide significant benefits including better pain control, faster discharge and reduced adverse effects compared to general anaesthesia. Prior to 2005 BPBs were performed using landmark, paraesthesia or electrical nerve stimulation (PNS) methods and were associated with reasonable success (70-80%) but were still associated with risk of failure and complications. Use of ultrasound (US) to guide local anaesthetic injection was first reported in 1989 but until 2004 remained unexplored. From 2004 we aimed to explore the feasibility, success and safety of ultrasound-guided brachial plexus block (USBPB) compared to techniques guided by anatomical landmarks or peripheral nerve stimulation. We hypothesized that USBPB would be feasible, have greater success and safety compared to standard methods. In 2004 we identified the possibility of using US to place infraclavicular block (ICB) and identified a pattern of local anaesthetic spread that predicated successful block. A subsequent randomized trial found improved success of US compared to existing methods. We examined success of US-guided axillary brachial plexus block (ABPB) and found that performance time and success were improved. In a large retrospective review of ABPB techniques we identified that US techniques were faster to perform, had a higher success and were safer compared to standard methods. We also assessed existing nerve localization methods in an observational study and found that both have poor sensitivity and specificity possibly explaining some of the limitations of these techniques. A bench study examining local anaesthetic injection using ultrasound found that both novices and experts could accurately determine local anaesthetic spread. In practice this is a useful marker for safe injection and could explain findings of increased safety with ultrasound methods. we systematically reviewed the literature for studies examining USBPB and this demonstrated that US improved block success and performance time. Subsequent pilot work indicated that US, in addition to improves block success and performance time. Subsequent pilot work indicated that US, in addition to improving quality, could also reduce volume of local anaesthetic required for successful block and we hypothesized that for certain techniques such as interscalene block this may improve safely. we compared US-guided interscalene block (ISB) using traditional volumes (20ml) and compared with a low volume (5ml) of ropivacaine 0.5%. Results demonstrated no difference in efficacy or duration but significant reduction in respiratory (and other) complications with lower volumes. We then compared US-guide ISB to PNS using and Up and Down Sequential Allocation design to estimate the minimum effective anaesthetic volume (MEAV50) for ropivavaine 0.5% for major shoulder surgery. Our findings indicated that volumes of local anaesthetic could be dramatically reduced with US (0.9 vs 5.4ml) whilst still providing effective pain relief. In the last ten years the cases and studies described have demonstrated that US improves BPB success and safety. For ISB US reduces volumes of local anaesthetic required for success whilst also reducing respiratory and other complications.

This study investigates the prevalence of peri-operative anxiety and the effective management of intra-operative anxiety during awake surgery. Plastic and vascular surgical patients were selected for the study as many procedures performed within these specialities are performed under local or regional anaesthesia. The study consists of two distinct stages. The first stage was a postal survey of patients (n=213) who had undergone awake plastic, renal access or carotid surgery up to two weeks previously, in order to determine retrospectively the prevalence of peri-operative anxiety. The second stage of the study was a randomised controlled trial of interventions for the effective management of intra-operative anxiety in patients (n=128) having undergone the same surgical procedures described in stage one. The interventions tested in stage two were handholding and an anxiety management package involving a relaxation technique and a procedural information leaflet, against a 'usual care' control. The findings from stage one of the study suggest that peri-operative anxiety prevalence is low, although unacceptable levels of anxiety are seen to elevate during the intra-operative phase. The RCT in stage two demonstrated that intra-operative anxiety was no more effectively managed by the interventions tested than by usual care alone. The validity and reliability of retrospective anxiety measurement was investigated by comparing anxiety scores from stage one with contemporaneous and post-hoc anxiety scores from stage two and found to be an accurate measure of anxiety experienced at the time of the event.

Orientador: Stelio Pacca Loureiro Luna / Resumo: Este estudo clínico prospectivo e aleatório objetivou descrever a sonoanatomia do espaço peridural lombossacral (LS) e avaliar e comparar a técnica guiada em tempo real com auxílio da ultrassonografia (US), em relação à palpação das referências anatômicas, para anestesia peridural em cães normais (escore de condição corporal – ECC ≤ 5) ou obesos (ECC ≥ 6). Para tal 72 animais provenientes de tutores, foram subdivididos igualmente em quatro grupos: PG1 e PG2 (Grupo Palpação 1 em animais normais e Grupo Palpação 2 em animais obesos, respectivamente), nos quais a técnica de anestesia peridural baseou-se nas referências anatômicas e perda de resistência à administração do fármaco e grupos USG1 e USG2 (Punção Guiada por US1 em animais normais e Punção Guiada por US2 em animais obesos, respectivamente), nos quais a técnica de anestesia peridural foi guiada exclusivamente pelo US. Para identificação das estruturas, utilizaram-se os cortes sagital, parassagital oblíquo e transversal. Aferiu-se a distância entre a pele e o ligamentum flavum (LF) nos grupos USG1 e USG2. Para confirmação exata da punção guiada por US, observaram-se a movimentação da agulha no momento da punção do LF e o fluxo de anestésico administrado, através da migração pelo canal peridural. Após a punção, confirmou-se a eficácia do bloqueio locorregional no período perioperatório. A utilização da ultrassonografia possibilitou a visualização das estruturas do espaço peridural LS, bem como o momento exato da punção e ... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: This prospective and randomized clinical study aimed to describe the sonoanatomy of the lumbosacral epidural space and to evaluate and compare the real time guided ultrassonography (US) technique in comparison to palpation of anatomical references, to perform epidural anesthesia in normal (body condition score ≤ 5) or obese (body condition score ≥ 6). Seventy two client dogs were equally distributed in four groups, PG1 and PG2 (Palpation group 1 in normal animals and Palpation group 2 in obese animals, respectively), in which epidural anesthesia technique was based on palpation of anatomical references and loss of resistance to injection, and groups USG1 e USG2 (Ultrasound guided group 1 in normal animals and ultrasound guided group 2 in obese animals, respectively), in which the technique was guided only by US. Structures were identified in the sagittal, parasagittal oblique and transverse sections. The distance between skin and ligamentum flavum (LF) was measured in groups USG1 and USG2. Correct introduction and position of the needle in the epidural space and the flow of local anesthetic through the epidural canal was confirmed by US. The effectiveness of epidural anesthesia was confirmed in the perioperative period. With the use of US it was possible to define the sonoanatomy and to observe both the correct placement of the needle in the lumbosacral epidural space and the local anesthetic flowing between the sixth (L6) and seventh (L7) or fifth (L5) and sixth lumbar verte... (Complete abstract click electronic access below) / Doutor

There is an urgent and unmet clinical need to improve accuracy and safety during needle-based interventional procedures including regional anaesthesia and cancer biopsy. In ultrasound guided percutaneous needle procedures, there is a universal problem of imaging the needle, particularly the tip, especially in dense tissues and steep insertion angles. Poor visualization of the needle tip can have serious consequences for the patients including nerve damage and internal bleeding in regional anaesthesia and, in the case of biopsy, mis-sampling, resulting in misdiagnosis or the need for repeat biopsy. The aim of the work was to design and develop an ergonomic ultrasound device to actuate standard, unmodified needles such that the visibility of needle can be enhanced when observed under colour Doppler mode of ultrasound imaging. This will make the needle procedures efficient through accurate needle placement while reducing the overall procedure duration. The research reported in this thesis provides an insight into the new breed of piezoelectric materials. A methodology is proposed and implemented to characterize the new piezocrystals under ambient and extreme practical conditions. For the first time, the IEEE standard method (1987) was applied to an investigation of this type with binary (PMN-PT) and ternary (PIN-PMN-PT) compositions of piezocrystals. Using the existing data and the data obtained through characterization, finite element analysis (FEA) were carried to adequately design the ultrasound device. Various configurations of the device were modelled and fabricated, using both piezoceramic and piezocrystal materials, in order to assess the dependency of device’s performance on the configuration and type of piezoelectric material used. In order to prove the design concept and to measure the benefits of the device, pre-clinical trials were carried out on a range of specimens including the soft embalmed Thiel cadavers. Furthermore, an ultrasound planar cutting tool with various configurations was also designed and developed as an alternative to the existing cumbersome ultrasonic scalpels. These configurations were based on new piezocrystals including the Mn-doped ternary (Mn:PIN-PMN-PT) material. It is concluded that the needle actuating device can significantly enhance the visibility of standard needles and additionally benefits in reducing the penetration force. However, in order to make it clinically viable, further work is required to make it compliant with the medical environment. The piezocrystals tested under practical conditions although offer extraordinary piezoelectric properties, are vulnerable to extreme temperature and drive conditions. However, it is observed that newer piezocrystals, especially Mn:PIN-PMN-PT have shown the potential to replace the conventional piezoceramics in high power and actuator applications. Moreover, the d31-mode based planar cutting tool contrasts with the cumbersome design of mass-spring transducer structure and has the potential to be used in surgical procedures.

Submitted by Leonardo de Freitas Guimarães Arcoverde Credie (leo_credie@yahoo.com.br) on 2018-05-14T22:08:59Z No. of bitstreams: 1 Tese completa.pdf: 11151658 bytes, checksum: de6b02496163d822cbea198d463ac878 (MD5) / Approved for entry into archive by Sulamita Selma C Colnago null (sulamita@btu.unesp.br) on 2018-05-15T14:14:48Z (GMT) No. of bitstreams: 1 credie_lfga_dr_bot.pdf: 11151658 bytes, checksum: de6b02496163d822cbea198d463ac878 (MD5) / Made available in DSpace on 2018-05-15T14:14:48Z (GMT). No. of bitstreams: 1 credie_lfga_dr_bot.pdf: 11151658 bytes, checksum: de6b02496163d822cbea198d463ac878 (MD5) Previous issue date: 2018-03-27 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / Este estudo clínico prospectivo e aleatório objetivou descrever a sonoanatomia do espaço peridural lombossacral (LS) e avaliar e comparar a técnica guiada em tempo real com auxílio da ultrassonografia (US), em relação à palpação das referências anatômicas, para anestesia peridural em cães normais (escore de condição corporal – ECC ≤ 5) ou obesos (ECC ≥ 6). Para tal 72 animais provenientes de tutores, foram subdivididos igualmente em quatro grupos: PG1 e PG2 (Grupo Palpação 1 em animais normais e Grupo Palpação 2 em animais obesos, respectivamente), nos quais a técnica de anestesia peridural baseou-se nas referências anatômicas e perda de resistência à administração do fármaco e grupos USG1 e USG2 (Punção Guiada por US1 em animais normais e Punção Guiada por US2 em animais obesos, respectivamente), nos quais a técnica de anestesia peridural foi guiada exclusivamente pelo US. Para identificação das estruturas, utilizaram-se os cortes sagital, parassagital oblíquo e transversal. Aferiu-se a distância entre a pele e o ligamentum flavum (LF) nos grupos USG1 e USG2. Para confirmação exata da punção guiada por US, observaram-se a movimentação da agulha no momento da punção do LF e o fluxo de anestésico administrado, através da migração pelo canal peridural. Após a punção, confirmou-se a eficácia do bloqueio locorregional no período perioperatório. A utilização da ultrassonografia possibilitou a visualização das estruturas do espaço peridural LS, bem como o momento exato da punção e o fluxo do anestésico local nos espaços intervertebrais entre a 6ª (L6) e 7ª vértebras (L7), ou entre a 5a (L5) e 6a vértebras (L6) em todos os pacientes dos grupos USG1 e USG2, em ambos os cortes. As medidas entre pele e LF foram iguais nos cortes sagital e transversal, sendo 2,45 0,48 cm e 2,42 0,49 cm respectivamente para USG1 e 3,07 0,74 cm e 3,06 0,73 cm respectivamente para USG2. Nos grupos guiados por US, o número de contato entre agulha e tecido ósseo (USG1= 0,16 0,38 e USG2= 0,88 1,67) e refluxo de sangue na agulha (USG1= 5,5% e USG2= 0%) foram menores do que nos grupos guiados por palpação (contato agulha/osso: PG1= 0,88 1,67 e PG2= 2,72 2,02; refluxo de sangue: PG1= 11,1% e PG2= 22,2%). Concluiu-se que a anestesia peridural LS guiada por US possibilitou observar a sonoanatomia da região, acompanhar a introdução da agulha até o correto posicionamento no espaço peridural e visualizar a administração do anestésico local em tempo real, de forma independente de palpação de estruturas anatômicas, tanto em animais normais como em obesos, o que é uma vantagem ao se realizar anestesia peridural em animais com ECC ≥ 6. / This prospective and randomized clinical study aimed to describe the sonoanatomy of the lumbosacral epidural space and to evaluate and compare the real time guided ultrassonography (US) technique in comparison to palpation of anatomical references, to perform epidural anesthesia in normal (body condition score ≤ 5) or obese (body condition score ≥ 6). Seventy two client dogs were equally distributed in four groups, PG1 and PG2 (Palpation group 1 in normal animals and Palpation group 2 in obese animals, respectively), in which epidural anesthesia technique was based on palpation of anatomical references and loss of resistance to injection, and groups USG1 e USG2 (Ultrasound guided group 1 in normal animals and ultrasound guided group 2 in obese animals, respectively), in which the technique was guided only by US. Structures were identified in the sagittal, parasagittal oblique and transverse sections. The distance between skin and ligamentum flavum (LF) was measured in groups USG1 and USG2. Correct introduction and position of the needle in the epidural space and the flow of local anesthetic through the epidural canal was confirmed by US. The effectiveness of epidural anesthesia was confirmed in the perioperative period. With the use of US it was possible to define the sonoanatomy and to observe both the correct placement of the needle in the lumbosacral epidural space and the local anesthetic flowing between the sixth (L6) and seventh (L7) or fifth (L5) and sixth lumbar vertebrae in all dogs of the USG1 and USG2 groups, both in parasagittal oblique and in transversal approaches. The distances between skin and LF at the sagittal and transversal approaches were 2.45 0.48 cm and 2.42 0.49 cm respectively for USG1 and 3.07 0.74 cm and 3.06 0.73 cm respectively for USG2. The needle to bone contact events (USG1= 0.16 0.38 and USG2= 0.88 1.67) and presence of blood in the syringe (USG1= 5.5% e USG2= 0%) were lower than the palpation guided epidural anesthesia (needle to bone contacts: PG1= 0.88 1.67 and PG2= 2.72 2.02; blood in the syringe: PG1= 11.1% and PG2= 22.2%). The use of US provided accurate information about sonoanatomy of the LS epidural space in dogs, guided the positioning for the introduction of the needle without palpation of the anatomical structures, enabled to observe the correct injection of local anesthetic into the epidural space even in obese patients, and reduced the number of attempts to perform epidural anesthesia when compared to palpation of anatomical landmarks and loss of resistance technique. / 049/2015

Bakgrund: Förtroende, omhändertagande, närvaro och kunskap är viktiga faktorer hos sjuksköterskan för att patienten skall känna trygghet. Det opereras dagligen hundratals patienter med elektiv ortopedisk dagkirurgi i regional anestesi i Sverige. För dessa patienter spelar anestesisjuksköterskan en viktig roll under den perioperativa processen. Oro och ångest hos patienten inför operation är vanligt förekommande, vilket kan leda till en försämrad återhämtning. Ortopediska patienter upplever dessutom sämre postoperativ återhämtning jämfört med andra patientkategorier. Det är därför av stor vikt att undersöka patientens perioperativa upplevelse av trygghet för att få en större förståelse kring vilka faktorer som kan påverka patientens trygghet och därmed postoperativa återhämtning. Syfte: Syftet med denna studie var att undersöka patienters upplevelse av trygghet i samband med ortopedisk elektiv dagkirurgi i regional anestesi. Metod: En kvantitativ icke-experimentell enkätstudie har genomförts. Patienter över 18 år som genomgått ett elektivt ortopediskt ingrepp i regional anestesi under dagkirurgisk vård inkluderades. Patienterna valdes ut från tre sjukhus i norra Sverige. Konsekutivt urval användes, vilket resulterade i 132 analyserade enkäter. På grund av icke normalfördelat data användes Mann-Whitneys U-test, Kruskall-Wallis och Spearmans korrelationstest. Resultat: Patienter upplever trygghet under den perioperativa processen och personalen spelar en viktig roll i huruvida patienten upplever trygghet. Om patienten upplever ångest påverkar detta upplevelsen av trygghet negativt. Patienter med hög utbildningsnivå kände sig mindre trygga under operationen jämfört med patienter med lägre nivå av utbildning. Slutsats: Patienterna upplever trygghet i samband med perioperativ omvårdnad och patientens upplevelse av trygghet påverkas av faktorer som vi i personalen har stor möjlighet att påverka. Bland annat spelar kommunikation, information, bemötande och attityd en viktig roll.

This study investigates the prevalence of peri-operative anxiety and the effective management of intra-operative anxiety during awake surgery. Plastic and vascular surgical patients were selected for the study as many procedures performed within these specialities are performed under local or regional anaesthesia. The study consists of two distinct stages. The first stage was a postal survey of patients (n=213) who had undergone awake plastic, renal access or carotid surgery up to two weeks previously, in order to determine retrospectively the prevalence of peri-operative anxiety. The second stage of the study was a randomised controlled trial of interventions for the effective management of intra-operative anxiety in patients (n=128) having undergone the same surgical procedures described in stage one. The interventions tested in stage two were handholding and an anxiety management package involving a relaxation technique and a procedural information leaflet, against a ¿usual care¿ control. The findings from stage one of the study suggest that peri-operative anxiety prevalence is low, although unacceptable levels of anxiety are seen to elevate during the intra-operative phase. The RCT in stage two demonstrated that intra-operative anxiety was no more effectively managed by the interventions tested than by usual care alone. The validity and reliability of retrospective anxiety measurement was investigated by comparing anxiety scores from stage one with contemporaneous and post-hoc anxiety scores from stage two and found to be an accurate measure of anxiety experienced at the time of the event.

Titel: Patienters upplevelser av att vara vaken i regional anestesi - En systematisk litteraturstudie med kvalitativ innehållsanalys  Bakgrund: Regional anestesi används idag i allt större utsträckning. Genom att blockera nervsignaler kan smärtsignaler blockeras och möjliggöra operationer på bedövad kroppsdel. Detta medför att patienten kan vara vaken under operationen och därmed ges möjlighet att interagera med vårdpersonalen i operationsrummet.  Syfte: Studiens syfte var att genom en systematisk litteraturstudie undersöka patienters upplevelser av att vara vaken i regional anestesi.   Metod: Litteraturstudien har genomförts genom en kvalitativ innehållsanalys. Resultatet från tio vetenskapliga artiklar har sammanställts och analyserats enligt Bettany-Saltikov och McSherry (2016).  Resultat: Upplevelsen av att vara vaken under operation är individuell och varierar mellan nyfikenhet och djup oro. I litteraturstudien framkommer behovet av att patienten erhåller information som är anpassad efter deras behov samt att de finns en vårdrelation med vårdpersonal och då framförallt med anestesisjuksköterskan. Genom en god vårdrelation kan upplevelsen av operationen förbättras.  Slutsats: Vikten av kommunikation mellan patient och anestesisjuksköterska har framkommit ha en stor betydelse för hur operationen och anestesin upplevs. Genom en god vårdrelation minskar behovet av läkemedel och leder till ett snabbare tillfrisknande och hemgång. / Title: Patients experiences of being awake in regional anesthesia – A systematic litterature review with a qualitative content analysis.  Background: The use of regional anesthesia in surgery is increasing. By blocking nerve signals this enables different kind of surgeries on the anesthetized body. This means that the patient can be awake during the surgery and is able to interact with caregivers in the operating room.  Aim: The aim was to illuminate patients’ experiences of being awake in regional anesthesia.  Method: The litterature review has been conducted using a content analysis. The result from ten qualitative articles has been compiled and analyzed according to Bettany-Saltikov and McSherry (2016).  Results: The experience of being awake during surgery is individual and varies between curiosity and deep anxiety. The result of this study revealed the need of patient to get customized information according to their needs and the significance of the relationship with caregivers and especially the nurse anesthetist. Through a good relationship with caregivers the experience of the surgery can improve.  Conclusions: The importance of communication between the patient and the anaesthesia nurse has emerged to have a significant impact on how the surgery and anaesthesia are experienced. Through a good care relationship reduces the need for drugs and leads to a faster recovery.

Methods of regional anaesthesia and regional postoperative analgesia are common in perioperative management of patients in traumatology-orthopaedics. One of most challenging fields of traumatology-orthopaedics is shoulder surgery. Shoulder surgery is associated with intense and long-lasting postoperative pain. It affects patients’ well-being, limits limb function and worsens results of surgical treatment. Determination of optimal methods for postoperative pain relief is very important in clinical practice. Several modern studies compared methods of systemic analgesia with continuous interscalene infusion of bupivacaine 0,15 - 0,25 % solution. Application of these concentrations of bupivacaine resulted in sufficient analgesia but profound motor blockade and anaesthetic toxicity were observed. There are few studies on interscalene infusions of small concentrations of bupivacaine. Data on effects of small doses of bupivacaine on intensity of motor blockade and adjuvant drugs on postoperative analgesia is lacking. AIM OF THE STUDY: to evaluate the quality of post-operative pain treatment after shoulder surgery using continuous perineural infusions of different concentrations (0.1% and 0.15%) of bupivacaine and bupicacaine (0.1%) in combination with adjuvant clonidine and effects on operated hand motor function. To assess clinical advisability of interscalene brachial plexus identification and catheterization using G. Meier’s technique. 159 patients scheduled for elective... [to full text]

Tesis por compendio de publicaciones / El presente estudio fue llevado a cabo para describir la apariencia ecográfica y desarrollar los abordajes ecoguiados para el bloqueo de los nervios ciático y femoral, así como evaluar la eficacia clínica del bloqueo ecoguiado del nervio ciático en el gato. Se realizaron disecciones anatómicas y criosecciones para determinar las marcas anatómicas para localizar los nervios de interés. La apariencia ecográfica de los nervios ciático y femoral fue estudiada tanto en cadáveres como en gatos vivos, utilizando un transductor linear de 4-13 MHz. EL bloqueo ecoguiado del nervio ciático se realizó insertando una aguja para bloqueo de nervios periféricos cerca del nervio ciático y se infiltró lidocaína alrededor del mismo. El abordaje medio-femoral y el abordaje dorsal permitieron la evaluación ecográfica y aproximación ecoguiada de los nervios ciático y femoral respectivamente. El abordaje medio-femoral permitió el bloqueo clínicamente efectivo del nervio ciático en el gato. Palabras clave: ecografía, anestesia, anestesia regional, bloqueo de nervios periféricos, nervio ciático, nervio femoral, gato. / Use of ultrasound for the blockade of the peripheral nerves of the pelvic limb in the cat (Felis catus L.) This study was carried out to describe the ultrasonographic appearance and to develop the ultrasound (US)-guided approaches to block the sciatic (SCN) and femoral (FN) nerves, and to evaluate the clinical efficacy of the US-guided blockade of the ScN in the cat. Anatomical dissections and transversal cryosections were performed to determine the anatomical landmarks to localise the ScN and FN nerves. The ultrasonographic appearance of the ScN and FN were determined on cadavers and alive cats using a 4-13MHz linear transducer. The US-guided blockade of the ScN was performed inserting a peripheral nerve block needle close to the ScN and lidocaine was infiltrated around it. The midfemoral approach for the ScN and the dorsal approach for the FN, allowed an optimal US-guided location to evaluate and block these nerves. The midfemoral allowed an accurate US-guided blockade of the ScN in felines.