ANESTHESIA Hadzic's Peripheral Nerve Blocks Hadzic parte 03

 

REFERENCES

. Suresh S, Templeton L. Superficial cervical plexus block for vocal cord surgery in an awake

pediatric patient. Anesth Analg. 2004;98:1656-1657.

. Goldberg ME, Schwartzman RJ, Domsky R, Sabia M, Torjman MC. Deep cervical plexus block for

the treatment of cervicogenic headache. Pain Physician. 2008;11:849-854.

. Stoneham MD, Knighton JD. Regional anaesthesia for carotid endarterectomy. Br J Anaesth.

1999;82:910-919.

. Naja ZM, Al-Tannir MA, Zeidan A, et al. Bilateral guided cervical block for Zenker diverticulum

excision in a patient with ankylosing spondylitis. J Anesth. 2009;23:143-146.

. Ling KU, Hasan MS, Ha KO, Wang CY. Superficial cervical plexus block combined with

auriculotemporal nerve block for drainage of dental abscess in adults with difficult airways. Anaesth

Intensive Care. 2009;37:124-126.

. Shteif M, Lesmes D, Hartman G, Ruffino S, Laster Z. The use of the superficial cervical plexus block

in the drainage of submandibular and submental abscesses—an alternative for general anesthesia. J

Oral Maxillofac Surg. 2008;66:2642-2645.

. Pintaric TS, Hocevar M, Jereb S, Casati A, Jankovic VN. A prospective, randomized comparison

between combined (deep and superficial) and superficial cervical plexus block with levobupivacaine

for minimally invasive parathyroidectomy. Anesth Analg. 2007;105:1160-1163; table of contents.

. Jones HG, Stoneham MD. Continuous cervical plexus block for carotid body tumour excision in a

patient with Eisenmenger’s syndrome. Anaesthesia. 2006;61:1214-1218.

. Choi DS, Atchabahian A, Brown AR. Cervical plexus block provides postoperative analgesia after

clavicle surgery. Anesth Analg. 2005;100:1542-1543.

0. Aunac S, Carlier M, Singelyn F, De Kock M. The analgesic efficacy of bilateral combined

superficial and deep cervical plexus block administered before thyroid surgery under general

anesthesia. Anesth Analg. 2002;95:746-750.

1. Nadig M, Ekatodramis G, Borgeat A. Continuous brachial plexus block at the cervical level using a

posterior approach in the management of neuropathic cancer pain. Reg Anesth Pain Med.

2002;27:446; author reply 446-447.

2. Christiansen TG, Nielsen R. Reduction of shoulder dislocations under interscalene brachial

blockade. Arch Orthop Trauma Surg. 1988;107:176-177.

3. Roubal PJ, Dobritt D, Placzek JD. Glenohumeral gliding manipulation following interscalene

brachial plexus block in patients with adhesive capsulitis. J Orthop Sports Phys Ther. 1996;24:66-

77.

4. Barak M, Iaroshevski D, Poppa E, Ben-Nun A, Katz Y. Low-volume interscalene brachial plexus

block for post-thoracotomy shoulder pain. J Cardiothorac Vasc Anesth. 2007;21:554-557.

5. Casati A, Borghi B, Fanelli G, et al. Interscalene brachial plexus anesthesia and analgesia for open

shoulder surgery: a randomized, double-blinded comparison between levobupivacaine and

ropivacaine. Anesth Analg. 2003;96:253-259.

6. Faryniarz D, Morelli C, Coleman S, et al. Interscalene block anesthesia at an ambulatory surgery

center performing predominantly regional anesthesia: a prospective study of one hundred thirty-three

patients undergoing shoulder surgery. J Shoulder Elbow Surg. 2006;15:686-690.

7. Hingorani AP, Ascher E, Gupta P, et al. Regional anesthesia: preferred technique for venodilatation

in the creation of upper extremity arteriovenous fistulae. Vascular. 2006;14:23-26.

8. Hadzic A, Williams BA, Karaca PE, et al. For outpatient rotator cuff surgery, nerve block

anesthesia provides superior same-day recovery over general anesthesia. Anesthesiology.

2005;102:1001-1007.

9. Stone MB, Price DD, Wang R. Ultrasound-guided supraclavicular block for the treatment of upper

extremity fractures, dislocations, and abscesses in the ED. Am J Emerg Med. 2007;25:472-475.

0. Harmon D, Frizelle HP. Supraclavicular block for day-case anaesthesia at altitude. Anaesthesia.

2001;56:197.

1. Ortells-Polo MA, Garcia-Guiral M, Garcia-Amigueti FJ, Carral-Olondris JN, Garcia-Godino T,

Aguiar-Mojarro JA. Brachial plexus anesthesia: results of a modified perivascular supraclavicular

technique [in Spanish]. Rev Esp Anestesiol Reanim. 1996;43:94-98.

2. Rigal MC, Esteve E, Alran R, Pech C. Brachial plexus block anesthesia in the upper limb surgery

[author’s translation]. Anesth Analg (Paris). 1979;36:231-234.

3. Thompson AM, Newman RJ, Semple JC. Brachial plexus anaesthesia for upper limb surgery: a

review of eight years’ experience. J Hand Surg Br. 1988;13:195-198.

4. Dhir S, Ganapathy S. Comparative evaluation of ultrasound-guided continuous infraclavicular

brachial plexus block with stimulating catheter and traditional technique: a prospective-randomized

trial. Acta Anaesthesiol Scand. 2008;52:1158-1166.

5. Morimoto M, Popovic J, Kim JT, Kiamzon H, Rosenberg AD. Case series: Septa can influence

local anesthetic spread during infraclavicular brachial plexus blocks. Can J Anaesth. 2007;54:1006-

1010.

6. Gurkan Y, Hosten T, Solak M, Toker K. Lateral sagittal infraclavicular block: clinical experience

in 380 patients. Acta Anaesthesiol Scand. 2008;52:262-266.

7. Dingemans E, Williams SR, Arcand G, et al. Neurostimulation in ultrasound-guided infraclavicular

block: a prospective randomized trial. Anesth Analg. 2007;104:1275-1280.

8. Hadžić A, Arliss J, Kerimoglu B, et al. A comparison of infraclavicular nerve block versus general

anesthesia for hand and wrist day-case surgeries. Anesthesiology. 2004;101:127-132.

9. De Jose Maria B, Banus E, Navarro Egea M, Serrano S, Perello M, Mabrok M. Ultrasound-guided

supraclavicular vs infraclavicular brachial plexus blocks in children. Paediatr Anaesth.

2008;18:838-844.

0. Ponde VC. Continuous infraclavicular brachial plexus block: a modified technique to better secure

catheter position in infants and children. Anesth Analg. 2008;106:94-96; table of contents.

1. Niemi TT, Salmela L, Aromaa U, Poyhia R, Rosenberg PH. Single-injection brachial plexus

anesthesia for arteriovenous fistula surgery of the forearm: a comparison of infraclavicular coracoid

and axillary approach. Reg Anesth Pain Med. 2007;32:55-59.

2. Day M, Pasupuleti R, Jacobs S. Infraclavicular brachial plexus block and infusion for treatment of

long-standing complex regional syndrome type 1: a case report. Pain Physician. 2004;7:265-268.

3. Rettig HC, Gielen MJ, Boersma E, Klein J. A comparison of the vertical infraclavicular and

axillary approaches for brachial plexus anaesthesia. Acta Anaesthesiol Scand. 2005;49:1501-1508.

4. Sauter AR, Dodgson MS, Stubhaug A, Halstensen AM, Klaastad O. Electrical nerve stimulation or

ultrasound guidance for lateral sagittal infraclavicular blocks: a randomized, controlled, observerblinded, comparative study. Anesth Analg. 2008;106:1910-1915.

5. Minville V, Fourcade O, Bourdet B, et al. The optimal motor response for infraclavicular brachial

plexus block. Anesth Analg. 2007;104:448-451.

6. Rodriguez J, Taboada M, Oliveira J, Ulloa B, Bascuas B, Alvarez J. Radial plus musculocutaneous

nerve stimulation for axillary block is inferior to triple nerve stimulation with 2% mepivacaine. J

Clin Anesth. 2008;20:253-256.

7. Kang SB, Rumball KM, Ettinger RS. Continuous axillary brachial plexus analgesia in a patient with

severe hemophilia. J Clin Anesth. 2003;15:38-40.

8. Brown AR. Anaesthesia for procedures of the hand and elbow. Best Pract Res Clin Anaesthesiol.

2002;16:227-246.

9. Chan VW, Perlas A, McCartney CJ, Brull R, Xu D, Abbas S. Ultrasound guidance improves success

rate of axillary brachial plexus block. Can J Anaesth. 2007;54:176-182.

0. Andersson A, Akeson J, Dahlin LB. Efficacy and safety of axillary brachial plexus block for

operations on the hand. Scand J Plast Reconstr Surg Hand Surg. 2006;40:225-229.

1. Freitag M, Zbieranek K, Gottschalk A, et al. Comparative study of different concentrations of

prilocaine and ropivacaine for intraoperative axillary brachial plexus block. Eur J Anaesthesiol.

2006;23:481-486.

2. Schwemmer U, Schleppers A, Markus C, Kredel M, Kirschner S, Roewer N. Operative

management in axillary brachial plexus blocks: comparison of ultrasound and nerve stimulation [in

German]. Anaesthesist. 2006;55:451-456.

3. Kefalianakis F, Spohner F. Ultrasound-guided blockade of axillary plexus brachialis for hand

surgery [in German]. Handchir Mikrochir Plast Chir. 2005;37:344-348.

4. Fuzier R, Fourcade O, Pianezza A, Gilbert ML, Bounes V, Olivier M. A comparison between

double-injection axillary brachial plexus block and midhumeral block for emergency upper limb

surgery. Anesth Analg. 2006;102:1856-1858.

5. Theroux MC, Dixit D, Brislin R, Como-Fluero S, Sacks K. Axillary catheter for brachial plexus

analgesia in children for postoperative pain control and rigorous physiotherapy—a simple and

effective procedure. Paediatr Anaesth. 2007;17:302-303.

6. Kjelstrup T. Transarterial block as an addition to a conventional catheter technique improves the

axillary block. Acta Anaesthesiol Scand. 2006;50:112-116.

7. Lim WS, Gammack JK, Van Niekerk J, Dangour AD. Omega 3 fatty acid for the prevention of

dementia. Cochrane Database Syst Rev. 2006:CD005379.

8. Woods RK, Thien FC, Abramson MJ. Dietary marine fatty acids (fish oil) for asthma in adults and

children. Cochrane Database Syst Rev. 2002:CD001283.

9. Bullmann V, Waurick R, Rodl R, et al. Corrective osteotomy of the humerus using perivascular

axillary anesthesia according to Weber in a patient suffering from McCune-Albright syndrome [in

German]. Anaesthesist. 2005;54:889-894.

0. Gradl G, Beyer A, Azad S, Schurmann M. Evaluation of sympathicolysis after continuous brachial

plexus analgesia using laser Doppler flowmetry in patients suffering from CRPS I [in German].

Anasthesiol Intensivmed Notfallmed Schmerzther. 2005;40:345-349.

1. Liu HT, Yu YS, Liu CK, et al. Delayed recovery of radial nerve function after axillary block in a

patient receiving ipsilateral ulnar nerve transposition surgery. Acta Anaesthesiol Taiwan.

2005;43:49-53.

2. Breschan C, Kraschl R, Jost R, Marhofer P, Likar R. Axillary brachial plexus block for treatment of

severe forearm ischemia after arterial cannulation in an extremely low birth-weight infant. Paediatr

Anaesth. 2004;14:681-684.

3. Hebl JR, Horlocker TT, Sorenson EJ, Schroeder DR. Regional anesthesia does not increase the risk

of postoperative neuropathy in patients undergoing ulnar nerve transposition. Anesth Analg.

2001;93:1606-1611.

4. van den Berg B, Berger A, van den Berg E, Zenz M, Brehmeier G, Tizian C. Continuous plexus

anesthesia to improve circulation in peripheral microvascular interventions [in German]. Handchir

Mikrochir Plast Chir. 1983;15:101-104.

5. Bekler H, Beyzadeoglu T, Mercan A. Groin flap immobilization by axillary brachial plexus block

anesthesia. Tech Hand Up Extrem Surg. 2008;12:68-70.

6. Kriwanek KL, Wan J, Beaty JH, Pershad J. Axillary block for analgesia during manipulation of

forearm fractures in the pediatric emergency department: a prospective randomized comparative trial.

J Pediatr Orthop. 2006;26:737-740.

7. Jablecki J, Syrko M. The application of nerve block in early post-operative rehabilitation after

tenolysis of the flexor tendon. Ortop Traumatol Rehabil. 2005;7:646-650.

8. Broekhuysen CL, Fechner MR, Kerkkamp HE. The use of a selective peripheral median nerve block

for pain-free early active motion after hand surgery. J Hand Surg Am. 2006;31:857-859.

9. Macaire P, Choquet O, Jochum D, Travers V, Capdevila X. Nerve blocks at the wrist for carpal

tunnel release revisited: the use of sensory-nerve and motor-nerve stimulation techniques. Reg Anesth

Pain Med. 2005;30:536-540.

0. Gebhard RE, Al-Samsam T, Greger J, Khan A, Chelly JE. Distal nerve blocks at the wrist for

outpatient carpal tunnel surgery offer intraoperative cardiovascular stability and reduce discharge

time. Anesth Analg. 2002;95:351-355.

1. Delaunay L, Chelly JE. Blocks at the wrist provide effective anesthesia for carpal tunnel release.

Can J Anaesth. 2001;48:656-660.

2. Derkash RS, Weaver JK, Berkeley ME, Dawson D. Office carpal tunnel release with wrist block

and wrist tourniquet. Orthopedics. 1996;19:589-590.

3. Siebert T, Sinkgraven R, Fuchslocher M, Rzany B. Efficacy, side effects and patient satisfaction

with wrist conduction block anaesthesia prior to the treatment of palmar hyperhidrosis with botulinumtoxin type A [in German]. J Dtsch Dermatol Ges. 2003;1:876-883.

4. Campanati A, Lagalla G, Penna L, Gesuita R, Offidani A. Local neural block at the wrist for

treatment of palmar hyperhidrosis with botulinum toxin: technical improvements. J Am Acad

Dermatol. 2004;51:345-348.

5. Thompson WL, Malchow RJ. Peripheral nerve blocks and anesthesia of the hand. Mil Med.

2002;167:478-482.

6. Ferrera PC, Chandler R. Anesthesia in the emergency setting: Part I. Hand and foot injuries. Am

Fam Physician. 1994;50:569-573.

7. Leversee JH, Bergman JJ. Wrist and digital nerve blocks. J Fam Pract. 1981;13:415-421.

8. Braun C, Henneberger G, Racenberg E. Techniques of continuous nerve block at the level of the

wrist [in French]. Ann Chir Main Memb Super. 1992;11:141-145.

9. Ward WA, Van Moore A. Management of finger ulcers in scleroderma. J Hand Surg Am.

1995;20:868-872.

0. Phelps DB, Rutherford RB, Boswick JA Jr. Control of vasospasm following trauma and

microvascular surgery. J Hand Surg Am. 1979;4:109-117.

1. Taras JS, Behrman MJ. Continuous peripheral nerve block in replantation and revascularization. J

Reconstr Microsurg. 1998;14:17-21.

2. Hart RG, Fernandas FA, Kutz JE. Transthecal digital block: an underutilized technique in the ED.

Am J Emerg Med. 2005;23:340-342.

3. Keramidas EG, Rodopoulou SG, Tsoutsos D, Miller G, Ioannovich J. Comparison of transthecal

digital block and traditional digital block for anesthesia of the finger. Plast Reconstr Surg.

2004;114:1131-1134; discussion 1135-1136.

4. Harness NG. Digital block anesthesia. J Hand Surg Am. 2009;34:142-145.

5. Kollersbeck C, Walcher T, Gradl G, Genelin F. Clinical experiences and dosage pattern in

subcutaneous single-injection digital block technique [in German]. Handchir Mikrochir Plast Chir.

2004;36:64-66.

6. Freedman RR, Mayes MD, Sabharwal SC. Digital nerve blockade in Raynaud’s disease.

Circulation. 1989;80:1923-1924.

7. Kirchhoff R, Jensen PB, Nielsen NS, Boeckstyns ME. Repeated digital nerve block for pain control

after tenolysis. Scand J Plast Reconstr Surg Hand Surg. 2000;34:257-258.

8. Daly DJ, Myles PS. Update on the role of paravertebral blocks for thoracic surgery: are they worth

it? Curr Opin Anaesthesiol. 2009;22:38-43.

9. Davies RG, Myles PS, Graham JM. A comparison of the analgesic efficacy and side-effects of

paravertebral vs epidural blockade for thoracotomy—a systematic review and meta-analysis of

randomized trials. Br J Anaesth. 2006;96:418-426.

0. Joshi GP, Bonnet F, Shah R, et al. A systematic review of randomized trials evaluating regional

techniques for postthoracotomy analgesia. Anesth Analg. 2008;107:1026-1040.

1. Boezaart AP, Raw RM. Continuous thoracic paravertebral block for major breast surgery. Reg

Anesth Pain Med. 2006;31:470-476.

2. Pusch F, Freitag H, Weinstabl C, Obwegeser R, Huber E, Wildling E. Single-injection

paravertebral block compared to general anaesthesia in breast surgery. Acta Anaesthesiol Scand.

1999;43:770-774.

3. Coveney E, Weltz CR, Greengrass R, et al. Use of paravertebral block anesthesia in the surgical

management of breast cancer: experience in 156 cases. Ann Surg. 1998;227:496-501.

4. Tsai T, Rodriguez-Diaz C, Deschner B, Thomas K, Wasnick JD. Thoracic paravertebral block for

implantable cardioverter-defibrillator and laser lead extraction. J Clin Anesth. 2008;20:379-382.

5. Moussa AA. Opioid saving strategy: bilateral single-site thoracic paravertebral block in right lobe

donor hepatectomy. Middle East J Anesthesiol. 2008;19:789-801.

6. Mehta Y, Arora D, Sharma KK, Mishra Y, Wasir H, Trehan N. Comparison of continuous thoracic

epidural and paravertebral block for postoperative analgesia after robotic-assisted coronary artery

bypass surgery. Ann Card Anaesth. 2008;11:91-96.

7. Serpetinis I, Bassiakou E, Xanthos T, Baltatzi L, Kouta A. Paravertebral block for open

cholecystectomy in patients with cardiopulmonary pathology. Acta Anaesthesiol Scand. 2008;52:872-

873.

8. Rudkin GE, Gardiner SE, Cooter RD. Bilateral thoracic paravertebral block for abdominoplasty. J

Clin Anesth. 2008;20:54-56.

9. Cooter RD, Rudkin GE, Gardiner SE. Day case breast augmentation under paravertebral blockade:

a prospective study of 100 consecutive patients. Aesthetic Plast Surg. 2007;31:666-673.

0. Culp WC, Payne MN, Montgomery ML. Thoracic paravertebral block for analgesia following liver

mass radiofrequency ablation. Br J Radiol. 2008;81:e23-e25.

1. Berta E, Spanhel J, Smakal O, Smolka V, Gabrhelik T, Lonnqvist PA. Single injection paravertebral

block for renal surgery in children. Paediatr Anaesth. 2008;18:593-597.

2. Lonnqvist PA, Olsson GL. Paravertebral vs epidural block in children. Effects on postoperative

morphine requirement after renal surgery. Acta Anaesthesiol Scand. 1994;38:346-349.

3. Lopez-Berlanga JL, Garutti I, Martinez-Campos E, Pineiro P, Salvatierra D. Bilateral paravertebral

block anesthesia for thymectomy by video-assisted thoracoscopy in patients with myasthenia gravis

[in Spanish]. Rev Esp Anestesiol Reanim. 2006;53:571-574.

4. Kaya FN, Turker G, Basagan-Mogol E, Goren S, Bayram S, Gebitekin C. Preoperative multipleinjection thoracic paravertebral blocks reduce postoperative pain and analgesic requirements after

video-assisted thoracic surgery. J Cardiothorac Vasc Anesth. 2006;20:639-643.

5. Culp WC Jr, Culp WC. Thoracic paravertebral block for percutaneous transhepatic biliary

drainage. J Vasc Interv Radiol. 2005;16:1397-1400.

6. Kelly FE, Murdoch JA, Sanders DJ, Berrisford RG. Continuous paravertebral block for thoracoabdominal oesophageal surgery. Anaesthesia. 2005;60:98-99.

7. Canto M, Sanchez MJ, Casas MA, Bataller ML. Bilateral paravertebral blockade for conventional

cardiac surgery. Anaesthesia. 2003;58:365-e70.

8. Karmakar MK, Ho AM. Acute pain management of patients with multiple fractured ribs. J Trauma.

2003;54:615-625.

9. Karmakar MK, Critchley LA, Ho AM, Gin T, Lee TW, Yim AP. Continuous thoracic paravertebral

infusion of bupivacaine for pain management in patients with multiple fractured ribs. Chest.

2003;123:424-431.

00. Dhole S, Mehta Y, Saxena H, Juneja R, Trehan N. Comparison of continuous thoracic epidural and

paravertebral blocks for postoperative analgesia after minimally invasive direct coronary artery

bypass surgery. J Cardiothorac Vasc Anesth. 2001;15:288-292.

01. Paniagua P, Catala E, Villar Landeira JM. Successful management of pleuritic pain with thoracic

paravertebral block. Reg Anesth Pain Med. 2000;25:651-653.

02. Sabanathan S, Shah R, Tsiamis A, Richardson J. Oesophagogastrectomy in the elderly high risk

patients: role of effective regional analgesia and early mobilisation. J Cardiovasc Surg (Torino).

1999;40:153-156.

03. Jamieson BD, Mariano ER. Thoracic and lumbar paravertebral blocks for outpatient lithotripsy. J

Clin Anesth. 2007;19:149-151.

04. Weltz CR, Klein SM, Arbo JE, Greengrass RA. Paravertebral block anesthesia for inguinal hernia

repair. World J Surg. 2003;27:425-429.

05. Naja Z, Ziade MF, Lonnqvist PA. Bilateral paravertebral somatic nerve block for ventral hernia

repair. Eur J Anaesthesiol. 2002;19:197-202.

06. Lee EM, Murphy KP, Ben-David B. Postoperative analgesia for hip arthroscopy: combined L1 and

L2 paravertebral blocks. J Clin Anesth. 2008;20:462-465.

07. Basagan-Mogol E, Turker G, Yilmaz M, Goren S. Combination of a psoas compartment, sciatic

nerve, and T12-L1 paravertebral blocks for femoropopliteal bypass surgery in a high-risk patient. J

Cardiothorac Vasc Anesth. 2008;22:337-339.

08. Nair V, Henry R. Bilateral paravertebral block: a satisfactory alternative for labour analgesia.

Can J Anaesth. 2001;48:179-184.

09. Suelto MD, Shaw DB. Labor analgesia with paravertebral lumbar sympathetic block. Reg Anesth

Pain Med. 1999;24:179-181.

10. Akin S, Aribogan A, Turunc T, Aridogan A. Lumbar plexus blockade with ropivacaine for

postoperative pain management in elderly patients undergoing urologic surgeries. Urol Int.

2005;75:345-349.

11. Asao Y, Higuchi T, Tsubaki N, Shimoda Y. Combined paravertebral lumbar plexus and parasacral

sciatic nerve block for reduction of hip fracture in four patients with severe heart failure [in

Japanese]. Masui. 2005;54:648-652.

12. Ho AM, Karmakar MK. Combined paravertebral lumbar plexus and parasacral sciatic nerve block

for reduction of hip fracture in a patient with severe aortic stenosis. Can J Anaesth. 2002;49:946-

950.

13. Morimoto M, Kim JT, Popovic J, Jain S, Bekker A. Ultrasound-guided lumbar plexus block for

open reduction and internal fixation of hip fracture. Pain Pract. 2006;6:124-126.

14. Bogoch ER, Henke M, Mackenzie T, Olschewski E, Mahomed NN. Lumbar paravertebral nerve

block in the management of pain after total hip and knee arthroplasty: a randomized controlled

clinical trial. J Arthroplasty. 2002;17:398-401.

15. Stevens RD, Van Gessel E, Flory N, Fournier R, Gamulin Z. Lumbar plexus block reduces pain

and blood loss associated with total hip arthroplasty. Anesthesiology. 2000;93:115-121.

16. Siddiqui ZI, Cepeda MS, Denman W, Schumann R, Carr DB. Continuous lumbar plexus block

provides improved analgesia with fewer side effects compared with systemic opioids after hip

arthroplasty: a randomized controlled trial. Reg Anesth Pain Med. 2007;32:393-398.

17. Marino J, Russo J, Kenny M, Herenstein R, Livote E, Chelly JE. Continuous lumbar plexus block

for postoperative pain control after total hip arthroplasty. A randomized controlled trial. J Bone Joint

Surg Am. 2009;91:29-37.

18. Capdevila X, Macaire P, Dadure C, et al. Continuous psoas compartment block for postoperative

analgesia after total hip arthroplasty: new landmarks, technical guidelines, and clinical evaluation.

Anesth Analg. 2002;94:1606-1613.

19. Ilfeld BM, Ball ST, Gearen PF, et al. Ambulatory continuous posterior lumbar plexus nerve blocks

after hip arthroplasty: a dual-center, randomized, triple-masked, placebo-controlled trial.

Anesthesiology. 2008;109:491-501.

20. Zetlaoui PJ. Block of the lumbar plexus [in French]. Cah Anesthesiol. 1994;42:771-780.

21. Mongan PD, Strong WE, Menk EJ. Anesthesia for percutaneous renal procedures. Reg Anesth.

1991;16:296-298.

22. Meguiar RV, Wheeler AS. Lumbar sympathetic block with bupivacaine: analgesia for labor.

Anesth Analg. 1978;57:486-492.

23. Meelhuysen FE, Halpern D, Quast J. Treatment of flexor spasticity of hip by paravertebral lumbar

spinal nerve block. Arch Phys Med Rehabil. 1968;49:717-722.

24. Asakura Y, Kandatsu N, Kato N, Sato Y, Fujiwara Y, Komatsu T. Ultra-sound guided sciatic nerve

block combined with lumbar plexus block for infra-inguinal artery bypass graft surgery. Acta

Anaesthesiol Scand. 2008;52:721-722.

25. Campbell A, McCormick M, McKinlay K, Scott NB. Epidural vs. lumbar plexus infusions

following total knee arthroplasty: randomized controlled trial. Eur J Anaesthesiol. 2008;25:502-507.

26. Mello SS, Saraiva RA, Marques RS, Gasparini JR, Assis CN, Goncalves MH. Posterior lumbar

plexus block in children: a new anatomical landmark. Reg Anesth Pain Med. 2007;32:522-527.

27. Dalens B, Tanguy A, Vanneuville G. Lumbar plexus block in children: a comparison of two

procedures in 50 patients. Anesth Analg. 1988;67:750-758.

28. Ota J, Sakura S, Hara K, Saito Y. Ultrasound-guided anterior approach to sciatic nerve block: a

comparison with the posterior approach. Anesth Analg. 2009;108:660-665.

29. del Fresno Caniaveras J, Campos A, Galiana M, Navarro-Martinez JA, Company R. Postoperative

analgesia in knee arthroplasty using an anterior sciatic nerve block and a femoral nerve block [in

Spanish]. Rev Esp Anestesiol Reanim. 2008;55:548-551.

30. Montes FR, Zarate E, Grueso R, et al. Comparison of spinal anesthesia with combined sciaticfemoral nerve block for outpatient knee arthroscopy. J Clin Anesth. 2008;20:415-420.

31. Casati A, Cappelleri G, Fanelli G, et al. Regional anaesthesia for outpatient knee arthroscopy: a

randomized clinical comparison of two different anaesthetic techniques. Acta Anaesthesiol Scand.

2000;44:543-547.

32. Taboada Muniz M, Rodriguez J, Bermudez M, et al. Low volume and high concentration of local

anesthetic is more efficacious than high volume and low concentration in Labat’s sciatic nerve block:

a prospective, randomized comparison. Anesth Analg. 2008;107:2085-2088.

33. Raith C, Kolblinger C, Walch H. Combined transgluteal ischial and femoral nerve block:

retrospective data on 65 risk patients with leg amputation [in German]. Anaesthesist. 2008;57:555-

561.

34. Fischler AH, Gross JB. Ultrasound-guided sciatic neuroma block for treatment of intractable stump

pain. J Clin Anesth. 2007;19:626-628.

35. van Geffen GJ, Scheuer M, Muller A, Garderniers J, Gielen M. Ultrasound-guided bilateral

continuous sciatic nerve blocks with stimulating catheters for postoperative pain relief after bilateral

lower limb amputations. Anaesthesia. 2006;61:1204-1207.

36. Casati A, Fanelli G, Danelli G, et al. Stimulating or conventional perineural catheters after hallux

valgus repair: a double-blind, pharmaco-economic evaluation. Acta Anaesthesiol Scand.

2006;50:1284-1289.

37. Serri S. Venous surgery of the lower limb: value of nerve blocks [in French]. Cah Anesthesiol.

1996;44:441-445.

38. Brodner G, Buerkle H, Van Aken H, et al. Postoperative analgesia after knee surgery: a

comparison of three different concentrations of ropivacaine for continuous femoral nerve blockade.

Anesth Analg. 2007;105:256-262.

39. Allen HW, Liu SS, Ware PD, Nairn CS, Owens BD. Peripheral nerve blocks improve analgesia

after total knee replacement surgery. Anesth Analg. 1998;87:93-97.

40. Ng HP, Cheong KF, Lim A, Lim J, Puhaindran ME. Intraoperative single-shot “3-in-1” femoral

nerve block with ropivacaine 0.25%, ropivacaine 0.5% or bupivacaine 0.25% provides comparable

48-hr analgesia after unilateral total knee replacement. Can J Anaesth. 2001;48:1102-1108.

41. Good RP, Snedden MH, Schieber FC, Polachek A. Effects of a preoperative femoral nerve block

on pain management and rehabilitation after total knee arthroplasty. Am J Orthop. 2007;36:554-557.

42. Iskandar H, Benard A, Ruel-Raymond J, Cochard G, Manaud B. Femoral block provides superior

analgesia compared with intra-articular ropivacaine after anterior cruciate ligament reconstruction.

Reg Anesth Pain Med. 2003;28:29-32.

43. Mutty CE, Jensen EJ, Manka MA Jr, Anders MJ, Bone LB. Femoral nerve block for diaphyseal

and distal femoral fractures in the emergency department. Surgical technique. J Bone Joint Surg Am.

2008;90 Suppl:218-226.

44. Fowler SJ, Symons J, Sabato S, Myles PS. Epidural analgesia compared with peripheral nerve

blockade after major knee surgery: a systematic review and meta-analysis of randomized trials. Br J

Anaesth. 2008;100:154-164.

45. Luhmann SJ, Schootman M, Schoenecker PL, Gordon JE, Schrock C. Use of femoral nerve blocks

in adolescents undergoing patellar realignment surgery. Am J Orthop. 2008;37:39-43.

46. Noiseux N, Prieto I, Bracco D, Basile F, Hemmerling T. Coronary artery bypass grafting in the

awake patient combining high thoracic epidural and femoral nerve block: first series of 15 patients.

Br J Anaesth. 2008;100:184-189.

47. Hemmerling TM, Noiseux N, Basile F, Noel MF, Prieto I. Awake cardiac surgery using a novel

anesthetic technique. Can J Anaesth. 2005;52:1088-1092.

48. Stewart B, Tudur Smith C, Teebay L, Cunliffe M, Low B. Emergency department use of a

continuous femoral nerve block for pain relief for fractured femur in children. Emerg Med J.

2007;24:113-114.

49. Barker R, Schiferer A, Gore C, et al. Femoral nerve blockade administered preclinically for pain

relief in severe knee trauma is more feasible and effective than intravenous metamizole: a randomized

controlled trial. J Trauma. 2008;64:1535-1538.

50. Viscomi CM, Reese J, Rathmell JP. Medial and lateral antebrachial cutaneous nerve blocks: an

easily learned regional anesthetic for forearm arteriovenous fistula surgery. Reg Anesth. 1996;21:2-5.

51. Cook JL, Cook J. The lateral femoral cutaneous nerve block. Dermatol Surg. 2000;26:81-83.

52. Wardrop PJ, Nishikawa H. Lateral cutaneous nerve of the thigh blockade as primary anaesthesia

for harvesting skin grafts. Br J Plast Surg. 1995;48:597-600.

53. Maccani RM, Wedel DJ, Melton A, Gronert GA. Femoral and lateral femoral cutaneous nerve

block for muscle biopsies in children. Paediatr Anaesth. 1995;5:223-227.

54. Hotta K, Sata N, Suzuki H, Takeuchi M, Seo N. Ultrasound-guided combined femoral nerve and

lateral femoral cutaneous nerve blocks for femur neck fracture surgery—case report [in Japanese].

Masui. 2008;57:892-894.

55. Tumber PS, Bhatia A, Chan VW. Ultrasound-guided lateral femoral cutaneous nerve block for

meralgia paresthetica. Anesth Analg. 2008;106:1021-1022.

56. Hurdle MF, Weingarten TN, Crisostomo RA, Psimos C, Smith J. Ultrasound-guided blockade of

the lateral femoral cutaneous nerve: technical description and review of 10 cases. Arch Phys Med

Rehabil. 2007;88:1362-1364.

57. Hirabayashi Y, Hotta K, Suzuki H, Igarashi T, Saitoh K, Seo N. Combined block of femoral,

sciatic, obturator nerves and lateral cutaneous nerve block with ropivacaine for leg amputation above

the knee [in Japanese]. Masui. 2002;51:1013-1035.

58. Vloka JD, Hadžić A, Mulcare R, Lesser JB, Koorn R, Thys DM. Combined popliteal and posterior

cutaneous nerve of the thigh blocks for short saphenous vein stripping in outpatients: an alternative to

spinal anesthesia. J Clin Anesth. 1997;9:618-622.

59. Akkaya T, Ersan O, Ozkan D, et al. Saphenous nerve block is an effective regional technique for

post-meniscectomy pain. Knee Surg Sports Traumatol Arthrosc. 2008;16:855-858.

60. Singelyn FJ. Single-injection applications for foot and ankle surgery. Best Pract Res Clin

Anaesthesiol. 2002;16:247-254.

61. van der Wal M, Lang SA, Yip RW. Transsartorial approach for saphenous nerve block. Can J

Anaesth. 1993;40:542-546.

62. Reilley TE, Gerhardt MA. Anesthesia for foot and ankle surgery. Clin Podiatr Med Surg.

2002;19:125-147, vii.

63. Sarrafian SK, Ibrahim IN, Breihan JH. Ankle-foot peripheral nerve block for mid and forefoot

surgery. Foot Ankle. 1983;4:86-90.

64. Rudkin GE, Rudkin AK, Dracopoulos GC. Bilateral ankle blocks: a prospective audit. ANZ J

Surg. 2005;75:39-42.

65. Rudkin GE, Rudkin AK, Dracopoulos GC. Ankle block success rate: a prospective analysis of

1,000 patients. Can J Anaesth. 2005;52:209-210.

66. Reuben SS, Steinberg RB, Maciolek H, Manikantan P. An evaluation of the analgesic efficacy of

intravenous regional anesthesia with lidocaine and ketorolac using a forearm versus upper arm

tourniquet. Anesth Analg. 2002;95:457-460.

67. Johnson CN. Intravenous regional anesthesia: new approaches to an old technique. CRNA.

2000;11:57-61.

68. Estebe JP. Locoregional intravenous anesthesia [in French]. Ann Fr Anesth Reanim. 1999;18:663-

673.

69. Bernateck M, Rolke R, Birklein F, Treede RD, Fink M, Karst M. Successful intravenous regional

block with low-dose tumor necrosis factor-alpha antibody infliximab for treatment of complex

regional pain syndrome 1. Anesth Analg. 2007;105:1148-1151.

70. Toda K, Muneshige H, Asou T. Intravenous regional block with lidocaine for treatment of complex

regional pain syndrome. Clin J Pain. 2006;22:222-224.

71. Lake AP. Intravenous regional sympathetic block: past, present and future? Pain Res Manag.

2004;9:35-37.

72. Bolte RG, Stevens PM, Scott SM, Schunk JE. Mini-dose Bier block intravenous regional

anesthesia in the emergency department treatment of pediatric upper-extremity injuries. J Pediatr

Orthop. 1994;14:534-537.

73. Barnes CL, Blasier RD, Dodge BM. Intravenous regional anesthesia: a safe and cost-effective

outpatient anesthetic for upper extremity fracture treatment in children. J Pediatr Orthop.

1991;11:717-720.

174. McCarty EC, Mencio GA, Green NE. Anesthesia and analgesia for the ambulatory management of

fractures in children. J Am Acad Orthop Surg. 1999;7:81-91.

175. Blaheta HJ, Vollert B, Zuder D, Rassner G. Intravenous regional anesthesia (Bier’s block) for

botulinum toxin therapy of palmar hyperhidrosis is safe and effective. Dermatol Surg. 2002;28:666-

671.

176. Blaheta HJ, Deusch H, Rassner G, Vollert B. Intravenous regional anesthesia (Bier’s block) is

superior to a peripheral nerve block for painless treatment of plantar hyperhidrosis with botulinum

toxin. J Am Acad Dermatol. 2003;48:302-304.

177. Handoll HH, Madhok R, Dodds C. Anaesthesia for treating distal radial fracture in adults.

Cochrane Database Syst Rev. 2002:CD003320.

178. Reuben SS, Sklar J. Intravenous regional anesthesia with clonidine in the management of complex

regional pain syndrome of the knee. J Clin Anesth. 2002;14:87-91.

179. Mohr B. Safety and effectiveness of intravenous regional anesthesia (Bier block) for outpatient

management of forearm trauma. CJEM. 2006;8:247-250.

7

Continuous Peripheral Nerve Blocks in Outpatients

Brian M. Ilfeld, Elizabeth M. Renehan and F. Kayser Enneking

Introduction

 Single-injection nerve blocks provide up to 16 hours of postoperative analgesia.

 Portable infusion pumps allow outpatients to receive continuous nerve blocks.

More than 40% of ambulatory patients experience moderate to severe postoperative pain at home

following orthopedic procedures.1

 Up to 16 hours of analgesia may be provided by single-injection

peripheral nerve blocks with long-acting local anesthetics. However, following block resolution,

ambulatory patients must usually rely on oral opioids to control pain. Unfortunately, opioids are

associated with undesirable side effects, such as pruritus, nausea and vomiting, sedation, and

constipation. To improve postoperative analgesia following ambulatory surgery, there has been an

increasing interest in providing “perineural local anesthetic infusions,” also called, “continuous

peripheral nerve blocks,” to outpatients. This technique involves the percutaneous insertion of a

catheter directly adjacent to the peripheral nerve(s) supplying the surgical site. Local anesthetic is

then infused via the catheter providing potent, site-specific analgesia. Outpatients may theoretically

experience the same level of analgesia previously afforded only to those remaining hospitalized by

combining the perineural catheter with a portable infusion pump.

In 1946, Ansbro first described continuous regional blockade using a cork to stabilize a needle

placed adjacent to the brachial plexus divisions to provide a “continuous” supraclavicular block.2

However, for decades patients were required to remain hospitalized because the available pumps

used to infuse local anesthetic were large, heavy, and technically sophisticated. It was not until 52

years later that Rawal described outpatient perineural infusion using a percutaneous catheter and a

small lightweight, portable infusion pump.3

Advantages and Evidence

 Significant decreases in postoperative pain and opioid side effects are possible.

 Earlier home discharge is possible for a select subset of hospitalized patients.

Following Rawal’s article, case reports or series of ambulatory perineural infusion were

described via catheters in various anatomic locations, including paravertebral,4

 interscalene,5–7

intersternocleidomastoid,8

 infraclavicular,6

 axillary,9

 psoas compartment,9,10 femoral,9,11 fascia

iliaca,5

 sciatic/Labat,9,10 sciatic/popliteal,6,12 and tibial nerve.6

 Ambulatory continuous peripheral

nerve blocks in pediatric patients have also been reported in patients as young as 8 years of age.13

However, Klein et al provided the first prospective evidence quantifying infusion benefits in 2000.14

This randomized, double-masked, placebo-controlled investigation by Klein et al involved

subjects undergoing open rotator cuff repair who received an interscalene block and perineural

catheter preoperatively, and they were randomized to receive either perineural ropivacaine 0.2% or

normal saline postoperatively (10 mL/h). Patients receiving perineural placebo averaged a 3 on a

visual analog pain scale of 0 to 10, compared with a 1 for subjects receiving ropivacaine. Although a

portable pump was used, patients remained hospitalized during local anesthetic infusion <24 hours,

and catheters were removed by investigators prior to home discharge. Patients had access to

intravenous morphine via patient-controlled opioid analgesia because the investigators “felt

compelled to provide more than oral analgesics,” since patients remained hospitalized.14 As a result,

patients receiving normal saline theoretically received a greater degree of analgesia than that

available to ambulatory patients who must rely on oral instead of intravenous opioids. Consequently,

although these data suggested perineural infusion may improve postoperative analgesia following

hospital discharge, the extent of improvement for patients actually at home remained unknown.

Data involving perineural infusion in outpatients were subsequently provided in four randomized

double-masked, placebo-controlled studies.15–18 Patients receiving perineural local anesthetic

achieved both clinically and statistically significant lower resting and breakthrough pain scores

compared with those using exclusively oral opioids for analgesia (Figure 7-1). In addition, they

required dramatically fewer oral analgesics to achieve their improved level of analgesia (Figure 7-

1). Preoperatively, subjects scheduled for moderately painful procedures had a perineural catheter

placed: an infraclavicular catheter for hand/forearm procedures,15 a popliteal catheter for foot/ankle

surgeries,16,18 or an interscalene catheter for shoulder procedures.17 Postoperatively, patients

received either perineural local anesthetic or normal saline and were followed at home for up to 60

hours. All patients were instructed to use a bolus from their infusion pump for breakthrough pain and

oral analgesics if this maneuver failed. In patients with an interscalene catheter following shoulder

surgery, the local anesthetic infusion provided analgesia so complete that 80% of patients receiving

ropivacaine required one or fewer opioid tablets per day during their infusion, and they reported

average resting pain <1.5 on a scale of 0–10.17 This compares with all patients receiving placebo

requiring four or more opioid tablets per day, beginning the evening of surgery, and reporting average

resting pain scores between 3 and 4. For breakthrough pain, the differences between treatment groups

were even more pronounced in all of these four placebo-controlled studies (Figure 7-1).

FIGURE 7-1. Effects of interscalene and sciatic/popliteal perineural infusion of either ropivacaine

or placebo on average pain at rest (panels A and D), worst pain overall (panels B and E), and opiate

use (panels C and F) following moderately painful shoulder or lower extremity surgery (scale: 0–10).

Each opiate tablet consisted of oxycodone, 5 mg. Note: The infusion was discontinued after

postoperative day 2 as indicated by the horizontal lines. Data are expressed as median (horizontal

bar) with 25th–75th (box) and 10th–90th (whiskers) percentiles for patients randomly assigned to

receive either 0.2% ropivacaine or 0.9% saline placebo. For tightly clustered data (e.g., panel A,

postoperative days 0 and 1, ropivacaine group), the median approximated the 10th and 25th percentile

values. In this case, the median is zero and only the 75th and 90th percentiles are clearly noted; p <

0.05: *, compared with saline for a given postoperative day. Reproduced with permission.16,17

Additional benefits related to improved analgesia were experienced by patients who received

perineural local anesthetic. Of patients receiving perineural ropivacaine, 0 to 30% reported insomnia

due to pain, compared with 60 to 70% of patients receiving placebo.15–17 Additionally, awakenings

from sleep because of pain averaged 0.0 to 0.2 times on the first postoperative night, compared with

2.0 to 2.3 times for patients using only oral opioids.15–17 Using fewer opioid tablets was associated

with a lower rate of nausea, vomiting, pruritus, and sedation.15–18 Satisfaction with postoperative

analgesia was both clinically and statistically higher for patients receiving local anesthetic.15–18

Finally, patients with popliteal local anesthetic infusion rated their “quality of recovery” (0–100; 100

= highest) an average of 96 compared with 83 for patients receiving placebo.18 Whether these

demonstrated benefits result in an improvement in patients’ health-related quality-of-life remains

unexamined.19 Also uninvestigated to date is the relative superiority of one location over another for

similar procedures (e.g., axillary vs. infraclavicular for hand surgery).

The possible advantages of using outpatient perineural infusion to allow earlier discharge of

patients who require potent analgesia has only recently been explored. Individual benefits of a shorter

hospitalization may include a decrease in nosocomial infection,20,21 harmful medical errors,22,23 and

increases in health-related quality-of-life.19 Societal benefits include a potentially enormous cost

savings.24–26 Using ambulatory perineural infusion, patients have been discharged home directly from

the recovery room following total elbow (unpublished data, Ilfeld et al, 2004) and shoulder

replacement,27 and on the first postoperative day following total hip (unpublished data, Ilfeld et al,

2004) and knee replacement.28 Additional data are required to define the appropriate subset of

patients and assess the benefits and incidence of complications associated with this practice.

Patient Selection

 Outpatient infusion is often limited to patients expected to have moderate pain.

 Appropriate patient selection is crucial for safe outpatient infusion.

Many investigators have limited the use of ambulatory infusion to patients who are expected to have

moderate or severe postoperative pain >24 hours that is not easily managed with oral opioids. This

practice is in an attempt to balance the potential benefits of this technique with the potential risks,29,30

financial cost, and patient inconvenience of carrying an infusion pump and up to 600 mL of local

anesthetic.27 However, outpatient infusion may be used following mildly painful procedures—defined

here as usually well-managed with oral opioids—to decrease opioid requirements and opioid-related

side effects.3,31 Appropriate patient selection is crucial for safe outpatient infusion because not all

patients desire, or are capable of accepting, the extra responsibility that comes with the catheter and

pump system. Because some degree of postoperative cognitive dysfunction is common following

surgery,32 patients are often required to have a “caretaker” during infusion.15–17

,

33–36 Whether a

caretaker is necessary for one night or for the entire duration of infusion remains unresolved.37 If

removal of the catheter is expected to occur at home, then a caretaker willing to perform this

procedure must be available at the infusion conclusion if the patient is unwilling or unable to do this

themselves (e.g., psoas compartment catheter).

In medically unsupervised outpatients, complications may take longer to identify or be more

difficult to manage than for hospitalized patients. Therefore, hepatic or renal insufficiency have been

relative contraindications to outpatient infusion in an effort to avoid local anesthetic toxicity.38 For

infusions that may effect the phrenic nerve and ipsilateral diaphragm function (e.g., interscalene or

cervical paravertebral catheters), patients with heart or lung disease are often excluded because

continuous interscalene local anesthetic infusions have been shown to cause frequent ipsilateral

diaphragm paralysis.39 Conservative application of this technique is warranted until additional

investigation of hospitalized medically supervised patients documents its safety,40,41 although the

effect on overall pulmonary function may be minimal for relatively healthy patients.42

Selection of Insertion Technique

 The optimal equipment and insertion techniques have yet to be determined.

 A “test dose” of local anesthetic and epinephrine via the catheter is mandatory.

 Securing the catheter adequately is of paramount concern.

In a substantial number of cases—as high as 40% in some reports43—inaccurate catheter placement

may occur.17,44,45 This issue is of critical importance for outpatients because catheter replacement is

not an option after leaving the medical facility. Many techniques and types of equipment have been

described for catheter insertion. Using one common technique, the initial local anesthetic bolus is

given via the needle, followed by catheter placement. However, using this method, it is possible to

provide a successful surgical block but inaccurate catheter placement.17 For ambulatory patients, the

inadequate perineural infusion often will not be detected until after surgical block resolution

following home discharge.17 Using another technique, investigators have first inserted the catheter and

then administered a bolus of local anesthetic via the catheter, with a reported failure rate of 1 to

8%.46,47

In an attempt to further improve catheter-placement success rates, “stimulating” catheters have

been developed that deliver current to the catheter tip.48 This design provides feedback on the

positional relationship of the catheter tip to the target nerve prior to local anesthetic dosing.33,34 To

date, there are no studies comparing stimulating and nonstimulating catheters. However, there is

limited evidence that passing current via the catheter may improve the accuracy of catheter

placement.49 The optimal placement techniques and equipment for ambulatory perineural infusion

have yet to be determined and require further investigation.50 A local anesthetic and epinephrine “test

dose” should be injected via the catheter in an effort to identify intrathecal,51 epidural,52 or

intravascular53 placement before infusion initiation, regardless of the equipment/technique used.

Local Anesthetic and Adjuvant Selection

 Most outpatient infusions reported involved ropivacaine or bupivacaine.

 No adjuvant added to local anesthetic has been demonstrated to be of benefit.

Although perineural infusions of levobupivacaine54 and shorter-acting agents have been reported,55–57

most publications have involved ropivacaine 0.2% or bupivacaine 0.125 to 0.25%. Currently, there is

insufficient information to determine if there is an optimal local anesthetic (or concentration) for

ambulatory infusions.31,54,58 The optimal concentration and infusion rate for a particular catheter site

in relationship to the degree of motor block has not been established either.

Patient-Controlled Regional Analgesia

 Providing patients the ability to self-administer bolus doses maximizes benefits

 The optimal basal rate, bolus volume, and lockout time have not been determined

 Commonly used: basal 4–8 mL/h, bolus 2–5 mL, and lockout time 20–60 minutes

Available inpatient and outpatient data suggest that following procedures producing moderate to

severe pain, providing patients with the ability to self-administer local anesthetic doses (patientcontrolled regional analgesia) increases perioperative benefits and/or decreases local anesthetic

consumption.33,34,36,59–61 However, no information is available to base recommendations on the

optimal basal rate, bolus volume, or lockout period, other than for interscalene catheters.33 Until

recommendations based on prospectively collected data are published, practitioners should be aware

that investigators have reported successful analgesia using the following with long-acting local

anesthetics: basal rate of 4 to 8 mL/h, bolus volume of 2 to 5 mL, and lockout duration of 20 to 60

minutes. Practitioners should be aware that the maximum safe doses for the long-acting local

anesthetics remain unknown. However, multiple investigations involving patients free of renal or

hepatic disease have reported blood concentrations within acceptable limits following up to 5 days of

perineural infusion with similar dosing schedules.38,62–64 Extrapolating from data involving patients

receiving epidural bupivacaine infusion, a maximum infusion rate of 0.5 mg/kg per hour of

bupivacaine may be considered.38

Following ambulatory shoulder surgery with an interscalene catheter, infusion duration may be

increased and similar baseline analgesia may be provided by decreasing the basal rate from 8 to 4

mL/h when patients supplement their block with large bolus doses (6 mL).33 However, patients

experience an increase in breakthrough pain incidence and intensity, sleep disturbances, and a

decrease in satisfaction with their analgesia. Therefore, if ambulatory patients do not return for

additional local anesthetic, practitioners are left with the dilemma of superior analgesia for a shorter

duration versus a lesser degree of analgesia for a longer period of time. Of note, the infusion duration

may be increased by progressively decreasing the basal infusion rate with a reprogrammable infusion

pump, thus theoretically maximizing postoperative analgesia.7

The publications that investigated the optimal dosing regimen for outpatients involved surgical

procedures producing moderate postoperative pain. For procedures inducing mild postoperative pain,

it is possible—even probable—that adequate analgesia would be adequately treated with a bolusonly dosing regimen.31 There is also the possibility that stimulating catheters may be placed, on

average, closer to the target nerve/plexus compared with nonstimulating devices.49 If so, then the

optimal dosing regimens, basal rates, and bolus doses may vary among different catheter types.

Unfortunately, there are currently insufficient published data to draw any conclusions.

Equipment

 There is no one perfect infusion pump for all applications.

 A multitude of factors must be taken into account when choosing a pump.

Multiple small portable infusion pumps are currently available (Table 7-1; Figures 7-2 and 7-3),

each with benefits and limitations (Table 7-2). Many factors must be taken into account when

determining the optimal device for a given clinical situation. The provided list of infusion devices

includes those for which performance data are available from independent sources and is not meant to

be an exhaustive list of available units.

TABLE 7-1 Infusion Pump Distributors

FIGURE 7-2. Examples of portable disposable basal- and bolus-capable infusion pumps. (A) Pain

Care 3200, (B) Pain Pump II, (C) On-Q C-Bloc with OnDemand, (D) Accufuser Plus XL, (E) ambIT

PCA, (F) AutoMed 3200. Distributor information and pump attributes are included in the appendix

and Table 7-2. Note that the ambIT PCA is produced as a disposable model as well as a more

expensive reusable unit and therefore appears in both Figures 7-2 and 7-3.

FIGURE 7-3. Examples of portable reusable basal- and bolus-capable infusion pumps. (A) 6060

MT, (B) Ipump PMS, (C) CADD-Legacy PCA, (D) ambIT PCA, (E) BlockIt, (F) AutoMed 3400.

Distributor information and pump attributes are included in the appendix and Table 7-2. Note that the

ambIT PCA is produced as a disposable model as well as a more expensive reusable unit, and

therefore appears in both Figures 7-2 and 7-3.

TABLE 7-2 Infusion Pump Attributes

Bolus-Dose Capability

Various pumps allow for both patient-controlled local anesthetic boluses and a basal infusion (Table

7–2); others allow for only one of these.65–69 Bolus-dose capability (also termed patient-controlled

regional analgesia, or PCRA) offers two significant benefits over continuous infusions alone. First,

higher doses of oral opiates are often required for breakthrough pain without patient-controlled bolus

doses.34,68 Second, for outpatients using a limited local anesthetic reservoir, PCRA allows a provider

to minimize the basal rate and, in turn, allows maximum infusion duration and minimal motor block7

yet also permits bolus dosing for breakthrough pain34 and physical therapy.27,33,36,70 Compared with

continuous infusions alone, equivalent or superior analgesia with a lower rate of local anesthetic

consumption may be provided by using patient-controlled local anesthetic.34,59–61

Disposability and Cost

Reusable electronic infusion pumps are generally more expensive than the available singleuse/disposable models (Table 7–2). However, reusable pumps that use relatively inexpensive

disposable “cassettes” for each new patient (usually about US$10) may be more cost effective for

practitioners who use these devices repeatedly (Table 7–2). But a reusable unit requires the patient to

return the infusion pump by either the mail service or revisiting the surgical center.33,34,36

Patient Instructions

 A prescription for oral opioids should be filled by patients following discharge.

 Oral and written instructions, including health care provider contact numbers, should be provided.

Following a single-injection nerve block for ambulatory surgery, discharge with an insensate

extremity results in minimal complications.71 However, whether or not patients should weight-bear

with a continuous peripheral nerve block remains unexamined. Therefore, conservative management

may be optimal, and some investigators have recommended that patients avoid using their surgical

limb for weightbearing.8,16,36 A prescription for oral analgesics should be provided to all patients,

and the importance of filling the prescription immediately after leaving the surgical center should be

emphasized. If patients wait to fill the prescription until after they have determined if oral analgesics

are required, a period of inadequate analgesia may result.

Most investigators educate both the patient and his or her caretaker at the same time before

discharge because most patients have some degree of postoperative cognitive dysfunction. Both

verbal and written instructions should be provided, along with contact numbers for health care

providers who are available throughout the infusion duration.6,15,31,72 In addition to standard

outpatient instructions, topics reviewed often include expectations regarding surgical block

resolution, infusion pump instructions, breakthrough pain treatment, catheter site care, limb protection,

and the plan for catheter removal. Forewarning that pain in the operative limb is anticipated

following surgical block resolution and fluid leakage at the catheter site is common—and what to do

if these are experienced—often proves helpful. Signs and symptoms of possible catheter- and local

anesthetic-related complications include, but are not limited to, pulmonary compromise,40,41 nerve

injury,73 site infection,74 and local anesthetic toxicity.53 Although there are case reports of initially

misplaced catheters, migration following a documented correct placement has not been described but

remains a theoretical risk.51–53

,

75,76 Possible complications of an unidentified initially misplaced

catheter or of a catheter migration include intravascular or interpleural catheterization resulting in

local anesthetic toxicity, intramuscular catheterization resulting in myonecrosis, and

epidural/intrathecal catheterization when using interscalene, intersternocleidomastoid, paravertebral,

or psoas compartment catheters. As is standard of care for inpatients, health care providers may want

to consider documenting each patient contact (Figure 7-4).

FIGURE 7-4. An example of a progress note that may be used to record telephone contacts with

ambulatory patients. Reproduced with permission.79

Catheter removal may be achieved with various techniques: Patients may be discharged with

written instructions,12 a health care provider may perform this procedure,77 or patients’ caretakers (or

occasionally the patients themselves) may remove the catheters with instructions given by a provider

over the telephone.15–17

,

33,34,36 Although one technique has not been demonstrated to be superior to the

others, one survey revealed that with instructions given by phone, 98% of patients felt comfortable

removing their catheter at home.78 Of note, only 4% would have preferred to return for a health care

provider to remove the catheter, and 43% responded they would have felt comfortable with

exclusively written instructions.78 Nonsterile gloves may be provided for patients having their

catheters removed at home.15–17

REFERENCES

. Rawal N, Hylander J, Nydahl PA, Olofsson I, Gupta A. Survey of postoperative analgesia following

ambulatory surgery. Acta Anaesthesiol Scand. 1997;41:1017-1022.

. Ansbro FP. A method of continuous brachial plexus block. Am J Surg. 1946;71:716-722.

. Rawal N, Axelsson K, Hylander J, et al. Postoperative patient-controlled local anesthetic

administration at home. Anesth Analg. 1998;86:86-89.

. Buckenmaier CC III, Klein SM, Nielsen KC, Steele SM. Continuous paravertebral catheter and

outpatient infusion for breast surgery. Anesth Analg. 2003;97:715-717.

. Ganapathy S, Amendola A, Lichfield R, Fowler PJ, Ling E. Elastomeric pumps for ambulatory

patient controlled regional analgesia. Can J Anaesth. 2000;47:897-902.

. Macaire P, Gaertner E, Capdevila X. Continuous post-operative regional analgesia at home. Minerva

Anesthesiol. 2001;67:109-116.

. Ilfeld BM, Enneking FK. A portable mechanical pump providing over four days of patient-controlled

analgesia by perineural infusion at home. Reg Anesth Pain Med. 2002;27:100-104.

. Corda DM, Enneking FK. A unique approach to postoperative analgesia for ambulatory surgery. J

Clin Anesth. 2000;12:595-599.

. Grant SA, Nielsen KC, Greengrass RA, Steele SM, Klein SM. Continuous peripheral nerve block for

ambulatory surgery. Reg Anesth Pain Med. 2001;26:209-214.

0. Klein SM, Greengrass RA, Grant SA, Higgins LD, Nielsen KC, Steele SM. Ambulatory surgery for

multi-ligament knee reconstruction with continuous dual catheter peripheral nerve blockade. Can J

Anaesth. 2001;48:375-378.

1. Chelly JE, Gebhard R, Coupe K, Greger J, Khan A. Local anesthetic delivered via a femoral

catheter by patient-controlled analgesia pump for pain relief after an anterior cruciate ligament

outpatient procedure. Am J Anesthesiol. 2001;28:192-194.

2. Klein SM, Greengrass RA, Gleason DH, Nunley JA, Steele SM. Major ambulatory surgery with

continuous regional anesthesia and a disposable infusion pump. Anesthesiology. 1999;91:563-565.

3. Ilfeld BM, Smith DW, Enneking FK. Continuous regional analgesia following ambulatory pediatric

orthopedic surgery. Am J Orthop. 2004;33:405-408.

4. Klein SM, Grant SA, Greengrass RA, et al. Interscalene brachial plexus block with a continuous

catheter insertion system and a disposable infusion pump. Anesth Analg. 2000;91:1473-1478.

5. Ilfeld BM, Morey TE, Enneking FK. Continuous infraclavicular brachial plexus block for

postoperative pain control at home: a randomized, double-blinded, placebo-controlled study.

Anesthesiology. 2002;96:1297-1304.

6. Ilfeld BM, Morey TE, Wang RD, Enneking FK. Continuous popliteal sciatic nerve block for

postoperative pain control at home: a randomized, double-blinded, placebo-controlled study.

Anesthesiology. 2002;97:959-965.

7. Ilfeld BM, Morey TE, Wright TW, Chidgey LK, Enneking FK. Continuous interscalene brachial

plexus block for postoperative pain control at home: a randomized, double-blinded, placebocontrolled study. Anesth Analg. 2003;96:1089-1095.

8. White PF, Issioui T, Skrivanek GD, Early JS, Wakefield C. The use of a continuous popliteal sciatic

nerve block after surgery involving the foot and ankle: does it improve the quality of recovery?

Anesth Analg. 2003;97:1303-1309.

9. Wu CL, Naqibuddin M, Rowlingson AJ, Lietman SA, Jermyn RM, Fleisher LA. The effect of pain

on health-related quality of life in the immediate postoperative period. Anesth Analg. 2003;97:1078-

1085.

0. Public health focus: surveillance, prevention, and control of nosocomial infections. MMWR CDC

Surveill Summ. 1992;41:783-787.

1. Wenzel RP, Edmond MB. The impact of hospital-acquired bloodstream infections. Emerg Infect

Dis. 2001;7:174-177.

2. Relman AS. The institute of medicine report on the quality of health care. N Engl J Med.

2001;345:702-703.

3. Leape LL. Institute of Medicine medical error figures are not exaggerated. JAMA. 2000;284:95-97.

4. Mushinski M. Average charges for hip replacement surgeries: United States, 1997. Stat Bull

Metrop Insur Co. 1999;80:32-40.

5. Mushinski M. Average charges for a total knee replacement: United States, 1994. Stat Bull Metrop

Insur Co. 1996;77:24-30.

6. Weinstein J. The Dartmouth Atlas of Musculoskeletal Health Care. Chicago, IL: AHA Press;

2000:72-78.

7. Ilfeld BM, Wright TW, Enneking FK, et al. Effect of interscalene perineural local anesthetic

infusion on postoperative physical therapy following total shoulder replacement. Reg Anesth Pain

Med. 2004;29:A18.

8. Ilfeld BM, Gearen PF, Enneking FK, et al. Effect of femoral perineural local anesthetic infusion on

postoperative functional ability following total knee arthroplasty. Anesthesiology. 2004;101:A945.

9. Ekatodramis G, Macaire P, Borgeat A. Prolonged Horner syndrome due to neck hematoma after

continuous interscalene block. Anesthesiology. 2001;95:801-803.

0. Ribeiro FC, Georgousis H, Bertram R, Scheiber G. Plexus irritation caused by interscalene brachial

plexus catheter for shoulder surgery. Anesth Analg. 1996;82:870-872.

1. Rawal N, Allvin R, Axelsson K, et al. Patient-controlled regional analgesia (PCRA) at home:

controlled comparison between bupivacaine and ropivacaine brachial plexus analgesia.

Anesthesiology. 2002;96:1290-1296.

2. Johnson T, Monk T, Rasmussen LS, et al. Postoperative cognitive dysfunction in middle-aged

patients. Anesthesiology. 2002;96:1351-1357.

3. Ilfeld BM, Morey TE, Wright TW, Chidgey LK, Enneking FK. Interscalene perineural ropivacaine

infusion: a comparison of two dosing regimens for postoperative analgesia. Reg Anesth Pain Med.

2004;29:9-16.

4. Ilfeld BM, Morey TE, Enneking FK. Infraclavicular perineural local anesthetic infusion: a

comparison of three dosing regimens for postoperative analgesia. Anesthesiology. 2004;100:395-

402.

5. Ilfeld BM, Morey TE, Enneking FK. Continuous infraclavicular perineural infusion with clonidine

and ropivacaine compared with ropivacaine alone: a randomized, double-blinded, controlled study.

Anesth Analg. 2003;97:706-712.

6. Ilfeld BM, Thannikary LJ, Morey TE, Vander Griend RA, Enneking FK. Popliteal sciatic perineural

local anesthetic infusion: a comparison of three dosing regimens for postoperative analgesia.

Anesthesiology. 2004;101:970-977.

7. Klein SM, Steele SM, Nielsen KC, et al. The difficulties of ambulatory interscalene and intraarticular infusions for rotator cuff surgery: a preliminary report. Can J Anaesth. 2003;50:265-269.

8. Denson DD, Raj PP, Saldahna F, et al. Continuous perineural infusion of bupivacaine for prolonged

analgesia: pharmacokinetic considerations. Int J Clin Pharmacol Ther Toxicol. 1983;21:591-597.

9. Pere P. The effect of continuous interscalene brachial plexus block with 0.125% bupivacaine plus

fentanyl on diaphragmatic motility and ventilatory function. Reg Anesth. 1993;18:93-97.

0. Smith MP, Tetzlaff JE, Brems JJ. Asymptomatic profound oxyhemoglobin desaturation following

interscalene block in a geriatric patient. Reg Anesth Pain Med. 1998;23:210-213.

1. Sardesai AM, Chakrabarti AJ, Denny NM. Lower lobe collapse during continuous interscalene

brachial plexus local anesthesia at home. Reg Anesth Pain Med. 2004;29:65-68.

2. Borgeat A, Perschak H, Bird P, Hodler J, Gerber C. Patient-controlled interscalene analgesia with

ropivacaine 0.2% versus patient-controlled intravenous analgesia after major shoulder surgery:

effects on diaphragmatic and respiratory function. Anesthesiology. 2000;92:102-108.

3. Salinas FV. Location, location, location: Continuous peripheral nerve blocks and stimulating

catheters. Reg Anesth Pain Med. 2003;28:79-82.

4. Coleman MM, Chan VW. Continuous interscalene brachial plexus block. Can J Anaesth.

1999;46:209-214.

5. Ganapathy S, Wasserman RA, Watson JT, et al. Modified continuous femoral three-in-one block for

postoperative pain after total knee arthroplasty. Anesth Analg. 1999;89:1197-1202.

6. Borgeat A, Dullenkopf A, Ekatodramis G, Nagy L. Evaluation of the lateral modified approach for

continuous interscalene block after shoulder surgery. Anesthesiology. 2003;99:436-442.

7. Borgeat A, Blumenthal S, Karovic D, Delbos A, Vienne P. Clinical evaluation of a modified

posterior anatomical approach to performing the popliteal block. Reg Anesth Pain Med.

2004;29:290-296.

8. Boezaart AP, de Beer JF, du Toit C, van Rooyen K. A new technique of continuous interscalene

nerve block. Can J Anaesth. 1999;46:275-281.

9. Salinas FV, Neal JM, Sueda LA, Kopacz DJ, Liu SS. Prospective comparison of continuous femoral

nerve block with nonstimulating catheter placement versus stimulating catheter-guided perineural

placement in volunteers. Reg Anesth Pain Med. 2004;29:212-220.

0. Chelly JE, Williams BA. Continuous perineural infusions at home: narrowing the focus. Reg Anesth

Pain Med. 2004;29:1-3.

1. Litz RJ, Vicent O, Wiessner D, Heller AR. Misplacement of a psoas compartment catheter in the

subarachnoid space. Reg Anesth Pain Med. 2004;29:60-64.

2. Cook LB. Unsuspected extradural catheterization in an interscalene block. Br J Anaesth.

1991;67:473-475.

3. Tuominen MK, Pere P, Rosenberg PH. Unintentional arterial catheterization and bupivacaine

toxicity associated with continuous interscalene brachial plexus block. Anesthesiology. 1991;75:356-

358.

4. Casati A, Borghi B, Fanelli G, et al. Interscalene brachial plexus anesthesia and analgesia for open

shoulder surgery: a randomized, double-blinded comparison between levobupivacaine and

ropivacaine. Anesth Analg. 2003;96:253-259.

5. Buettner J, Klose R, Hoppe U, Wresch P. Serum levels of mepivacaine-HCl during continuous

axillary brachial plexus block. Reg Anesth. 1989;14:124-127.

6. Wajima Z, Shitara T, Nakajima Y, et al. Comparison of continuous brachial plexus infusion of

butorphanol, mepivacaine and mepivacaine-butorphanol mixtures for postoperative analgesia. Br J

Anaesth. 1995;75:548-551.

7. Bergman BD, Hebl JR, Kent J, Horlocker TT. Neurologic complications of 405 consecutive

continuous axillary catheters. Anesth Analg. 2003;96:247-252.

8. Borgeat A, Kalberer F, Jacob H, Ruetsch YA, Gerber C. Patient-controlled interscalene analgesia

with ropivacaine 0.2% versus bupivacaine 0.15% after major open shoulder surgery: the effects on

hand motor function. Anesth Analg. 2001;92:218-223.

9. Singelyn FJ, Gouverneur JM: Extended “three-in-one” block after total knee arthroplasty:

continuous versus patient-controlled techniques. Anesth Analg. 2000;91:176-180.

0. Singelyn FJ, Seguy S, Gouverneur JM. Interscalene brachial plexus analgesia after open shoulder

surgery: continuous versus patient-controlled infusion. Anesth Analg. 1999;89:1216-1220.

1. Singelyn FJ, Vanderelst PE, Gouverneur JM: Extended femoral nerve sheath block after total hip

arthroplasty: continuous versus patient-controlled techniques. Anesth Analg. 2001;92:455-459.

2. Ekatodramis G, Borgeat A, Huledal G, Jeppsson L, Westman L, Sjovall J. Continuous interscalene

analgesia with ropivacaine 2 mg/ml after major shoulder surgery. Anesthesiology. 2003;98:143-150.

3. Kaloul I, Guay J, Cote C, Halwagi A, Varin F. Ropivacaine plasma concentrations are similar

during continuous lumbar plexus blockade using the anterior three-in-one and the posterior psoas

compartment techniques. Can J Anaesth. 2004;51:52-56.

4. Anker-Moller E, Spangsberg N, Dahl JB, Christensen EF, Schultz P, Carlsson P. Continuous

blockade of the lumbar plexus after knee surgery: a comparison of the plasma concentrations and

analgesic effect of bupivacaine 0.250% and 0.125%. Acta Anaesthesiol Scand. 1990;34:468-472.

5. Ilfeld BM, Morey TE, Enneking FK. The delivery rate accuracy of portable infusion pumps used for

continuous regional analgesia. Anesth Analg. 2002;95:1331-1336.

6. Ilfeld BM, Morey TE, Enneking FK. Delivery rate accuracy of portable, bolus-capable infusion

pumps used for patient-controlled continuous regional analgesia. Reg Anesth Pain Med. 2003;28:17-

23.

67. Ilfeld BM, Morey TE, Enneking FK. Portable infusion pumps used for continuous regional

analgesia: delivery rate accuracy and consistency. Reg Anesth Pain Med. 2003;28:424-432.

68. Ilfeld BM, Morey TE. Use of term “patient-controlled” may be confusing in study of elastometric

pump. Anesth Analg. 2003;97:916-917.

69. Ilfeld BM, Morey TE, Enneking FK. New portable infusion pumps: real advantages or just more of

the same in a different package? Reg Anesth Pain Med. 2004;29:371-376.

70. Ilfeld BM, Gearen PF, Enneking FK, et al. Effect of femoral perineural local anesthetic infusion on

postoperative functional ability following total knee arthroplasty. Anesthesiology. 2004;101:A945.

71. Klein SM, Nielsen KC, Greengrass RA, Warner DS, Martin A, Steele SM. Ambulatory discharge

after long-acting peripheral nerve blockade: 2382 blocks with ropivacaine. Anesth Analg.

2002;94:65-70.

72. Grant SA, Nielsen KC. Continuous peripheral nerve catheters for ambulatory anesthesia. Curr

Anesthesiol Reports. 2000;2:304-307.

73. Borgeat A, Ekatodramis G, Kalberer F, Benz C. Acute and nonacute complications associated with

interscalene block and shoulder surgery: a prospective study. Anesthesiology. 2001;95:875-880.

74. Cuvillon P, Ripart J, Lalourcey L, et al. The continuous femoral nerve block catheter for

postoperative analgesia: bacterial colonization, infectious rate and adverse effects. Anesth Analg.

2001;93:1045-1049.

75. Souron V, Reiland Y, De Traverse A, Delaunay L, Lafosse L. Interpleural migration of an

interscalene catheter. Anesth Analg. 2003;97:1200-1201.

76. Hogan Q, Dotson R, Erickson S, Kettler R, Hogan K. Local anesthetic myotoxicity: a case and

review. Anesthesiology. 1994;80:942-947.

77. Chelly JE, Greger J, Gebhard R. Ambulatory continuous perineural infusion: are we ready? [letter].

Anesthesiology. 2000;93:581-582.

78. Ilfeld BM, Esener DE, Morey TE, Enneking FK. Ambulatory perineural infusion: the patients’

perspective. Reg Anesth Pain Med. 2003;28:418-423.

79. Ilfeld BM, Enneking FK. Continuous nerve blocks at home: a review. Anesth Analg.

2005;100:1822–1833.

8

Regional Anesthesia in the Anticoagulated Patient

Honorio T. Benzon

Intraspinal Hematoma

The incidence of intraspinal hematoma is approximately 0.1 per 100,000 patients per year.1

 It is more

likely to occur in anticoagulated or thrombocytopenic patients, patients with neoplastic disease, or in

those with liver disease or alcoholism.2

 The incidence of neurologic dysfunction resulting from

hemorrhagic complications associated with neuraxial blockade is estimated to be <1 in 150,000

epidural procedures and <1 in 220,000 with spinal anesthetics. The risk of formation of intraspinal

hematoma after administration of neuraxial injections is increased in patients who received

anticoagulant therapy or have a coagulation disorder, technical difficulties in the performance of the

neuraxial procedures due to anatomic abnormalities of the spine, and multiple or bloody punctures.

The American Society of Regional Anesthesia and Pain Medicine (ASRA) issued recommended

guidelines for the safe performance of neuraxial blocks in patients who are on anticoagulants.3,4 The

third edition of the ASRA guidelines was published in 2010.

Antiplatelet Therapy

Antiplatelet medications inhibit platelet cyclo-oxygenase and prevent the synthesis of thromboxane

A2. Thromboxane A2 is a potent vasoconstrictor and facilitates secondary platelet aggregation and

release reactions. An adequate, although potentially fragile, clot may form.5

 Platelet function in

patients receiving antiplatelet medications should be assumed to be decreased for 1 week after

treatment with aspirin and 1 to 3 days with nonsteroidal anti-inflammatory drugs (NSAIDs). New

platelets are produced every day, and these new platelets partly explain the relative safety of

performing neuraxial procedures in these patients.

Although Vandermeulen et al6

 implicated antiplatelet therapy in 3 of the 61 cases of spinal

hematoma occurring after spinal or epidural anesthesia, the results of several large studies

demonstrated the relative safety of neuraxial blockade in combination with antiplatelet therapy. The

Collaborative Low-Dose Aspirin Study in Pregnancy Group7

 included 1422 high-risk obstetric

patients who were administered 60 mg aspirin daily and underwent epidural anesthesia without any

neurologic sequelae. The studies of Horlocker et al,8,9 of approximately 1000 patients in each study,

showed no spinal hematomas, although blood was noted during needle or catheter placement in 22%

of the patients. A later study in patients who were on NSAIDs and underwent epidural steroid

injections did not develop the signs and symptoms of intraspinal hematoma.10 A review of the case

reports of intraspinal hematoma in patients on aspirin and NSAIDs showed complicating factors that

included concomitant heparin administration, epidural venous angioma, and technical difficulty when

performing the procedure.11

The thienopyridine drugs, ticlopidine and clopidogrel, prevent platelet aggregation by inhibiting

adenosine diphosphate (ADP) receptor-mediated platelet activation. Ticlopidine is rarely used

because it causes neutropenia, thrombocytopenic purpura, and hypercholesterolemia. Clopidogrel is

preferred because of its increased safety profile and proven efficacy. The maximal inhibition of ADPinduced platelet aggregation with clopidogrel occurs 3 to 5 days after the initiation of a standard dose

(75 mg), but within 4 to 6 hours after the administration of a large loading dose of 300 to 600 mg.12

There is a case report of spinal hematoma in a patient on ticlopidine13 and a case of quadriplegia in a

patient on clopidogrel, diclofenac, and possibly aspirin.14

Neuraxial blocks can be safely performed on patients taking aspirin or NSAIDs.4

 It is safe to

perform neuraxial blocks on patients taking cyclo-oxygenase (COX)-2 inhibitors. For the

thienopyridine drugs, it is recommended that clopidogrel be discontinued for 7 days and ticlopidine

for 10 to 14 days before a neuraxial injection. It is possible for epidural catheters to be removed or

neuraxial injections to be performed 5 days, and not 7 days, after clopidogrel is discontinued.15 If a

neuraxial injection is to be performed in a patient on clopidogrel before 7 days of discontinuation, a

P2Y12 assay, a new assay of residual antiplatelet activity, can be performed; <10% activity probably

means that a neuraxial block is safe.16

Here is a summary of current recommendations:

. Neuraxial blocks can be performed on patients taking aspirin or NSAIDs.4

. It is safe to perform neuraxial blocks on patients taking COX-2 inhibitors.

. For the thienopyridine drugs, the ASRA recommendation is that clopidogrel be discontinued for 7

days and ticlopidine for 10 to 14 days before a neuraxial injection.

. Epidural catheters can be removed safely and neuraxial injections can be performed 5 days (not 7

days, as once advised) after clopidogrel is discontinued.15

. If a neuraxial injection is to be performed in a patient on clopidogrel before 7 days of

discontinuation, a P2Y12 assay, a new assay of residual antiplatelet activity, is performed; <10%

activity probably means that a neuraxial block is safe.16

Oral Anticoagulants

Warfarin exerts its anticoagulant effect by interfering with the synthesis of the vitamin K–dependent

clotting factors (VII, IX, X, and thrombin).17 It also inhibits the anticoagulants protein C and S. Factor

VII and protein C have short half-lives (6–8 hours), and the prolongation of the international

normalized ratio (INR) during the early phase of warfarin therapy is the result of the competing

effects of reduced factor VII and protein C.18 Adequate anticoagulation is not achieved until the levels

of biologically active factors II (half-life of 50 hours) and X are sufficiently depressed, that is, 4 to 6

days.

Few data exist regarding the risk of spinal hematoma in patients with indwelling spinal or epidural

catheters who are subsequently anticoagulated with warfarin. Horlocker et al19 and Wu and Perkins20

found no neuraxial hemorrhagic complications in patients who received postoperative epidural

analgesia in conjunction with low-dose warfarin after total knee arthroplasty. Because intraspinal

hematomas have occurred after removal of the catheter,6

 some have recommended that the same

laboratory values apply to placement and removal of an epidural catheter.21 The current ASRA

guidelines recommends an INR value of ≤1.4 as acceptable for the performance of neuraxial blocks.4

The value was based on studies that showed excellent perioperative hemostasis when the INR value

was ≤1.5. The concurrent use of other medications, such as aspirin, NSAIDs, and heparins that affect

the clotting mechanism, increases the risk of bleeding complications without affecting the INR.

A controversy exists regarding whether or not the epidural catheter can be removed on

postoperative day 1, or 12–14 hours after warfarin is started, when the INR is >1.4. In the absence of

other risk factors for increased bleeding, the catheter can probably be removed. The factor VII

activity should be determined if risk factors such as low platelets, advanced age, kidney failure, or

intake of other anticoagulants are present.18

Warfarin is metabolized primarily by the CYP2C9 enzyme of the cytochrome P450 system.

Mutations in the gene coding for the cytochrome P450 2C9 hepatic microsomal enzyme affect the

elimination clearance of warfarin by impairing the patient’s ability to metabolize S-warfarin. Other

genetic factors affecting the warfarin dose–response relationship include polymorphisms of the

vitamin K oxide reductase (VKOR) enzyme. Mutations in the gene encoding for isoforms of the

protein that can lead to enzymes with varied sensitivities to warfarin is rare, and the American

College of Chest Physicians (ACCP) advises against pharmacokinetic-based initial dosing of

warfarin at this time.17

Intravenous Heparin

Heparin is a complex polysaccharide that exerts its anticoagulant effect by binding to antithrombin III.

The conformational change in antithrombin accelerates its ability to inactivate thrombin, factor Xa,

and factor IXa. The anticoagulant effect of subcutaneous heparin takes 1 to 2 hours, but the effect of

intravenous heparin is immediate. Heparin has a half-life of 1.5 to 2 hours. The activated partial

thromboplastin time (aPTT) is used to monitor the effect of heparin; therapeutic anticoagulation is

achieved with a prolongation of the aPTT to >1.5 times the baseline value.

There were no spinal hematomas in >4000 patients who underwent lower extremity vascular

surgery under continuous spinal or epidural anesthesia.22 In this study, patients with preexisting

coagulation disorders were excluded, heparinization occurred at least 60 minutes after catheter

placement, the level of anticoagulation was carefully monitored, and the indwelling catheters were

removed at a time when heparin activity was low. Ruff and Dougherty23 noted the occurrence of

spinal hematomas in patients who underwent lumbar puncture with subsequent heparinization. The

presence of blood during the procedure, concomitant aspirin therapy, and heparinization within 1 hour

were identified as risk factors for the development of a spinal hematoma.

When intraoperative anticoagulation is planned, neuraxial technique should be avoided in patients

with coexisting coagulopathies. The following considerations are in order:

. There should be at least a 1-hour delay between needle placement and heparin administration.

. The catheter should be removed 1 hour before subsequent heparin administration and 2 to 4 hours

after the last heparin dose.4

. The partial thromboplastin time or activated clotting time should be monitored to avoid excessive

heparin effect.

Subcutaneous Heparin

The therapeutic basis of low-dose subcutaneous heparin (5000 units every 8–12 hours) is heparinmediated inhibition of activated factor X. Following intramuscular or subcutaneous injection of 5000

units of heparin, maximum anticoagulation effect is observed in 40 to 50 minutes and returns to

baseline within 4 to 6 hours. The aPTT may remain in the normal range and often is not monitored.

However, wide variations in individual patient responses to subcutaneous heparin have been

reported. Neuraxial techniques are not contraindicated during subcutaneous (mini-dose) prophylaxis.

Some have suggested that the risk of bleeding can be further reduced by delay of the heparin

administration until after the block.4

The 2008 ACCP guidelines have suggested a more frequent dosing of subcutaneous heparin to

three times a day.24 Case reports show an increased risk for bleeding in patients receiving thricedaily subcutaneous heparin.25 In view of this increased bleeding and in the absence of prospective

studies that looked into the implications of neuraxial injections in this setting, the third edition of the

ASRA guidelines will advise that patients not receive thrice-daily heparin when receiving epidural

infusions.

Low Molecular Weight Heparin

The anticoagulant effect of low molecular weight heparin (LMWH) is similar to unfractionated

heparin, that is, activation of antithrombin and acceleration of its interaction with thrombin and factor

Xa.26 LMWH has a greater activity against factor Xa; unfractionated heparin has equivalent activity

against thrombin and factor Xa. The plasma half-life of the LMWH ranges from 2 to 4 hours after an

intravenous injection and 3 to 6 hours after a subcutaneous injection. Its half-life is two to four times

that of standard heparin. The recovery of anti-factor Xa activity after a subcutaneous injection of

LMWH approaches 100%. This characteristic makes laboratory monitoring unnecessary, except in

patients with renal insufficiency or those with body weight <50 kg or >80 kg.

The summary of recommendations for patients receiving LMWH and neuraxial anesthesia are as

follows4

:

. The administration of other anticoagulant medications with LMWHs may increase the risk of spinal

hematoma.

. The presence of blood during needle placement and catheter placement does not necessitate

postponement of surgery. However, the initiation of LMWH therapy should be delayed for 24 hours

postoperatively.

. The first dose of LMWH prophylaxis should be given no earlier than 24 hours postoperatively and

only in the presence of adequate hemostasis.

. In patients who are on LMWH, needle/catheter placement (or catheter removal) should be performed

at least 12 hours after the last prophylactic dose of enoxaparin or 24 hours after higher doses of

enoxaparin (1 mg/kg every 12 hours), and 24 hours after dalteparin (120 U/kg every 12 hours or 200

U/kg every 12 hours) or tinzaparin (175 U/kg daily).

. The LMWH can be administered 2 hours after the epidural catheter is removed.

. Monitoring of anti-Xa level is not recommended.

Thrombolytic Therapy

Thrombolytic agents actively dissolve fibrin clots that have already formed, secondary to the action

of plasmin. Plasminogen activators, such as streptokinase and urokinase, dissolve thrombus and affect

circulating plasminogen leading to decreased levels of both plasminogen and fibrin. Clot lysis leads

to elevation of fibrin degradation products, which have an anticoagulant effect by inhibiting platelet

aggregation. Fibrinogen and plasminogen are maximally depressed at 5 hours after thrombolytic

therapy and remain significantly depressed at 27 hours.4,27

Although epidural or spinal needle and catheter placement with subsequent heparinization appears

relatively safe, the risk of spinal hematoma in patients who receive thrombolytic therapy is less welldefined. Cases of spinal hematoma in patients who received neuraxial injections and thrombolytic

agents were reported recently in the medical literature.

Fibrinolytic and thrombolytic agents pose a unique problem when performing neuraxial anesthesia.

The time frame for avoidance of these drugs and puncture of noncompressible vessels is 10 days.

Except in highly unusual circumstances, patients who received fibrinolytic or thrombolytic drugs

should be cautioned against receiving spinal or epidural anesthesia.4,27 There are no available data to

clearly determine the length of time after discontinuation of these drugs for the safe performance of a

neuraxial technique. There is no definitive recommendation on the timing of removal of neuraxial

catheters in patients who unexpectedly receive fibrinolytic or thrombolytic therapy. Measurement of

fibrinogen levels may be helpful in guiding a decision about removal of the catheter.

Herbal Therapy

Herbal preparations do have some effect on platelet aggregation. For example, garlic inhibits platelet

aggregation and its effect on hemostasis appears to last 7 days. Ginkgo biloba inhibits plateletactivating factor and its effect lasts 36 hours. These effects last 24 hours with the use of ginseng.4

 The

effects of dietary supplements on platelet function and coagulation are not well described, and

outcomes are difficult to predict.28 In spite of these characteristics, herbal preparations appear to

present no added significant risk in the development of spinal hematoma in patients having epidural or

spinal anesthesia. At this time, there appears to be no specific concerns as to the timing of neuraxial

block in relationship to the dosing of herbal therapy, postoperative monitoring, or the timing of

neuraxial catheter removal.4

Fondaparinux

Fondaparinux is a synthetic anticoagulant that produces its antithrombotic effect through selective

inhibition of factor Xa.29 The drug exhibits consistency in its anticoagulant effect because it is

chemically synthesized and its bioavailability is 100%. Rapidly absorbed, it reaches maximum

concentration within 1.7 hours of administration. Its half-life is 17 to 21 hours, allowing once-daily

dosing.30 The actual risk of spinal hematoma with fondaparinux is unknown. The daily dosing makes

safe catheter removal harder to predict. The ASRA4

 recommends against the use of fondaparinux in

the presence of an indwelling epidural catheter. These recommendations were based on the sustained

and irreversible antithrombotic effect of fondaparinux, early postoperative dosing (6 hours after

surgery), and the spinal hematoma reported during initial clinical trials. Performance of neuraxial

techniques should occur under the conditions used in clinical trials (single needle pass, atraumatic

needle placement, and avoidance of indwelling neuraxial catheters).4

A 2007 study showed no complications in patients who had neuraxial injections or deep

peripheral nerve blocks.31 In this study, the catheters were removed 36 hours after the last dose of

fondaparinux and dosing was delayed for 12 hours after the catheter was removed. In a review

article, Rosencher et al32 recommended that catheter removal should be delayed at least 36 hours

(equivalent to two half-lives) and that the subsequent injection should be timed to at least 7 hours

after the removal of the catheter.

anesthesia hadzic's peripheral vision

anesthesia hadzic's peripheral nervous system

anesthesia hadzic's peripheral neuropathy

anesthesia hadzic's peripheral analysis

anesthesia hadzic's peripheral artery disease

anesthesia hadzic's peripheral attention

anesthesia hadzic's peripheral artery disease treatment

anesthesia hadzic's peripheral blood mononuclear cells

anesthesia hadzic's peripheral book

anesthesia hadzic's peripheral brain for the pharmacist

anesthesia hadzic's peripheral blood smear

anesthesia hadzic's peripheral blood

anesthesia hadzic's peripheral cyanosis

anesthesia hadzic's peripheral chemoreceptors

anesthesia hadzic's peripheral circulation

anesthesia hadzic's peripheral device

anesthesia hadzic's peripheral diagnosis

anesthesia hadzic's peripheral definition

anesthesia hadzic's peripheral experience

anesthesia hadzic's peripheral evaluation

anesthesia hadzic's peripheral eye

anesthesia hadzic's peripheral edema

anesthesia hadzic's peripheral edema causes

anesthesia hadzic's peripheral edema treatment

anesthesia hadzic's peripheral family

anesthesia hadzic's peripheral friend

anesthesia hadzic's peripheral function

anesthesia hadzic's peripheral film

anesthesia hadzic's peripheral for sale

anesthesia hadzic's peripheral fatigue

anesthesia hadzic's peripheral follicles

anesthesia hadzic's peripheral furthest

anesthesia hadzic's peripheral guidance

anesthesia hadzic's peripheral gene

anesthesia hadzic's peripheral growth

anesthesia hadzic's peripheral guide

anesthesia hadzic's peripheral genealogy

anesthesia hadzic's peripheral giant cell granuloma

anesthesia hadzic's peripheral history

anesthesia hadzic's peripheral heart action training

anesthesia hadzic's peripheral heart action

anesthesia hadzic's peripheral heart action system

anesthesia hadzic's peripheral iv

anesthesia hadzic's peripheral injury

anesthesia hadzic's peripheral intervention

anesthesia hadzic's peripheral iridotomy

anesthesia hadzic's peripheral iv catheter

anesthesia hadzic's peripheral journey

anesthesia hadzic's peripheral job

anesthesia hadzic's peripheral journal

anesthesia hadzic's peripheral judgement

anesthesia hadzic's peripheral jewel

anesthesia hadzic's peripheral knowledge

anesthesia hadzic's peripheral kidney

anesthesia hadzic's peripheral kit

anesthesia hadzic's peripheral learning

anesthesia hadzic's peripheral line

anesthesia hadzic's peripheral lung fields

anesthesia hadzic's peripheral lung

anesthesia hadzic's peripheral learning theory

anesthesia hadzic's peripheral lighting

anesthesia hadzic's peripheral lighting fortnite

anesthesia hadzic's peripheral memory

anesthesia hadzic's peripheral movement

anesthesia hadzic's peripheral membrane proteins

anesthesia hadzic's peripheral movie

anesthesia hadzic's peripheral meaning

anesthesia hadzic's peripheral neuropathy icd 10

anesthesia hadzic's peripheral nerves

anesthesia hadzic's peripheral output

anesthesia hadzic's peripheral on amazon

anesthesia hadzic's peripheral or incidental transactions

anesthesia hadzic's peripheral ossifying fibroma

anesthesia hadzic's peripheral personality

anesthesia hadzic's peripheral pulses

anesthesia hadzic's peripheral play

anesthesia hadzic's peripheral playbook

anesthesia hadzic's peripheral proteins

anesthesia hadzic's peripheral quest

anesthesia hadzic's peripheral quiz

anesthesia hadzic's peripheral queue

anesthesia hadzic's peripheral queries

anesthesia hadzic's peripheral qatar

anesthesia hadzic's peripheral resistance

anesthesia hadzic's peripheral route to persuasion

anesthesia hadzic's peripheral route

anesthesia hadzic's peripheral resistance to blood flow

anesthesia hadzic's peripheral system

anesthesia hadzic's peripheral skills

anesthesia hadzic's peripheral sense

anesthesia hadzic's peripheral smear

anesthesia hadzic's peripheral synonym

anesthesia hadzic's peripheral sensory neuropathy

anesthesia hadzic's peripheral theory

anesthesia hadzic's peripheral training

anesthesia hadzic's peripheral test

anesthesia hadzic's peripheral tv series

anesthesia hadzic's peripheral tv show

anesthesia hadzic's peripheral tissue perfusion

anesthesia hadzic's peripheral t cell lymphoma

anesthesia hadzic's peripheral tissues

anesthesia hadzic's peripheral use

anesthesia hadzic's peripheral ukraine

anesthesia hadzic's peripheral user

anesthesia hadzic's peripheral uprising

anesthesia hadzic's peripheral use cases

anesthesia hadzic's peripheral ulcerative keratitis

anesthesia hadzic's peripheral ulcerative keratitis treatment

anesthesia hadzic's peripheral ulcerative keratitis icd 10

anesthesia hadzic's peripheral vascular disease

anesthesia hadzic's peripheral wife

anesthesia hadzic's peripheral website

anesthesia hadzic's peripheral work

anesthesia hadzic's peripheral war

anesthesia hadzic's peripheral workflow

anesthesia hadzic's peripheral xiv

anesthesia hadzic's peripheral xanax

anesthesia hadzic's peripheral youtube

anesthesia hadzic's peripheral year

anesthesia hadzic's peripheral youtube channel

anesthesia hadzic's peripheral you

anesthesia hadzic's peripheral youtube video

anesthesia hadzic's peripheral zone

anesthesia hadzic's peripheral zoom

anesthesia hadzic's peripheral zoominfo

can anesthesia hadzic's peripheral analysis

can anesthesia hadzic's peripheral artery disease

can anesthesia hadzic's peripheral attention

can anesthesia hadzic's peripheral act

can anesthesia hadzic's peripheral artery disease treatment

can anesthesia hadzic's peripheral blood mononuclear cells

can anesthesia hadzic's peripheral brain

can anesthesia hadzic's peripheral blood

can anesthesia hadzic's peripheral brain for the pharmacist

can anesthesia hadzic's peripheral book

can anesthesia hadzic's peripheral blood smear

can anesthesia hadzic's peripheral complex

can anesthesia hadzic's peripheral cyanosis

can anesthesia hadzic's peripheral chemoreceptors

can anesthesia hadzic's peripheral circulation

can anesthesia hadzic's peripheral device

can anesthesia hadzic's peripheral diagnosis

can anesthesia hadzic's peripheral drug association

can anesthesia hadzic's peripheral definition

can anesthesia hadzic's peripheral experience

can anesthesia hadzic's peripheral evaluation

can anesthesia hadzic's peripheral eye

can anesthesia hadzic's peripheral edema

can anesthesia hadzic's peripheral edema causes

can anesthesia hadzic's peripheral edema treatment

can anesthesia hadzic's peripheral friend

can anesthesia hadzic's peripheral function

can anesthesia hadzic's peripheral family

can anesthesia hadzic's peripheral for sale

can anesthesia hadzic's peripheral fatigue

can anesthesia hadzic's peripheral follicles

can anesthesia hadzic's peripheral furthest

can anesthesia hadzic's peripheral guidance

can anesthesia hadzic's peripheral gene

can anesthesia hadzic's peripheral growth

can anesthesia hadzic's peripheral genealogy

can anesthesia hadzic's peripheral giant cell granuloma

can anesthesia hadzic's peripheral history

can anesthesia hadzic's peripheral heart action training

can anesthesia hadzic's peripheral heart action

can anesthesia hadzic's peripheral hair

can anesthesia hadzic's peripheral heart action system

can anesthesia hadzic's peripheral iv

can anesthesia hadzic's peripheral injury

can anesthesia hadzic's peripheral intervention

can anesthesia hadzic's peripheral iv insertion

can anesthesia hadzic's peripheral iridotomy

can anesthesia hadzic's peripheral iv catheter

can anesthesia hadzic's peripheral journey

can anesthesia hadzic's peripheral job

can anesthesia hadzic's peripheral judgement

can anesthesia hadzic's peripheral knowledge

can anesthesia hadzic's peripheral kidney

can anesthesia hadzic's peripheral line

can anesthesia hadzic's peripheral lung fields

can anesthesia hadzic's peripheral learning

can anesthesia hadzic's peripheral leg

can anesthesia hadzic's peripheral lung

can anesthesia hadzic's peripheral lighting

can anesthesia hadzic's peripheral lighting fortnite

can anesthesia hadzic's peripheral memory

can anesthesia hadzic's peripheral movement

can anesthesia hadzic's peripheral membrane proteins

can anesthesia hadzic's peripheral meaning

can anesthesia hadzic's peripheral neuropathy

can anesthesia hadzic's peripheral nervous system

can anesthesia hadzic's peripheral nerve

can anesthesia hadzic's peripheral neuropathy icd 10

can anesthesia hadzic's peripheral oxygen

can anesthesia hadzic's peripheral on amazon

can anesthesia hadzic's peripheral or incidental transactions

can anesthesia hadzic's peripheral ossifying fibroma

can anesthesia hadzic's peripheral personality

can anesthesia hadzic's peripheral pulses

can anesthesia hadzic's peripheral proteins

can anesthesia hadzic's peripheral quest

can anesthesia hadzic's peripheral quizlet

can anesthesia hadzic's peripheral queue

can anesthesia hadzic's peripheral resistance

can anesthesia hadzic's peripheral route to persuasion

can anesthesia hadzic's peripheral route

can anesthesia hadzic's peripheral relationship

can anesthesia hadzic's peripheral resistance to blood flow

can anesthesia hadzic's peripheral system

can anesthesia hadzic's peripheral sense

can anesthesia hadzic's peripheral smear

can anesthesia hadzic's peripheral synonym

can anesthesia hadzic's peripheral sensory neuropathy

can anesthesia hadzic's peripheral theory

can anesthesia hadzic's peripheral treatment

can anesthesia hadzic's peripheral training

can anesthesia hadzic's peripheral tv series

can anesthesia hadzic's peripheral tv show

can anesthesia hadzic's peripheral tissue perfusion

can anesthesia hadzic's peripheral t cell lymphoma

can anesthesia hadzic's peripheral tissues

can anesthesia hadzic's peripheral use

can anesthesia hadzic's peripheral user

can anesthesia hadzic's peripheral urine

can anesthesia hadzic's peripheral use cases

can anesthesia hadzic's peripheral up

can anesthesia hadzic's peripheral ulcerative keratitis

can anesthesia hadzic's peripheral ulcerative keratitis treatment

can anesthesia hadzic's peripheral ulcerative keratitis icd 10

can anesthesia hadzic's peripheral vision

can anesthesia hadzic's peripheral vascular

can anesthesia hadzic's peripheral vascular system

can anesthesia hadzic's peripheral vascular resistance

can anesthesia hadzic's peripheral vascular disease

can anesthesia hadzic's peripheral wife

can anesthesia hadzic's peripheral website

can anesthesia hadzic's peripheral work

can anesthesia hadzic's peripheral will

can anesthesia hadzic's peripheral xanax

can anesthesia hadzic's peripheral xiv

can anesthesia hadzic's peripheral youtube

can anesthesia hadzic's peripheral year

can anesthesia hadzic's peripheral you

can anesthesia hadzic's peripheral youtube channel

can anesthesia hadzic's peripheral yet

can anesthesia hadzic's peripheral zone

can anesthesia hadzic's peripheral zoom

can anesthesia hadzic's peripheral zoom meeting

can anesthesia hadzic's peripheral zoominfo

how anesthesia hadzic's peripheral analysis

how anesthesia hadzic's peripheral artery disease

how anesthesia hadzic's peripheral attention

how anesthesia hadzic's peripheral art

how anesthesia hadzic's peripheral artery disease treatment

how anesthesia hadzic's peripheral blood mononuclear cells

how anesthesia hadzic's peripheral book

how anesthesia hadzic's peripheral brain for the pharmacist

how anesthesia hadzic's peripheral brain

how anesthesia hadzic's peripheral blood smear

how anesthesia hadzic's peripheral blood

how anesthesia hadzic's peripheral career

how anesthesia hadzic's peripheral cyanosis

how anesthesia hadzic's peripheral chemoreceptors

how anesthesia hadzic's peripheral circulation

how anesthesia hadzic's peripheral device

how anesthesia hadzic's peripheral diagnosis

how anesthesia hadzic's peripheral dna

how anesthesia hadzic's peripheral definition

how anesthesia hadzic's peripheral experience

how anesthesia hadzic's peripheral evaluation

how anesthesia hadzic's peripheral edema

how anesthesia hadzic's peripheral edema causes

how anesthesia hadzic's peripheral edema treatment

how anesthesia hadzic's peripheral friend

how anesthesia hadzic's peripheral family

how anesthesia hadzic's peripheral function

how anesthesia hadzic's peripheral film

how anesthesia hadzic's peripheral for sale

how anesthesia hadzic's peripheral fatigue

how anesthesia hadzic's peripheral follicles

how anesthesia hadzic's peripheral furthest

how anesthesia hadzic's peripheral guidance

how anesthesia hadzic's peripheral gene

how anesthesia hadzic's peripheral growth

how anesthesia hadzic's peripheral guide

how anesthesia hadzic's peripheral genealogy

how anesthesia hadzic's peripheral giant cell granuloma

how anesthesia hadzic's peripheral history

how anesthesia hadzic's peripheral heart action training

how anesthesia hadzic's peripheral heart action

how anesthesia hadzic's peripheral heart action system

how anesthesia hadzic's peripheral iv

how anesthesia hadzic's peripheral injury

how anesthesia hadzic's peripheral information

how anesthesia hadzic's peripheral intervention

how anesthesia hadzic's peripheral influence

how anesthesia hadzic's peripheral iridotomy

how anesthesia hadzic's peripheral iv catheter

how anesthesia hadzic's peripheral journey

how anesthesia hadzic's peripheral job

how anesthesia hadzic's peripheral journal

how anesthesia hadzic's peripheral judgement

how anesthesia hadzic's peripheral knowledge

how anesthesia hadzic's peripheral kidney

how anesthesia hadzic's peripheral learning

how anesthesia hadzic's peripheral line

how anesthesia hadzic's peripheral lung fields

how anesthesia hadzic's peripheral lung

how anesthesia hadzic's peripheral learning theory

how anesthesia hadzic's peripheral lighting

how anesthesia hadzic's peripheral lighting fortnite

how anesthesia hadzic's peripheral memory

how anesthesia hadzic's peripheral movement

how anesthesia hadzic's peripheral membrane proteins

how anesthesia hadzic's peripheral meaning

how anesthesia hadzic's peripheral neuropathy

how anesthesia hadzic's peripheral nervous system

how anesthesia hadzic's peripheral nerves

how anesthesia hadzic's peripheral neuropathy icd 10

how anesthesia hadzic's peripheral output

how anesthesia hadzic's peripheral oxygen

how anesthesia hadzic's peripheral on amazon

how anesthesia hadzic's peripheral or incidental transactions

how anesthesia hadzic's peripheral ossifying fibroma

how anesthesia hadzic's peripheral personality

how anesthesia hadzic's peripheral pulses

how anesthesia hadzic's peripheral path

how anesthesia hadzic's peripheral proteins

how anesthesia hadzic's peripheral quest

how anesthesia hadzic's peripheral quizlet

how anesthesia hadzic's peripheral resistance

how anesthesia hadzic's peripheral route to persuasion

how anesthesia hadzic's peripheral route

how anesthesia hadzic's peripheral resistance to blood flow

how anesthesia hadzic's peripheral system

how anesthesia hadzic's peripheral skills

how anesthesia hadzic's peripheral sense

how anesthesia hadzic's peripheral smear

how anesthesia hadzic's peripheral synonym

how anesthesia hadzic's peripheral sensory neuropathy

how anesthesia hadzic's peripheral theory

how anesthesia hadzic's peripheral training

how anesthesia hadzic's peripheral test

how anesthesia hadzic's peripheral tv series

how anesthesia hadzic's peripheral tv show

how anesthesia hadzic's peripheral tissue perfusion

how anesthesia hadzic's peripheral t cell lymphoma

how anesthesia hadzic's peripheral tissues

how anesthesia hadzic's peripheral units

how anesthesia hadzic's peripheral use

how anesthesia hadzic's peripheral user

how anesthesia hadzic's peripheral ukraine

how anesthesia hadzic's peripheral use cases

how anesthesia hadzic's peripheral ulcerative keratitis

how anesthesia hadzic's peripheral ulcerative keratitis treatment

how anesthesia hadzic's peripheral ulcerative keratitis icd 10

how anesthesia hadzic's peripheral vision

how anesthesia hadzic's peripheral vascular disease

how anesthesia hadzic's peripheral wife

how anesthesia hadzic's peripheral website

how anesthesia hadzic's peripheral work

how anesthesia hadzic's peripheral war

how anesthesia hadzic's peripheral will

how anesthesia hadzic's peripheral xiv

how anesthesia hadzic's peripheral xanax

how anesthesia hadzic's peripheral youtube

how anesthesia hadzic's peripheral years

how anesthesia hadzic's peripheral youtube channel

how anesthesia hadzic's peripheral you

how anesthesia hadzic's peripheral zone

how anesthesia hadzic's peripheral zoom

hadzic's peripheral nerve blocks

hadzic anesthesia

hadzic regional anesthesia

hadzic's textbook of regional anesthesia

how to get anesthesia at home

how to perform spinal anesthesia

which anesthesia hadzic's peripheral analysis

which anesthesia hadzic's peripheral abilities

which anesthesia hadzic's peripheral artery disease

which anesthesia hadzic's peripheral attention

which anesthesia hadzic's peripheral artery disease treatment

which anesthesia hadzic's peripheral blood mononuclear cells

which anesthesia hadzic's peripheral book

which anesthesia hadzic's peripheral brain

which anesthesia hadzic's peripheral brain for the pharmacist

which anesthesia hadzic's peripheral blood

which anesthesia hadzic's peripheral blood smear

which anesthesia hadzic's peripheral career

which anesthesia hadzic's peripheral complex

which anesthesia hadzic's peripheral cyanosis

which anesthesia hadzic's peripheral chemoreceptors

which anesthesia hadzic's peripheral circulation

which anesthesia hadzic's peripheral device

which anesthesia hadzic's peripheral diagnosis

which anesthesia hadzic's peripheral disease

which anesthesia hadzic's peripheral dna

which anesthesia hadzic's peripheral definition

which anesthesia hadzic's peripheral experience

which anesthesia hadzic's peripheral evaluation

which anesthesia hadzic's peripheral edema

which anesthesia hadzic's peripheral edema causes

which anesthesia hadzic's peripheral edema treatment

which anesthesia hadzic's peripheral function

which anesthesia hadzic's peripheral friend

which anesthesia hadzic's peripheral family

which anesthesia hadzic's peripheral focus

which anesthesia hadzic's peripheral for

which anesthesia hadzic's peripheral fatigue

which anesthesia hadzic's peripheral follicles

which anesthesia hadzic's peripheral furthest

which anesthesia hadzic's peripheral guidance

which anesthesia hadzic's peripheral gene

which anesthesia hadzic's peripheral growth

which anesthesia hadzic's peripheral genealogy

which anesthesia hadzic's peripheral giant cell granuloma

which anesthesia hadzic's peripheral history

which anesthesia hadzic's peripheral heart action training

which anesthesia hadzic's peripheral heart action

which anesthesia hadzic's peripheral heart action system

which anesthesia hadzic's peripheral iv

which anesthesia hadzic's peripheral injury

which anesthesia hadzic's peripheral identity

which anesthesia hadzic's peripheral information

which anesthesia hadzic's peripheral intervention

which anesthesia hadzic's peripheral iridotomy

which anesthesia hadzic's peripheral iv catheter

which anesthesia hadzic's peripheral journey

which anesthesia hadzic's peripheral job

which anesthesia hadzic's peripheral judgement

which anesthesia hadzic's peripheral knowledge

which anesthesia hadzic's peripheral kidney

which anesthesia hadzic's peripheral learning

which anesthesia hadzic's peripheral line

which anesthesia hadzic's peripheral life

which anesthesia hadzic's peripheral lung fields

which anesthesia hadzic's peripheral lung

which anesthesia hadzic's peripheral lighting

which anesthesia hadzic's peripheral lighting fortnite

which anesthesia hadzic's peripheral memory

which anesthesia hadzic's peripheral movement

which anesthesia hadzic's peripheral membrane proteins

which anesthesia hadzic's peripheral meaning

which anesthesia hadzic's peripheral neuropathy

which anesthesia hadzic's peripheral nervous system

which anesthesia hadzic's peripheral nerve

which anesthesia hadzic's peripheral neuropathy icd 10

which anesthesia hadzic's peripheral output

which anesthesia hadzic's peripheral or incidental transactions

which anesthesia hadzic's peripheral ossifying fibroma

which anesthesia hadzic's peripheral personality

which anesthesia hadzic's peripheral pulses

which anesthesia hadzic's peripheral path

which anesthesia hadzic's peripheral proteins

which anesthesia hadzic's peripheral quest

which anesthesia hadzic's peripheral quizlet

which anesthesia hadzic's peripheral quiz

which anesthesia hadzic's peripheral resistance

which anesthesia hadzic's peripheral route to persuasion

which anesthesia hadzic's peripheral route

which anesthesia hadzic's peripheral relationship

which anesthesia hadzic's peripheral response

which anesthesia hadzic's peripheral resistance to blood flow

which anesthesia hadzic's peripheral system

which anesthesia hadzic's peripheral skills

which anesthesia hadzic's peripheral study

which anesthesia hadzic's peripheral sense

which anesthesia hadzic's peripheral smear

which anesthesia hadzic's peripheral synonym

which anesthesia hadzic's peripheral sensory neuropathy

which anesthesia hadzic's peripheral theory

which anesthesia hadzic's peripheral test

which anesthesia hadzic's peripheral training

which anesthesia hadzic's peripheral treatment

which anesthesia hadzic's peripheral tissue perfusion

which anesthesia hadzic's peripheral t cell lymphoma

which anesthesia hadzic's peripheral tissues

which anesthesia hadzic's peripheral use

which anesthesia hadzic's peripheral units

which anesthesia hadzic's peripheral user

which anesthesia hadzic's peripheral use cases

which anesthesia hadzic's peripheral uprising

which anesthesia hadzic's peripheral ulcerative keratitis

which anesthesia hadzic's peripheral ulcerative keratitis treatment

which anesthesia hadzic's peripheral ulcerative keratitis icd 10

which anesthesia hadzic's peripheral vision

which anesthesia hadzic's peripheral vascular

which anesthesia hadzic's peripheral vascular system

which anesthesia hadzic's peripheral vascular disease

which anesthesia hadzic's peripheral wife

which anesthesia hadzic's peripheral website

which anesthesia hadzic's peripheral work

which anesthesia hadzic's peripheral will

which anesthesia hadzic's peripheral workflow

which anesthesia hadzic's peripheral xiv

which anesthesia hadzic's peripheral xanax

which anesthesia hadzic's peripheral youtube

which anesthesia hadzic's peripheral years

which anesthesia hadzic's peripheral you

which anesthesia hadzic's peripheral youtube channel

which anesthesia hadzic's peripheral zone

which anesthesia hadzic's peripheral zoom

which anesthesia hadzic's peripheral zoominfo

dr hadzic nysora

best anesthetic for hip replacement

dr hadzic anesthesia

hadzic's-peripheral-nerve-blocks-and-anatomy-for-ultrasound-guided-regional-anesthesia

peripheral nerve block vs general anesthesia

how soon after general anesthesia can you go under anesthesia again

what is general anesthesia with lma

hadzic's peripheral nerve blocks and anatomy for ultrasound-guided regional anesthesia

types of anesthesia nerve blocks

hadzic peripheral nerve blocks pdf

how close can you have general anesthesia

tips for going under anesthesia

anesthesia peripheral nerve block

can anesthesia cause peripheral neuropathy

peripheral nerve block vs regional anesthesia

anesthesia r positions

anesthesia considerations for robotic surgery

is it safe to be put under general anesthesia

who should not be put under anesthesia

anesthesia hadzic's peripherals

anesthesia hadzic's peripheral artery

anesthesia hadzic's peripheral blueprint

anesthesia hadzic's peripheral block

anesthesia hadzic's peripheral catheter

anesthesia hadzic's peripheral devices

anesthesia hadzic's peripheral dialogue

anesthesia hadzic's peripheral dissection

anesthesia hadzic's peripheral design

anesthesia hadzic's peripheral entry

anesthesia hadzic's peripheral exam

anesthesia hadzic's peripheral flux

anesthesia hadzic's peripheral full album

anesthesia hadzic's peripheral gyroscope

anesthesia hadzic's peripheral heart disease

anesthesia hadzic's peripheral heart

anesthesia hadzic's peripheral hemorrha

anesthesia hadzic's peripheral hematoma

anesthesia hadzic's peripheral joint

anesthesia hadzic's peripheral joint disease

anesthesia hadzic's peripheral knee

anesthesia hadzic's peripheral lab

anesthesia hadzic's peripheral location

anesthesia hadzic's peripheral media

anesthesia hadzic's peripheral mind

anesthesia hadzic's peripheral method

anesthesia hadzic's peripheral nerve

anesthesia hadzic's peripheral osteotomy

anesthesia hadzic's peripheral osteopathi

anesthesia hadzic's peripheral ost

anesthesia hadzic's peripheral port

anesthesia hadzic's peripheral portion

anesthesia hadzic's peripheral question

anesthesia hadzic's peripheral route persuasion

anesthesia hadzic's peripheral review

anesthesia hadzic's peripheral reaction

anesthesia hadzic's peripheral repair

anesthesia hadzic's peripheral reflex

anesthesia hadzic's peripheral radiography

anesthesia hadzic's peripheral surgery

anesthesia hadzic's peripheral speech

anesthesia hadzic's peripheral trailer

anesthesia hadzic's peripheral ulcer

anesthesia hadzic's peripheral universe

anesthesia hadzic's peripheral ulnar

anesthesia hadzic's peripheral ulcerative colitis

anesthesia hadzic's peripheral vascular

anesthesia hadzic's peripheral vase

anesthesia hadzic's peripheral vasectomy

anesthesia hadzic's peripheral world

anesthesia hadzic's peripheral wallpaper

anesthesia hadzic's peripheral wave

anesthesia hadzic's peripheral xbox

anesthesia hadzic's peripheral xl

anesthesia hadzic's peripheral xbox 36

anesthesia hadzic's peripheral xenoblade 2

anesthesia hadzic's peripheral yeast infection

anesthesia hadzic's peripheral zenith

anesthesia hadzic's peripheral zarathustra

can anesthesia hadzic's peripheral artery

can anesthesia hadzic's peripheral arthritis

can anesthesia hadzic's peripheral blueprint

can anesthesia hadzic's peripheral block

can anesthesia hadzic's peripheral bandage

can anesthesia hadzic's peripheral build

can anesthesia hadzic's peripheral canal

can anesthesia hadzic's peripheral catheter

can anesthesia hadzic's peripheral devices

can anesthesia hadzic's peripheral dissection

can anesthesia hadzic's peripheral exam

can anesthesia hadzic's peripheral eyes

can anesthesia hadzic's peripheral guide

can anesthesia hadzic's peripheral heart disease

can anesthesia hadzic's peripheral hematoma

can anesthesia hadzic's peripheral heart

can anesthesia hadzic's peripheral hemorr

can anesthesia hadzic's peripheral joint

can anesthesia hadzic's peripheral joint disease

can anesthesia hadzic's peripheral kit

can anesthesia hadzic's peripheral knee

can anesthesia hadzic's peripheral keg

can anesthesia hadzic's peripheral lab

can anesthesia hadzic's peripheral location

can anesthesia hadzic's peripheral lens

can anesthesia hadzic's peripheral media

can anesthesia hadzic's peripheral metabolism

can anesthesia hadzic's peripheral mind

can anesthesia hadzic's peripheral neuropat

can anesthesia hadzic's peripheral osteoto

can anesthesia hadzic's peripheral ost

can anesthesia hadzic's peripheral osteopat

can anesthesia hadzic's peripheral outlet

can anesthesia hadzic's peripheral ostomy

can anesthesia hadzic's peripheral port

can anesthesia hadzic's peripheral portion

can anesthesia hadzic's peripheral questions

can anesthesia hadzic's peripheral quiz

can anesthesia hadzic's peripheral route persuasion

can anesthesia hadzic's peripheral review

can anesthesia hadzic's peripheral reaction

can anesthesia hadzic's peripheral release

can anesthesia hadzic's peripheral reflex

can anesthesia hadzic's peripheral radiography

can anesthesia hadzic's peripheral score

can anesthesia hadzic's peripheral surgery

can anesthesia hadzic's peripheral status

can anesthesia hadzic's peripheral test

can anesthesia hadzic's peripheral trailer

can anesthesia hadzic's peripheral tube

can anesthesia hadzic's peripheral ulcers

can anesthesia hadzic's peripheral universe

can anesthesia hadzic's peripheral uses

can anesthesia hadzic's peripheral ulnar

can anesthesia hadzic's peripheral vasectomy

can anesthesia hadzic's peripheral vase

can anesthesia hadzic's peripheral wallpaper

can anesthesia hadzic's peripheral way

can anesthesia hadzic's peripheral world

can anesthesia hadzic's peripheral xl

can anesthesia hadzic's peripheral xbox

can anesthesia hadzic's peripheral xenoblade

can anesthesia hadzic's peripheral yeast infection

can anesthesia hadzic's peripheral yellow

can anesthesia hadzic's peripheral yeast

can anesthesia hadzic's peripheral yellow spot

can anesthesia hadzic's peripheral zenith

can anesthesia hadzic's peripheral zara

can anesthesia hadzic's peripheral zarathust

how anesthesia hadzic's peripheral artery

how anesthesia hadzic's peripheral arthritis

how anesthesia hadzic's peripheral block

how anesthesia hadzic's peripheral bandage

how anesthesia hadzic's peripheral blueprint

how anesthesia hadzic's peripheral canal

how anesthesia hadzic's peripheral catheter

how anesthesia hadzic's peripheral devices

how anesthesia hadzic's peripheral disease

how anesthesia hadzic's peripheral dissection

how anesthesia hadzic's peripheral eyes

how anesthesia hadzic's peripheral exam

how anesthesia hadzic's peripheral gyroscope

how anesthesia hadzic's peripheral heart disease

how anesthesia hadzic's peripheral hernia

how anesthesia hadzic's peripheral hematoma

how anesthesia hadzic's peripheral health

how anesthesia hadzic's peripheral joint

how anesthesia hadzic's peripheral joint disease

how anesthesia hadzic's peripheral joint syndrome

how anesthesia hadzic's peripheral kit

how anesthesia hadzic's peripheral knee

how anesthesia hadzic's peripheral lab

how anesthesia hadzic's peripheral location

how anesthesia hadzic's peripheral lens

how anesthesia hadzic's peripheral lenses

how anesthesia hadzic's peripheral media

how anesthesia hadzic's peripheral metabolism

how anesthesia hadzic's peripheral mind

how anesthesia hadzic's peripheral neuropat

how anesthesia hadzic's peripheral nerve

how anesthesia hadzic's peripheral outlet

how anesthesia hadzic's peripheral osteoto

how anesthesia hadzic's peripheral osteopat

how anesthesia hadzic's peripheral port

how anesthesia hadzic's peripheral position

how anesthesia hadzic's peripheral questions

how anesthesia hadzic's peripheral quiz

how anesthesia hadzic's peripheral quadrant

how anesthesia hadzic's peripheral route persuasion

how anesthesia hadzic's peripheral review

how anesthesia hadzic's peripheral reflex

how anesthesia hadzic's peripheral reaction

how anesthesia hadzic's peripheral radiography

how anesthesia hadzic's peripheral rotation

how anesthesia hadzic's peripheral surgery

how anesthesia hadzic's peripheral status

how anesthesia hadzic's peripheral score

how anesthesia hadzic's peripheral trailer

how anesthesia hadzic's peripheral tube

how anesthesia hadzic's peripheral ulcers

how anesthesia hadzic's peripheral ultrasound

how anesthesia hadzic's peripheral ulnar

how anesthesia hadzic's peripheral universe

how anesthesia hadzic's peripheral vascular

how anesthesia hadzic's peripheral vasectomy

how anesthesia hadzic's peripheral wallpaper

how anesthesia hadzic's peripheral world

how anesthesia hadzic's peripheral way

how anesthesia hadzic's peripheral xbox

how anesthesia hadzic's peripheral xl

how anesthesia hadzic's peripheral yeast infection

how anesthesia hadzic's peripheral yba

how anesthesia hadzic's peripheral yeast

how anesthesia hadzic's peripheral zenith

how anesthesia hadzic's peripheral zara

how to do anaesthesia

how to do anesthesia

how to administer general anesthesia

how to perform anesthesia

which anesthesia hadzic's peripheral artery

which anesthesia hadzic's peripheral arthritis

which anesthesia hadzic's peripheral bandage

which anesthesia hadzic's peripheral biopsy

which anesthesia hadzic's peripheral canal

which anesthesia hadzic's peripheral devices

which anesthesia hadzic's peripheral dissection

which anesthesia hadzic's peripheral exam

which anesthesia hadzic's peripheral ed

which anesthesia hadzic's peripheral eyes

which anesthesia hadzic's peripheral entry

which anesthesia hadzic's peripheral gyroscope

which anesthesia hadzic's peripheral guide

which anesthesia hadzic's peripheral gas

which anesthesia hadzic's peripheral heart disease

which anesthesia hadzic's peripheral hematoma

which anesthesia hadzic's peripheral hernia

which anesthesia hadzic's peripheral hemorr

which anesthesia hadzic's peripheral health

which anesthesia hadzic's peripheral joint

which anesthesia hadzic's peripheral joint disease

which anesthesia hadzic's peripheral kit

which anesthesia hadzic's peripheral knee

which anesthesia hadzic's peripheral keurig

which anesthesia hadzic's peripheral keg

which anesthesia hadzic's peripheral knife

which anesthesia hadzic's peripheral lab

which anesthesia hadzic's peripheral location

which anesthesia hadzic's peripheral lens

which anesthesia hadzic's peripheral media

which anesthesia hadzic's peripheral metabolism

which anesthesia hadzic's peripheral mind

which anesthesia hadzic's peripheral neuropat

which anesthesia hadzic's peripheral nebulizer

which anesthesia hadzic's peripheral ointment

which anesthesia hadzic's peripheral osteoto

nerve blocks hadzici

nerve blocks hadzic pdf

hadzic's-peripheral-nerve-blocks-and-anatomy-for-ultrasound-guided-regional-anesthesia

how long does nerve blocks last

can nerve blocks be permanent

what happens when a nerve block doesn't work

nerve blocks hadzic book

nerve blocks hadzic biografija

nerve blocks hadzic book pdf

nerve blocks hadzic bio

nerve blocks hadzic basketball

nerve blocks hadzic cb&i

nerve blocks hadzic clifford chance

nerve blocks hadzic dds

nerve blocks hadzic dentist

nerve blocks hadzic do

hadzic peripheral nerve blocks third edition

can a nerve block cause permanent nerve damage

hadzic peripheral nerve blocks pdf free download

what does nerve block feel like

nerve blocks hadzic google scholar

nerve blocks hadzic group

nerve blocks hadzic group llc

nerve blocks hadzic google

nerve blocks hadzic hr

nerve blocks hadzic haiti

nerve blocks hadzic in english

nerve blocks hadzic icd 10

nerve blocks hadzic in spanish

nerve blocks hadzic instagram

nerve blocks hadzic jelentése

nerve blocks hadzic jacksonville fl

nerve blocks hadzic krakow

nerve blocks hadzic kosovic

nerve blocks hadzic kristiansand norway

nerve blocks hadzic kristiansand

nerve blocks hadzic kristiansand norway weather

nerve blocks hadzic lyrics

nerve blocks hadzic lab

nerve blocks hadzic law

nerve blocks hadzic law firm

nerve blocks hadzic littlefield

nerve blocks hadzic littlefield tx

nerve blocks hadzic last name

nerve blocks hadzic md

nerve blocks hadzic md phd

nerve blocks hadzic mdc

nerve blocks hadzic mount mercy

nerve blocks hadzic marine

nerve blocks hadzic npi

nerve blocks hadzic npi number

nerve blocks hadzic neurologist

nerve blocks hadzic nikad nije kasno

nerve blocks hadzic nikad nije kasno 2018

nerve blocks hadzic nikad nije kasno youtube

nerve blocks hadzic ortho

nerve blocks hadzic orthobullets

nerve blocks hadzic od

hadzic's peripheral nerve blocks

hadzic peripheral nerve blocks pdf

are nerve blocks bad for you

nerve blocks hadzic quizlet

nerve blocks hadzic quiz

nerve blocks hadzic quest

nerve blocks hadzic quest diagnostics

nerve blocks hadzic quiz 1

nerve blocks hadzic reviews

nerve blocks hadzic romania

nerve blocks hadzic radovic

nerve blocks hadzic regional anesthesia

nerve blocks hadzic regional anesthesia pdf

nerve blocks hadzic referee

nerve blocks hadzic soccer

do nerve blocks cause numbness

nerve blocks hadzic urologist

nerve blocks hadzic ua

nerve blocks hadzic uab

nerve blocks hadzic urdu

nerve blocks hadzic video

nerve blocks hadzic velika kladusa

nerve blocks hadzic wikipedia

nerve blocks hadzic w polsce

nerve blocks hadzic what

nerve blocks hadzic wa

nerve blocks hadzic xavier

nerve blocks hadzic youtube

nerve blocks hadzic youtube channel

nerve blocks hadzic youtube video

nerve blocks hadzic znaczenie

nerve blocks hadzic zvezde granda

can nerve blocks hadzic age

can nerve blocks hadzic amra

can nerve blocks hadzic be

can nerve blocks hadzic beograd

can nerve blocks hadzic biografija

can nerve blocks hadzic basketball

can nerve blocks hadzic come

can nerve blocks hadzic cb&i

can nerve blocks hadzic clifford chance

can nerve blocks hadzic do

can nerve blocks hadzic dentist

can nerve blocks hadzic die

can nerve blocks hadzic eat

can nerve blocks hadzic et al

can nerve blocks hadzic eng

can nerve blocks hadzic ep

can nerve blocks hadzic for dogs

can nerve blocks hadzic for sale

can nerve blocks hadzic follow

can nerve blocks hadzic fencing

can nerve blocks hadzic google scholar

can nerve blocks hadzic go

can nerve blocks hadzic get

can nerve blocks hadzic have

can nerve blocks hadzic have in common

can nerve blocks hadzic icd 10

can nerve blocks hadzic in english

can nerve blocks hadzic instagram

can nerve blocks hadzic jelentése

can nerve blocks hadzic jacksonville fl

can nerve blocks hadzic know

can nerve blocks hadzic kristiansand norway

can nerve blocks hadzic kristiansand

can nerve blocks hadzic kristiansand norway weather

can nerve blocks hadzic lyrics

can nerve blocks hadzic lab

can nerve blocks hadzic law firm

can nerve blocks hadzic law

can nerve blocks hadzic last

can nerve blocks hadzic littlefield

can nerve blocks hadzic littlefield tx

can nerve blocks hadzic last name

can nerve blocks hadzic md

can nerve blocks hadzic make

can nerve blocks hadzic make you sick

can nerve blocks hadzic mount mercy

can nerve blocks hadzic marine

can nerve blocks hadzic npi

can nerve blocks hadzic npi number

can nerve blocks hadzic neurologist

can nerve blocks hadzic nikad nije kasno

can nerve blocks hadzic nikad nije kasno 2018

can nerve blocks hadzic nikad nije kasno youtube

can nerve blocks hadzic open

can nerve blocks hadzic ortho

can nerve blocks hadzic orthotics

can nerve blocks hadzic orthobullets

can nerve blocks hadzic pdf

can nerve blocks hadzic pdf download

can nerve blocks hadzic putin

can nerve blocks hadzic pdf free download

can nerve blocks hadzic peripheral nerve blocks

can nerve blocks hadzic peripheral nerve blocks anticoagulation

can nerve blocks hadzic quizlet

can nerve blocks hadzic quest

can nerve blocks hadzic questions

can nerve blocks hadzic quiz

can nerve blocks hadzic quest diagnostics

can nerve blocks hadzic recept

can nerve blocks hadzic regional anesthesia

can nerve blocks hadzic regional anesthesia pdf

can nerve blocks hadzic referee

can nerve blocks hadzic soccer

can nerve blocks hadzic test

can nerve blocks hadzic translate to english

can nerve blocks hadzic take

can nerve blocks hadzic translate

can nerve blocks hadzic tokyo

can nerve blocks hadzic tennis

can nerve blocks hadzic tarik

can nerve blocks hadzic use

can nerve blocks hadzic update

can nerve blocks hadzic up

can nerve blocks hadzic v2

can nerve blocks hadzic v3

can nerve blocks hadzic v1

can nerve blocks hadzic work

can nerve blocks hadzic what

can nerve blocks hadzic w polsce

can nerve blocks hadzic xray

can nerve blocks hadzic xii

can nerve blocks hadzic youtube

can nerve blocks hadzic youtube video

can nerve blocks hadzic youtube channel

can nerve blocks hadzic yet

can nerve blocks hadzic you

can nerve blocks hadzic znaczenie

can nerve blocks hadzic zvezde granda

how nerve blocks hadzic and associates

how nerve blocks hadzic age

how nerve blocks hadzic amra

how nerve blocks hadzic book

how nerve blocks hadzic bio

how nerve blocks hadzic beograd

how nerve blocks hadzic biografija

how nerve blocks hadzic basketball

how nerve blocks hadzic cb&i

how nerve blocks hadzic clifford chance

how nerve blocks hadzic dentist

how nerve blocks hadzic do

how nerve blocks hadzic dds

how nerve blocks hadzic dental

how nerve blocks hadzic exam

how nerve blocks hadzic et al

how nerve blocks hadzic family

how nerve blocks hadzic for sale

how nerve blocks hadzic for dogs

how nerve blocks hadzic fencing

how nerve blocks hadzic google scholar

how nerve blocks hadzic group

how nerve blocks hadzic group llc

how nerve blocks hadzic google

how nerve blocks hadzic hr

how nerve blocks hadzic in english

how nerve blocks hadzic icd 10

how nerve blocks hadzic in spanish

how nerve blocks hadzic instagram

how nerve blocks hadzic jelentése

how nerve blocks hadzic jacksonville fl

how nerve blocks hadzic kosovic

how nerve blocks hadzic kristiansand norway

how nerve blocks hadzic kristiansand

how nerve blocks hadzic kristiansand norway weather

how nerve blocks hadzic lab

how nerve blocks hadzic lyrics

how nerve blocks hadzic law

how nerve blocks hadzic law firm

how nerve blocks hadzic littlefield

how nerve blocks hadzic littlefield tx

how nerve blocks hadzic last name

how nerve blocks hadzic md

how nerve blocks hadzic med

how nerve blocks hadzic mdc

how nerve blocks hadzic mount mercy

how nerve blocks hadzic marine

how nerve blocks hadzic npi

how nerve blocks hadzic npi number

how nerve blocks hadzic name

how nerve blocks hadzic neurologist

how nerve blocks hadzic nikad nije kasno

how nerve blocks hadzic nikad nije kasno 2018

how nerve blocks hadzic nikad nije kasno youtube

how nerve blocks hadzic ortho

how nerve blocks hadzic od

how nerve blocks hadzic orthotics

how nerve blocks hadzic pdf

how nerve blocks hadzic pdf download

how nerve blocks hadzic pdf free download

how nerve blocks hadzic peripheral nerve blocks

how nerve blocks hadzic peripheral nerve blocks anticoagulation

how nerve blocks hadzic quizlet

how nerve blocks hadzic quiz

how nerve blocks hadzic quest

how nerve blocks hadzic quest diagnostics

how nerve blocks hadzic recept

how nerve blocks hadzic regional anesthesia

how nerve blocks hadzic regional anesthesia pdf

how nerve blocks hadzic referee

how nerve blocks hadzic soccer

how nerve blocks hadzic test

how nerve blocks hadzic to

how nerve blocks hadzic testimony

how nerve blocks hadzic toc

how nerve blocks hadzic tokyo

how nerve blocks hadzic tennis

how nerve blocks hadzic tarik

how nerve blocks hadzic upenn

how nerve blocks hadzic ua

how nerve blocks hadzic urologist

how nerve blocks hadzic up

how nerve blocks hadzic video

how nerve blocks hadzic wikipedia

how nerve blocks hadzic what

how nerve blocks hadzic w polsce

how nerve blocks hadzic xavier

how nerve blocks hadzic youtube

how nerve blocks hadzic youtube video

how nerve blocks hadzic youtube channel

how nerve blocks hadzic znaczenie

how nerve blocks hadzic znacenje

how nerve blocks hadzic zvezde granda

how to nerve block a toe

how to nerve block a finger

how to perform nerve block

hadzic's peripheral nerve blocks and anatomy for ultrasound-guided regional anesthesia

how to block nerves

how to do nerve block

how to do digital nerve block

how well do nerve blocks work

how to use nerve stimulator for blocks

how to nerve block

how effective are nerve block injections

how to get nerve block out of your system

how to get a nerve block

how to block nerve pain

how to do nerve blocks hadzic

how to perform penile nerve block

how to remove nerve block

which nerve blocks hadzic age

which nerve blocks hadzic amra

which nerve blocks hadzic be

which nerve blocks hadzic beograd

which nerve blocks hadzic biografija

which nerve blocks hadzic basketball

which nerve blocks hadzic cb&i

which nerve blocks hadzic clifford chance

which nerve blocks hadzic do

which nerve blocks hadzic dental

which nerve blocks hadzic dentist

which nerve blocks hadzic dds

which nerve blocks hadzic exam

which nerve blocks hadzic exam 1

which nerve blocks hadzic et al

which nerve blocks hadzic eye

which nerve blocks hadzic family

which nerve blocks hadzic for sale

which nerve blocks hadzic for cervical radiculopathy

which nerve blocks hadzic for cervical

which nerve blocks hadzic fencing

which nerve blocks hadzic group

which nerve blocks hadzic have

which nerve blocks hadzic have in common

which nerve blocks hadzic in it

which nerve blocks hadzic icd 10

which nerve blocks hadzic in the brain

which nerve blocks hadzic instagram

which nerve blocks hadzic jelentése

which nerve blocks hadzic jiu jitsu

which nerve blocks hadzic jacksonville fl

which nerve blocks hadzic knee

which nerve blocks hadzic kristiansand norway

which nerve blocks hadzic kristiansand

which nerve blocks hadzic kristiansand norway weather

which nerve blocks hadzic lab

which nerve blocks hadzic last name

which nerve blocks hadzic last

which nerve blocks hadzic lab report

which nerve blocks hadzic littlefield

which nerve blocks hadzic littlefield tx

which nerve blocks hadzic md

which nerve blocks hadzic med

which nerve blocks hadzic medovic

which nerve blocks hadzic mount mercy

which nerve blocks hadzic marine

which nerve blocks hadzic npi

which nerve blocks hadzic name

which nerve blocks hadzic npi number

which nerve blocks hadzic neurologist

which nerve blocks hadzic nerve

which nerve blocks hadzic nikad nije kasno

which nerve blocks hadzic nikad nije kasno 2018

which nerve blocks hadzic nikad nije kasno youtube

which nerve blocks hadzic orthotics

which nerve blocks hadzic pdf

which nerve blocks hadzic procedure

which nerve blocks hadzic pdf download

which nerve blocks hadzic pdf free download

which nerve blocks hadzic peripheral nerve blocks

which nerve blocks hadzic peripheral nerve blocks anticoagulation

which nerve blocks hadzic quizlet

which nerve blocks hadzic quiz

which nerve blocks hadzic quiz 1

which nerve blocks hadzic quizizz

which nerve blocks hadzic recept

which nerve blocks hadzic regional anesthesia

which nerve blocks hadzic regional anesthesia pdf

which nerve blocks hadzic referee

which nerve blocks hadzic soccer

which nerve blocks hadzic test

which nerve blocks hadzic toca

which nerve blocks hadzic toc

which nerve blocks hadzic tokyo

which nerve blocks hadzic tennis

which nerve blocks hadzic tarik

which nerve blocks hadzic use

which nerve blocks hadzic up

which nerve blocks hadzic upenn

which nerve blocks hadzic upmc

which nerve blocks hadzic v2

which nerve blocks hadzic vascular

which nerve blocks hadzic vascular surgery

which nerve blocks hadzic what

which nerve blocks hadzic w polsce

which nerve blocks hadzic xavier

which nerve blocks hadzic xray

which nerve blocks hadzic youtube

which nerve blocks hadzic youtube video

which nerve blocks hadzic yiddish

which nerve blocks hadzic youtube channel

which nerve blocks hadzic znaczenie

which nerve blocks hadzic znacenje

which nerve blocks hadzic zvezde granda

best nerve block for hand surgery

best nerve blockers

best nerve block medication

best nerve block app

best nerve block for hip fracture

best nerve block for humerus fracture

best nerve block for thumb surgery

what are the types of nerve blocks

nerve blocks for horses

nerve blocks for hip fractures

nerve blocks for hand surgery

nerve blocks for headaches

nerve blocks for cluster headaches

nerve blocks for herniated discs

nerve blocks horse limb

nerve blocks for head pain

what type of doctor does nerve blocks