Download The Fourth Edition Of Cousins And Bridenbaughs Neural Blockade In Clinical Anesthesia And P

This comprehensive, authoritative text presents the scientific foundations and clinical practice of neural blockade in both regional anesthesia and the management of pain. The descriptions and illustrations of pain mechanisms are considered classic examples. The Fourth Edition has been refined for clarity and flows logically from principles and pharmacology, to techniques for each anatomic region, to applications. This edition has two new co-editors and several new chapters on topics including neurologic complications, neural blockade for surgery, treatment of pain in older people, and complications in pain medicine.A companion Website will offer the fully searchable text and an image bank.

The perception of pain requires the transmission of an impulse from the periphery to the brain via neural elements. Multiple synapses take place along this route and at these junctions there may be augmentation or attenuation of the pain signal. This review will highlight the three-dimensional understanding of human anatomy relevant to the pain practitioner. It will discuss the autonomic nervous system and specific locations of ganglia that may be amenable to neural blockade. The somatic nervous system will also be discussed in detail, including regions amenable to neural blockade. An understanding of spinal anatomy is also paramount for the pain practitioner. This synthesis of anatomic descriptions and computerenhanced images offers the reader a complete guide for safe and successful performance of regional anesthesia.

Cousins And Bridenbaughs Neural Blockade In Clinical Anesthesia And Pain Medicine Download

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Pain may come from the site of surgical incision, from rib damage or rib removal, from intercostal nerves injury, from incision of pulmonary parenchyma or pleura and from the presence and subsequent irritation due to drainage tubes. Inrercostal nerves mediate nociceptive pain after thoracic surgery from structures of chest wall and the pleura, the phrenic nerve from the diaphragmatic pleura and the vagal nerve from the lung, mediastinum and the mediastinal pleura (1,2). It is believed that the shoulder pain accompanying frequently thoracic procedures is produced by afferent impulses conducted with phrenic nerves. This kind of pain can appear even when thoracic epidural or suprascapular blockade is established (3), but this is not the case if phrenic blockade is performed (4). Sympathetic nerves mediate pain from the pleura to the central nervous system causing visceral pain (1,2). The most common case of persistent pain after thoracotomy is due to damage of myofascial structures (muscle, bone, tendons and ligaments) (5,6). The presence of drainage tubes and residual pleural blood may compress and irritate the intercostal nerves, causing further inflammation and pain. In addition, intercostal nerves may be damaged if sutures or wires are passed around the ribs close to the neurovascular bundle. The subsequent neuralgia is a burning and lancinating pain, which is worsened in the night and by stretching the affected nerve (5). Generally, any movement that causes tension on the incision can increase the severity of pain. Such movements are deep breathing, coughing and extensive body movements.

Intercostal blockade interrupts ipsilaterally the transmission of neural impulses from the intercostal sensory and motor fibers of intercostal nerves to and from spinal cord and upper centers. This technique is in practice since many years. By this way, spinal nerves from T1 through T 11 can be blocked effectively decreasing VAS pain scores significantly. Local anesthetics can be infused as a single dose just before closure of the thoracotomy (11,33-36), as a single (37) or multiple (38) percutaneous injections or via an indwelling intercostal catheter (39-41). Intercostal blockade can reduce opioid requirements, however, cannot eliminate them. Supplemental systemic analgesia is almost always needed. Upon removal of pain, the respiratory mechanics improve impressively.

Thoracic epidural anesthesia is frequently used for postoperative pain control after thoracotomy or after VATS. It is accepted that thoracic epidural analgesia can reduce significantly the incidence of acute and chronic postoperative pain. However, there is a controversy relating the timing that the epidural analgesia is performed. There are trials that support the preoperative initiation of epidural analgesia, because it causes a significant reduction of the severity and incidence of the postoperative pain syndrome (43,44). On the other side, one trial supports the absence of significance regarding the timing of epidural initiation (45). Epidural blockade cannot block the pain stimuli travelled through the phrenic nerves, resulting in shoulder pain after thoracotomy, although a successful epidural blockade is in place.

The absence of histological evidence of neurolysis with perineural administration of Aquasonic 100 and PDI in this model argues against significant risk with passing the needle through the studied gels during regional anesthesia. Removing excess gel from the injection site may reduce perineural inflammation but this inflammatory response is of uncertain clinical significance.

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