Cross-sectional area of the median nerve after intraneural vs perineural low volume administration | Revista Española de Anestesiología y Reanimación (English Edition)

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Silva Herrera, A. Serrá Sandoval, M. Gonzalez Venegas, S. de Lara González, J. Gracia, X. Sala-Blanch" "autores" => array:6 [ 0 => array:3 [ "nombre" => "R.E." "apellidos" => "Silva Herrera" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Serrá Sandoval" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "M." "apellidos" => "Gonzalez Venegas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "S." "apellidos" => "de Lara González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "J." "apellidos" => "Gracia" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 5 => array:4 [ "nombre" => "X." "apellidos" => "Sala-Blanch" "email" => array:2 [ 0 => "xsala@clinic.ub.es" 1 => "xavi.sala.blanch@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Facultad de Medicina, Universitat de Barcelona, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital Clinic, Universitat de Barcelona, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Evaluación del área de sección del nervio mediano tras la inyección intraneural o perineural" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1260 "Ancho" => 2938 "Tamanyo" => 131734 ] ] "descripcion" => array:1 [ "en" => "Correlation between pre-injection and post-injection cross-section in Perineural (A) (y=0.9744x+0.0357; R2=0.897) and Intraneural (B) (y=0.9008x+0.0186; R2=0.921) groups." ] ] ] "textoCompleto" => "IntroductionIn his book Anesthésie Régionale published in 1914, Victor Pauchet describes how nerves react to intraneural injection of local anaesthetic after exposure: “Direct intraneural injection produces a fusiform enlargement of the nerve that disappears quickly when the injection has stopped. This occurs because the anaesthetic spreads to both ends of the nerve from the site of injection”.<a class="elsevierStyleCrossRef" href="#bib0125">1</a> These words, based on direct visual observation of the nerve during injection, constitute the first description of the morphological changes in peripheral nerves after an intraneural injection. Since 1914, safety in anaesthesiology has improved, and today safer drugs and specific needles are available, neurostimulation is standard practice, and regional anaesthesia benefits from image-guided techniques.<a class="elsevierStyleCrossRefs" href="#bib0130">2,3</a> The introduction of ultrasound has again shown how nerves react during injection of local anaesthetics, and new observations of intraneural injection have been reported.<a class="elsevierStyleCrossRefs" href="#bib0140">4,5</a> The criteria used to assess intraneural injection are poorly defined in several studies; however, Sala-Blanch et al.<a class="elsevierStyleCrossRef" href="#bib0150">6</a> attempted to define objective criteria based on Victor Pauchet's original description. These criteria focus on the increased cross-section and thickening of the nerve (fusiform thickening described by Pauchet), followed by spread of the injected anaesthetic towards the longitudinal axis of the nerve.The aim of this study has been to evaluate changes in the cross-section of the nerve, determined by ultrasound, as the primary criterion for identifying intraneural injection.MethodsThis was a descriptive, prospective study, in which 60 ultrasound-guided in plane injections were performed on the median nerve: 30 intraneural and 30 perineural. The injections were performed by a single anaesthesiologist, with experience in ultrasound-guided nerve block techniques. The injections were performed on fresh (cryopreserved) cadavers from the Human Anatomy and Embryology Laboratory of the Faculty of Medicine of the University of Barcelona. It was decided to use the left and right median nerves in the arm and forearm. The project was accepted for performance in the dissection room, and fresh adult female and male cadavers with no history of infectious medical pathologies were used. The cadavers were maintained at a temperature of 4°C for 36h until the standard safety criteria for manipulation had been met. They were placed in the supine position, and remained in the dissection laboratory at a room temperature of 22–23°C for at least 4h before start of the study. Then, the corresponding median nerve was selected and located using a Sonosite M-Turbo ultrasound system (Sonosite Inc., Bothell, WA, USA) and a high frequency HFL 38X (6–13MHz) linear transducer. A different needle approach was used in each group, always “in plane” and with the bevel of the needle facing the transducer. In the Intraneural group, the needle was directed towards the centre of the nerve, while in the Perineural group, it was directed towards the deep edge of the nerve. The criteria to define intraneural placement of the needle were: visualisation of the needle in the interior of the nerve and the ability to pull the nerve by moving the needle. Perineural placement was defined as visualisation of the tip of the needle outside the edge of the nerve, and inability to pull the nerve by moving the needle. In both cases, placement was confirmed by consensus of all 7 anaesthesiologists prior to the start of infusion. Once the needle had been placed in the corresponding position (intraneural or perineural), 1ml of solution was injected using a syringe pump (Alaris™GH Plus). The solution was obtained by diluting 10ml of methylene blue in 90ml of physiological saline. A 23G needle connected to a 50cc syringe via a 90cm long extender was used. The order in which intraneural or perineural injections were administered was randomised using an online randomisation tool (<a id="intr0010" class="elsevierStyleInterRef" href="http://pinetools.com/es/aleatorizar-lista">http://pinetools.com/es/aleatorizar-lista</a>). The procedure was recorded on video and saved to digital format. Recording started immediately before start of the infusion pump, and lasted for 10s. The videos of all injection procedures were uploaded to a computer in order to analyse the nerve cross-section before and after injection of 1ml of solution. All the “frames” for measuring the cross-section of the nerve were chosen by the same anaesthesiologist (RS). For this purpose, two frames from the video image were chosen: a frame showing the nerve before injection (baseline) and another showing the largest cross-section of the nerve after administration of 1ml of solution. The selected images were analysed using the open source image processing program ImageJ (Image J, version 1.51s, NIH).Two anatomical specimen were frozen at −20°C for 48h, after which axial slices (2–2.5cm) were obtained, which were photographed to evaluate the spread of contrast.The results were entered in an Excel database prepared for this purpose. The variables were recorded in a single intervention.Study variablesIntraneural placement, i.e., visualisation of the needle in the interior of the nerve, was confirmed by consensus of all 7 anaesthesiologists. This dichotomous, non-parametric, nominal variable determined the group of assignment: Intraneural group, if the tip of the needle on the ultrasound image was inside the median nerve, and Perineural group if it was outside the nerve edge.The following variables were collected for analysis: Proximal spread (Yes/No), defined as the intraneural or perineural spread of the injected solution towards the proximal area of the median nerve; Distal spread (Yes/No), also dichotomous, defined as intraneural or perineural spread of the solution towards the distal area of the median nerve. Finally, the cross-section of the median nerve (cm2) was measured before and after injection.Statistical analysisData are presented as mean and standard deviation and/or percentages, according to the characteristics of the variable. The different variables were analysed using the statistical package SPSS version 21.0 (Statistical Package for Social Sciences, SPSS Inc., Chicago, IL, USA). Given the sample size and the study design (case-controlled), nonparametric tests (Mann–Whitney U test and Wilcoxon test) or the chi-square test were used to analyse proportions. Significance was set at p<0.05. The pre- and post-injection cross-section measurements of the median nerve were tested for correlation. Finally, the ROC curve of the sample was determined in order to show the validity of increased cross-section as an independent diagnostic criterion for intraneural injection.ResultsA total of 60 injections were performed on 10 fresh cadavers, 6 men and 4 women (“samples”), all of advanced age. The samples obtained were either fresh or completely thawed cryopreserved cadavers. Prior to the injection, the samples were kept at room temperature for no less than 4h. Thirty intraneural injections were made (Intraneural group; n=30) and the other 30 were perineural (Perineural group; n=30), following the pre-assigned randomisation schedule. All 7 study evaluators agreed on the intraneural or perineural placement of the needle before injection and video recording. All videos were recorded correctly and could be evaluated by the principal investigator (RS).Baseline measurements of median nerves were similar between groups (Perineural 0.116±0.045 vs. Intraneural 0.13±0.062cm2, p=0.313). The cross-section of the nerve increased significantly in both groups: in the Intraneural group it increased from 0.13±0.062 to 0.163±0.064cm2 (p<0.0001), while in the Perineural group it increased from 0.116±0.045 to 0.123±0.042cm2 (p<0.01). Post-injection differences between groups were significant (Perineural 0.123±0.042 vs. Intraneural 0.163±0.064cm2, p=0.007). The increase observed between groups was significant in both absolute and percentage terms (Perineural 0.007±0.013 vs. Intraneural 0.032±0.021cm2, p<0.0001; and Perineural 8±12 vs. Intraneural 28±21%, p<0.0001). These data are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and in <a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>There was a very significant correlation between the cross-section of the median nerves before and after injection in both groups, as shown in <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>ROC curve analysis, shown in <a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>, was used to evaluate the validity of increased cross-section as a criterion for intraneural injection. 4. The area under the curve was 0.834 (84%).<elsevierMultimedia ident="fig0020"></elsevierMultimedia>Proximal spread was observed in 25 patients (86%) in the Intraneural group vs. 4 patients (14%) in the Perineural group (p<0.0001). Distal spread was observed in 13 patients (43%) in the Intraneural group vs. 1 patient (4%) in the Perineural group (p<0.0001).Analysis of the spread of methylene blue in the cross-sectional anatomical images corroborated the intraneural or perineural administration of the injectate (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).<elsevierMultimedia ident="fig0025"></elsevierMultimedia>DiscussionOur study has shown that injecting 1ml of solution in the median nerve increases the cross-sectional dimension in all cases; however, we cannot confirm that the increased nerve dimension are due in all cases to injection of solution inside the nerve. This raises several issues: the differential characteristics of the different nerves and plexuses,<a class="elsevierStyleCrossRefs" href="#bib0155">7–9</a> the difficulty of defining nerve edges using ultrasound,<a class="elsevierStyleCrossRefs" href="#bib0160">8,10</a> neural changes associated with intraneural injection,<a class="elsevierStyleCrossRefs" href="#bib0150">6,11,12</a> and finally, the anaesthesiologist's efforts to avoid neural damage<a class="elsevierStyleCrossRefs" href="#bib0185">13,14</a> and decisions taken during anaesthetic administration.<a class="elsevierStyleCrossRefs" href="#bib0195">15–17</a>In median nerve block the nerve follows a relatively constant course through the forearm, with little variation in diameter and few collateral branches. Its position between 2 muscle planes facilities ultrasound visualisation, while its depth allows excellent visualisation of the needle in all cases. Because of this, consensus among investigators regarding the intraneural or extraneural position of the needle was very high; location was only disputed in a few cases, and the approach needed to be modified in a couple of samples. However, considering the increase in neural cross-section in the Perineural group, the results are not that straightforward, and show that accurate perineural placement of the needle is quite difficult in this easily located, identified and well-defined nerve (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>). This begs the obvious question: to what degree of accuracy can we define the margins of other nerves and/or nerve plexuses that are harder to visualise under ultrasound? The quality of the ultrasound image does not depend solely on the specific nerve to be blocked, but will be affected by many other variables, such as the patient's echogenicity, the ultrasound used, and the skill and experience of the operator. This leads us to conclude that it is not easy to identify the position of the needle in relation to the nerve solely on the basis of the ultrasound image.<elsevierMultimedia ident="fig0030"></elsevierMultimedia>We, like other authors,<a class="elsevierStyleCrossRefs" href="#bib0210">18,19</a> found increased cross-section of the nerve to be a reliable marker of intraneural injection, even with the administration of a small volume of local anaesthetic (1ml). If the nerve is observed to increase in diameter, administration of the local anaesthetic should be stopped immediately and the position of the needle with respect to the nerve re-evaluated. Secondary signs, such as the spread of anaesthetic along the nerve (proximal and distal hypoechoic ring around the nerve), can also be used. A significant increase in the cross-section of the nerve confirms intraneural injection; but in the case of the medial nerve, it is only confirmatory if the cross-section increases by more than 27%. This is because perineural anaesthetic administration can also increase the cross-section, albeit to a lesser extent than intraneural administration. There are 2 possible explanations for this phenomenon, both of which must be taken into account: perineural injection produces intraneural diffusion (i.e., there is a connection between the paraneurium and the epineural space); or, despite good delimitation of the median nerve, it is impossible to avoid piercing the epineural sheath, resulting in subepineural injection and increasing the cross-section of the nerve. Both hypotheses should compel us to reflect on safety mechanisms and to maximise precautions when administering regional nerve block.<a class="elsevierStyleCrossRef" href="#bib0220">20</a>Nerve block safety decision algorithms are essential; however, few have been put forward, and even fewer still have been implemented.<a class="elsevierStyleCrossRef" href="#bib0205">17</a> We are certain that our results support the use of technological aids to ensure correct needle placement and safe administration. These include monitoring patient response (paresthesia), response to neurostimulation,<a class="elsevierStyleCrossRefs" href="#bib0205">17,21</a> and electrical impedance,<a class="elsevierStyleCrossRefs" href="#bib0230">22,23</a> injection pressure monitoring,<a class="elsevierStyleCrossRef" href="#bib0240">24</a> and observing the spread of local anaesthetic immediately after<a class="elsevierStyleCrossRefs" href="#bib0160">8,19</a> and during administration. This will help us improve the safety of regional nerve block techniques.Our study presents some limitations. Investigators were not blinded to the objective of the study (placement decision) while performing the block; however, a majority vote was required to validate the injection site; secondly, the study nerve has special characteristics that prevent these data from being extrapolated to other nerves; third, the measurement method was based on capturing frames from a digital video recording instead of measuring the nerve immediately after the exploration; in this context, intraindividual variability in such a small structure as the median nerve in the forearm should not be underestimated. Finally, the study also has some methodological limitations, insofar as it was performed on cadavers, and we cannot be certain that the spread of the injectate would follow the same pattern in clinical practice on living patients.In conclusion, visualisation and mapping prior to performing peripheral nerve block is essential to correctly and clearly delimit the structure prior to administration, and thus ensure that the tip of the needle is correctly placed. Accurately determining the neural margins is essential to avoid the risk of nerve injury during peripheral nerve block. Based on our results, we can conclude that an increase (swelling) in the cross-sectional area of the nerve on ultrasound imaging after injection of 1ml of solution is an indication of the position of the needle with respect to the nerve, and allows us to reposition the tip in order to minimise the risk of nerve injury secondary to intraneural injection of a high volume of anaesthetic.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1160493" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1086795" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1160494" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1086794" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study variables" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-06-14" "fechaAceptado" => "2018-09-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1086795" "palabras" => array:5 [ 0 => "Median nerve" 1 => "Peripheral nerve block" 2 => "Ultrasound cross-sectional area" 3 => "Intraneural" 4 => "Perineural" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1086794" "palabras" => array:6 [ 0 => "Nervio mediano" 1 => "Bloqueo nervio periférico" 2 => "Ecografía" 3 => "Área de sección" 4 => "Intraneural" 5 => "Perineural" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionTo recognise the relationship between the needle tip and the median nerve during peripheral nerve block is of interest to avoid neural damage. However, signs of intraneural injection are not clearly established. The aim of this study was to define the changes observed in the peripheral nerve after the intraneural or perineural administration of 1ml of solution. Material and methodsUltrasound guided median nerve blocks were performed in the forearm of 10 fresh cadavers on 60 occasions (3 per forearm). They were randomised into the intraneural (n=30) or perineural (n=30) location of the needle tip, after the consensus of location by 7 specialists. After 1ml of solution was injected an evaluation was made of the changes in the cross-sectional area of the nerve, as well as the displacement along the nerve. ResultsThe cross-sectional area of the median nerve was increased in both groups, however, the increase was significantly higher in the Intraneural group (perineural 0.007±0.013cm2 vs. intraneural 0.032±0.021cm2, p<0.0001). An increase of more than 27% of the area ensures an intraneural injection in the median nerve according to the ROC curve analysis. Both proximal and distal diffusion were observed more frequently in the Intraneural group (proximal: 86% vs. 14%, p<0.0001, Distal: 43% vs. 4%, p<0.0001). ConclusionsBased on this experimental study, it is concluded that the injection of a small volume (1ml) allows to discriminate the disposition of the intraneural vs perineural needle in a high percentage of cases. Therefore, it is suggested that this “dose test” should be considered in the safety algorithms if it is required to reduce the incidence of intraneural injection." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónConocer la relación entre la aguja y el nervio durante el bloqueo de nervio periférico es de interés para evitar el daño neural; sin embargo, los signos de inyección intraneural no se hallan claramente establecidos. Nos propusimos determinar los cambios observados en el nervio periférico tras inyectar 1ml de solución en disposición intraneural o perineural de la aguja. Material y métodosSe utilizaron 10 cadáveres frescos, a los cuales se les realizó bloqueo de nervio mediano ecoguiado en plano en 60 ocasiones (3 por brazo), realizando una punción intraneural (n=30) o perineural (n=30) según aleatorización previa. Tras el consenso de localización por 7 especialistas, se inyectó 1ml de solución y se evaluó el cambio en el área de sección del nervio y el desplazamiento a lo largo del mismo. ResultadosEl área de sección del nervio mediano se aumentó en ambos grupos, sin embargo, el incremento fue significativamente mayor en el grupo intraneural (perineural 0,007±0,013 vs. intraneural 0,032±0,021cm2, p<0,0001). Un incremento superior al 27% del área de sección asegura una inyección intraneural en el nervio mediano según el análisis de la curva ROC. La difusión proximal y la distal se observó con mayor frecuencia en el grupo intraneural (proximal: 86 vs. 14%; p<0,0001. Distal: 43 vs. 4%; p<0,0001). ConclusionesEn base a nuestro estudio experimental concluimos que la inyección de un pequeño volumen (1ml) permite discriminar la disposición de la aguja intraneural vs. perineural en un porcentaje elevado de casos. Por ello, sugerimos que esta «dosis test» debe de considerarse en los algoritmos de seguridad si queremos reducir la incidencia de inyección intraneural." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Silva Herrera RE, Serrá Sandoval A, Gonzalez Venegas M, de Lara González S, Gracia J, Sala-Blanch X. Evaluación del área de sección del nervio mediano tras la inyección intraneural o perineural. Rev Esp Anestesiol Reanim. 2019;66:122–128." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0045" ] ] ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1225 "Ancho" => 1614 "Tamanyo" => 65937 ] ] "descripcion" => array:1 [ "en" => "Box-plot showing the differences between pre- and post-injection cross-section in both groups." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1261 "Ancho" => 2928 "Tamanyo" => 106399 ] ] "descripcion" => array:1 [ "en" => "Box-plot showing the changes in nerve area observed in each group (post-injection vs. pre-injection difference) in absolute numbers (cm2) (A) and as a percentage (B)." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1260 "Ancho" => 2938 "Tamanyo" => 131734 ] ] "descripcion" => array:1 [ "en" => "Correlation between pre-injection and post-injection cross-section in Perineural (A) (y=0.9744x+0.0357; R2=0.897) and Intraneural (B) (y=0.9008x+0.0186; R2=0.921) groups." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1477 "Ancho" => 1461 "Tamanyo" => 79962 ] ] "descripcion" => array:1 [ "en" => "ROC curve showing the correlation between the percentage increase in cross-section area following administration of 1ml volume and intraneural administration of the same volume." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1385 "Ancho" => 2083 "Tamanyo" => 431074 ] ] "descripcion" => array:1 [ "en" => "Anatomical cross-section of the forearm showing the intraneural (A) vs. perineural (B) injection of solution." ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1263 "Ancho" => 3000 "Tamanyo" => 227125 ] ] "descripcion" => array:1 [ "en" => "Ultrasound image of the median nerve. Image A shows the intraneural injection. The continuous line delimits the cross-section of the nerve. Image B shows the perineural puncture. 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Original article

Cross-sectional area of the median nerve after intraneural vs perineural low volume administration

Evaluación del área de sección del nervio mediano tras la inyección intraneural o perineural

R.E. Silva Herreraa, A. Serrá Sandovala, M. Gonzalez Venegasa, S. de Lara Gonzáleza, J. Graciab, X. Sala-Blancha,b,

Corresponding author

xsala@clinic.ub.es
xavi.sala.blanch@gmail.com

Corresponding author.

a Facultad de Medicina, Universitat de Barcelona, Barcelona, Spain

b Hospital Clinic, Universitat de Barcelona, Barcelona, Spain

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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Correlation between pre-injection and post-injection cross-section in Perineural &#40;A&#41; &#40;<span class="elsevierStyleItalic">y</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;9744<span class="elsevierStyleItalic">x</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>0&#46;0357&#59; <span class="elsevierStyleItalic">R</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;897&#41; and Intraneural &#40;B&#41; &#40;<span class="elsevierStyleItalic">y</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;9008<span class="elsevierStyleItalic">x</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>0&#46;0186&#59; <span class="elsevierStyleItalic">R</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;921&#41; groups&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In his book <span class="elsevierStyleItalic">Anesth&#233;sie R&#233;gionale</span> published in 1914&#44; Victor Pauchet describes how nerves react to intraneural injection of local anaesthetic after exposure&#58; &#8220;Direct intraneural injection produces a fusiform enlargement of the nerve that disappears quickly when the injection has stopped&#46; This occurs because the anaesthetic spreads to both ends of the nerve from the site of injection&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a> These words&#44; based on direct visual observation of the nerve during injection&#44; constitute the first description of the morphological changes in peripheral nerves after an intraneural injection&#46; Since 1914&#44; safety in anaesthesiology has improved&#44; and today safer drugs and specific needles are available&#44; neurostimulation is standard practice&#44; and regional anaesthesia benefits from image-guided techniques&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">2&#44;3</span></a> The introduction of ultrasound has again shown how nerves react during injection of local anaesthetics&#44; and new observations of intraneural injection have been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">4&#44;5</span></a> The criteria used to assess intraneural injection are poorly defined in several studies&#59; however&#44; Sala-Blanch et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">6</span></a> attempted to define objective criteria based on Victor Pauchet&#39;s original description&#46; These criteria focus on the increased cross-section and thickening of the nerve &#40;fusiform thickening described by Pauchet&#41;&#44; followed by spread of the injected anaesthetic towards the longitudinal axis of the nerve&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The aim of this study has been to evaluate changes in the cross-section of the nerve&#44; determined by ultrasound&#44; as the primary criterion for identifying intraneural injection&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">This was a descriptive&#44; prospective study&#44; in which 60 ultrasound-guided in plane injections were performed on the median nerve&#58; 30 intraneural and 30 perineural&#46; The injections were performed by a single anaesthesiologist&#44; with experience in ultrasound-guided nerve block techniques&#46; The injections were performed on fresh &#40;cryopreserved&#41; cadavers from the Human Anatomy and Embryology Laboratory of the Faculty of Medicine of the University of Barcelona&#46; It was decided to use the left and right median nerves in the arm and forearm&#46; The project was accepted for performance in the dissection room&#44; and fresh adult female and male cadavers with no history of infectious medical pathologies were used&#46; The cadavers were maintained at a temperature of 4<span class="elsevierStyleHsp" style=""></span>&#176;<span class="elsevierStyleSmallCaps">C</span> for 36<span class="elsevierStyleHsp" style=""></span>h until the standard safety criteria for manipulation had been met&#46; They were placed in the supine position&#44; and remained in the dissection laboratory at a room temperature of 22&#8211;23<span class="elsevierStyleHsp" style=""></span>&#176;C for at least 4<span class="elsevierStyleHsp" style=""></span>h before start of the study&#46; Then&#44; the corresponding median nerve was selected and located using a Sonosite M-Turbo ultrasound system &#40;Sonosite Inc&#46;&#44; Bothell&#44; WA&#44; USA&#41; and a high frequency HFL 38X &#40;6&#8211;13<span class="elsevierStyleHsp" style=""></span>MHz&#41; linear transducer&#46; A different needle approach was used in each group&#44; always &#8220;in plane&#8221; and with the bevel of the needle facing the transducer&#46; In the Intraneural group&#44; the needle was directed towards the centre of the nerve&#44; while in the Perineural group&#44; it was directed towards the deep edge of the nerve&#46; The criteria to define intraneural placement of the needle were&#58; visualisation of the needle in the interior of the nerve and the ability to pull the nerve by moving the needle&#46; Perineural placement was defined as visualisation of the tip of the needle outside the edge of the nerve&#44; and inability to pull the nerve by moving the needle&#46; In both cases&#44; placement was confirmed by consensus of all 7 anaesthesiologists prior to the start of infusion&#46; Once the needle had been placed in the corresponding position &#40;intraneural or perineural&#41;&#44; 1<span class="elsevierStyleHsp" style=""></span>ml of solution was injected using a syringe pump &#40;Alaris&#8482;GH Plus&#41;&#46; The solution was obtained by diluting 10<span class="elsevierStyleHsp" style=""></span>ml of methylene blue in 90<span class="elsevierStyleHsp" style=""></span>ml of physiological saline&#46; A 23<span class="elsevierStyleHsp" style=""></span>G needle connected to a 50<span class="elsevierStyleHsp" style=""></span>cc syringe via a 90<span class="elsevierStyleHsp" style=""></span>cm long extender was used&#46; The order in which intraneural or perineural injections were administered was randomised using an online randomisation tool &#40;<a id="intr0010" class="elsevierStyleInterRef" href="http://pinetools.com/es/aleatorizar-lista">http&#58;&#47;&#47;pinetools&#46;com&#47;es&#47;aleatorizar-lista</a>&#41;&#46; The procedure was recorded on video and saved to digital format&#46; Recording started immediately before start of the infusion pump&#44; and lasted for 10<span class="elsevierStyleHsp" style=""></span>s&#46; The videos of all injection procedures were uploaded to a computer in order to analyse the nerve cross-section before and after injection of 1<span class="elsevierStyleHsp" style=""></span>ml of solution&#46; All the &#8220;frames&#8221; for measuring the cross-section of the nerve were chosen by the same anaesthesiologist &#40;RS&#41;&#46; For this purpose&#44; two frames from the video image were chosen&#58; a frame showing the nerve before injection &#40;baseline&#41; and another showing the largest cross-section of the nerve after administration of 1<span class="elsevierStyleHsp" style=""></span>ml of solution&#46; The selected images were analysed using the open source image processing program ImageJ &#40;Image J&#44; version 1&#46;51s&#44; NIH&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Two anatomical specimen were frozen at &#8722;20<span class="elsevierStyleHsp" style=""></span>&#176;C for 48<span class="elsevierStyleHsp" style=""></span>h&#44; after which axial slices &#40;2&#8211;2&#46;5<span class="elsevierStyleHsp" style=""></span>cm&#41; were obtained&#44; which were photographed to evaluate the spread of contrast&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The results were entered in an Excel database prepared for this purpose&#46; The variables were recorded in a single intervention&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study variables</span><p id="par0030" class="elsevierStylePara elsevierViewall">Intraneural placement&#44; i&#46;e&#46;&#44; visualisation of the needle in the interior of the nerve&#44; was confirmed by consensus of all 7 anaesthesiologists&#46; This dichotomous&#44; non-parametric&#44; nominal variable determined the group of assignment&#58; Intraneural group&#44; if the tip of the needle on the ultrasound image was inside the median nerve&#44; and Perineural group if it was outside the nerve edge&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The following variables were collected for analysis&#58; Proximal spread &#40;Yes&#47;No&#41;&#44; defined as the intraneural or perineural spread of the injected solution towards the proximal area of the median nerve&#59; Distal spread &#40;Yes&#47;No&#41;&#44; also dichotomous&#44; defined as intraneural or perineural spread of the solution towards the distal area of the median nerve&#46; Finally&#44; the cross-section of the median nerve &#40;cm<span class="elsevierStyleSup">2</span>&#41; was measured before and after injection&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Statistical analysis</span><p id="par0040" class="elsevierStylePara elsevierViewall">Data are presented as mean and standard deviation and&#47;or percentages&#44; according to the characteristics of the variable&#46; The different variables were analysed using the statistical package SPSS version 21&#46;0 &#40;Statistical Package for Social Sciences&#44; SPSS Inc&#46;&#44; Chicago&#44; IL&#44; USA&#41;&#46; Given the sample size and the study design &#40;case-controlled&#41;&#44; nonparametric tests &#40;Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test and Wilcoxon test&#41; or the chi-square test were used to analyse proportions&#46; Significance was set at <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46; The pre- and post-injection cross-section measurements of the median nerve were tested for correlation&#46; Finally&#44; the ROC curve of the sample was determined in order to show the validity of increased cross-section as an independent diagnostic criterion for intraneural injection&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">A total of 60 injections were performed on 10 fresh cadavers&#44; 6 men and 4 women &#40;&#8220;samples&#8221;&#41;&#44; all of advanced age&#46; The samples obtained were either fresh or completely thawed cryopreserved cadavers&#46; Prior to the injection&#44; the samples were kept at room temperature for no less than 4<span class="elsevierStyleHsp" style=""></span>h&#46; Thirty intraneural injections were made &#40;Intraneural group&#59; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>30&#41; and the other 30 were perineural &#40;Perineural group&#59; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>30&#41;&#44; following the pre-assigned randomisation schedule&#46; All 7 study evaluators agreed on the intraneural or perineural placement of the needle before injection and video recording&#46; All videos were recorded correctly and could be evaluated by the principal investigator &#40;RS&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Baseline measurements of median nerves were similar between groups &#40;Perineural 0&#46;116<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;045 vs&#46; Intraneural 0&#46;13<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;062<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;313&#41;&#46; The cross-section of the nerve increased significantly in both groups&#58; in the Intraneural group it increased from 0&#46;13<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;062 to 0&#46;163<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;064<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#44; while in the Perineural group it increased from 0&#46;116<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;045 to 0&#46;123<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;042<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46; Post-injection differences between groups were significant &#40;Perineural 0&#46;123<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;042 vs&#46; Intraneural 0&#46;163<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;064<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;007&#41;&#46; The increase observed between groups was significant in both absolute and percentage terms &#40;Perineural 0&#46;007<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;013 vs&#46; Intraneural 0&#46;032<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;021<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#59; and Perineural 8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12 vs&#46; Intraneural 28<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>21&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; These data are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and in <a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">There was a very significant correlation between the cross-section of the median nerves before and after injection in both groups&#44; as shown in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">ROC curve analysis&#44; shown in <a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#44; was used to evaluate the validity of increased cross-section as a criterion for intraneural injection&#46; 4&#46; The area under the curve was 0&#46;834 &#40;84&#37;&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Proximal spread was observed in 25 patients &#40;86&#37;&#41; in the Intraneural group vs&#46; 4 patients &#40;14&#37;&#41; in the Perineural group &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; Distal spread was observed in 13 patients &#40;43&#37;&#41; in the Intraneural group vs&#46; 1 patient &#40;4&#37;&#41; in the Perineural group &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Analysis of the spread of methylene blue in the cross-sectional anatomical images corroborated the intraneural or perineural administration of the injectate &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">Our study has shown that injecting 1<span class="elsevierStyleHsp" style=""></span>ml of solution in the median nerve increases the cross-sectional dimension in all cases&#59; however&#44; we cannot confirm that the increased nerve dimension are due in all cases to injection of solution inside the nerve&#46; This raises several issues&#58; the differential characteristics of the different nerves and plexuses&#44;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">7&#8211;9</span></a> the difficulty of defining nerve edges using ultrasound&#44;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">8&#44;10</span></a> neural changes associated with intraneural injection&#44;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">6&#44;11&#44;12</span></a> and finally&#44; the anaesthesiologist&#39;s efforts to avoid neural damage<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">13&#44;14</span></a> and decisions taken during anaesthetic administration&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">15&#8211;17</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">In median nerve block the nerve follows a relatively constant course through the forearm&#44; with little variation in diameter and few collateral branches&#46; Its position between 2 muscle planes facilities ultrasound visualisation&#44; while its depth allows excellent visualisation of the needle in all cases&#46; Because of this&#44; consensus among investigators regarding the intraneural or extraneural position of the needle was very high&#59; location was only disputed in a few cases&#44; and the approach needed to be modified in a couple of samples&#46; However&#44; considering the increase in neural cross-section in the Perineural group&#44; the results are not that straightforward&#44; and show that accurate perineural placement of the needle is quite difficult in this easily located&#44; identified and well-defined nerve &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46; This begs the obvious question&#58; to what degree of accuracy can we define the margins of other nerves and&#47;or nerve plexuses that are harder to visualise under ultrasound&#63; The quality of the ultrasound image does not depend solely on the specific nerve to be blocked&#44; but will be affected by many other variables&#44; such as the patient&#39;s echogenicity&#44; the ultrasound used&#44; and the skill and experience of the operator&#46; This leads us to conclude that it is not easy to identify the position of the needle in relation to the nerve solely on the basis of the ultrasound image&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">We&#44; like other authors&#44;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">18&#44;19</span></a> found increased cross-section of the nerve to be a reliable marker of intraneural injection&#44; even with the administration of a small volume of local anaesthetic &#40;1<span class="elsevierStyleHsp" style=""></span>ml&#41;&#46; If the nerve is observed to increase in diameter&#44; administration of the local anaesthetic should be stopped immediately and the position of the needle with respect to the nerve re-evaluated&#46; Secondary signs&#44; such as the spread of anaesthetic along the nerve &#40;proximal and distal hypoechoic ring around the nerve&#41;&#44; can also be used&#46; A significant increase in the cross-section of the nerve confirms intraneural injection&#59; but in the case of the medial nerve&#44; it is only confirmatory if the cross-section increases by more than 27&#37;&#46; This is because perineural anaesthetic administration can also increase the cross-section&#44; albeit to a lesser extent than intraneural administration&#46; There are 2 possible explanations for this phenomenon&#44; both of which must be taken into account&#58; perineural injection produces intraneural diffusion &#40;i&#46;e&#46;&#44; there is a connection between the paraneurium and the epineural space&#41;&#59; or&#44; despite good delimitation of the median nerve&#44; it is impossible to avoid piercing the epineural sheath&#44; resulting in subepineural injection and increasing the cross-section of the nerve&#46; Both hypotheses should compel us to reflect on safety mechanisms and to maximise precautions when administering regional nerve block&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">20</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Nerve block safety decision algorithms are essential&#59; however&#44; few have been put forward&#44; and even fewer still have been implemented&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">17</span></a> We are certain that our results support the use of technological aids to ensure correct needle placement and safe administration&#46; These include monitoring patient response &#40;paresthesia&#41;&#44; response to neurostimulation&#44;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">17&#44;21</span></a> and electrical impedance&#44;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">22&#44;23</span></a> injection pressure monitoring&#44;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">24</span></a> and observing the spread of local anaesthetic immediately after<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">8&#44;19</span></a> and during administration&#46; This will help us improve the safety of regional nerve block techniques&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Our study presents some limitations&#46; Investigators were not blinded to the objective of the study &#40;placement decision&#41; while performing the block&#59; however&#44; a majority vote was required to validate the injection site&#59; secondly&#44; the study nerve has special characteristics that prevent these data from being extrapolated to other nerves&#59; third&#44; the measurement method was based on capturing frames from a digital video recording instead of measuring the nerve immediately after the exploration&#59; in this context&#44; intraindividual variability in such a small structure as the median nerve in the forearm should not be underestimated&#46; Finally&#44; the study also has some methodological limitations&#44; insofar as it was performed on cadavers&#44; and we cannot be certain that the spread of the injectate would follow the same pattern in clinical practice on living patients&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In conclusion&#44; visualisation and mapping prior to performing peripheral nerve block is essential to correctly and clearly delimit the structure prior to administration&#44; and thus ensure that the tip of the needle is correctly placed&#46; Accurately determining the neural margins is essential to avoid the risk of nerve injury during peripheral nerve block&#46; Based on our results&#44; we can conclude that an increase &#40;swelling&#41; in the cross-sectional area of the nerve on ultrasound imaging after injection of 1<span class="elsevierStyleHsp" style=""></span>ml of solution is an indication of the position of the needle with respect to the nerve&#44; and allows us to reposition the tip in order to minimise the risk of nerve injury secondary to intraneural injection of a high volume of anaesthetic&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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            0 => "Median nerve"
            1 => "Peripheral nerve block"
            2 => "Ultrasound cross-sectional area"
            3 => "Intraneural"
            4 => "Perineural"
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            0 => "Nervio mediano"
            1 => "Bloqueo nervio perif&#233;rico"
            2 => "Ecograf&#237;a"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To recognise the relationship between the needle tip and the median nerve during peripheral nerve block is of interest to avoid neural damage&#46; However&#44; signs of intraneural injection are not clearly established&#46; The aim of this study was to define the changes observed in the peripheral nerve after the intraneural or perineural administration of 1<span class="elsevierStyleHsp" style=""></span>ml of solution&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Ultrasound guided median nerve blocks were performed in the forearm of 10 fresh cadavers on 60 occasions &#40;3 per forearm&#41;&#46; They were randomised into the intraneural &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>30&#41; or perineural &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>30&#41; location of the needle tip&#44; after the consensus of location by 7 specialists&#46; After 1<span class="elsevierStyleHsp" style=""></span>ml of solution was injected an evaluation was made of the changes in the cross-sectional area of the nerve&#44; as well as the displacement along the nerve&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The cross-sectional area of the median nerve was increased in both groups&#44; however&#44; the increase was significantly higher in the Intraneural group &#40;perineural 0&#46;007<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;013<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> vs&#46; intraneural 0&#46;032<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;021<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; An increase of more than 27&#37; of the area ensures an intraneural injection in the median nerve according to the ROC curve analysis&#46; Both proximal and distal diffusion were observed more frequently in the Intraneural group &#40;proximal&#58; 86&#37; vs&#46; 14&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#44; Distal&#58; 43&#37; vs&#46; 4&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Based on this experimental study&#44; it is concluded that the injection of a small volume &#40;1<span class="elsevierStyleHsp" style=""></span>ml&#41; allows to discriminate the disposition of the intraneural vs perineural needle in a high percentage of cases&#46; Therefore&#44; it is suggested that this &#8220;dose test&#8221; should be considered in the safety algorithms if it is required to reduce the incidence of intraneural injection&#46;</p></span>"
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          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
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          2 => array:2 [
            "identificador" => "abst0015"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Conocer la relaci&#243;n entre la aguja y el nervio durante el bloqueo de nervio perif&#233;rico es de inter&#233;s para evitar el da&#241;o neural&#59; sin embargo&#44; los signos de inyecci&#243;n intraneural no se hallan claramente establecidos&#46; Nos propusimos determinar los cambios observados en el nervio perif&#233;rico tras inyectar 1<span class="elsevierStyleHsp" style=""></span>ml de soluci&#243;n en disposici&#243;n intraneural o perineural de la aguja&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se utilizaron 10 cad&#225;veres frescos&#44; a los cuales se les realiz&#243; bloqueo de nervio mediano ecoguiado en plano en 60 ocasiones &#40;3 por brazo&#41;&#44; realizando una punci&#243;n intraneural &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>30&#41; o perineural &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>30&#41; seg&#250;n aleatorizaci&#243;n previa&#46; Tras el consenso de localizaci&#243;n por 7 especialistas&#44; se inyect&#243; 1<span class="elsevierStyleHsp" style=""></span>ml de soluci&#243;n y se evalu&#243; el cambio en el &#225;rea de secci&#243;n del nervio y el desplazamiento a lo largo del mismo&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El &#225;rea de secci&#243;n del nervio mediano se aument&#243; en ambos grupos&#44; sin embargo&#44; el incremento fue significativamente mayor en el grupo intraneural &#40;perineural 0&#44;007<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;013 vs&#46; intraneural 0&#44;032<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;021<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#46; Un incremento superior al 27&#37; del &#225;rea de secci&#243;n asegura una inyecci&#243;n intraneural en el nervio mediano seg&#250;n el an&#225;lisis de la curva ROC&#46; La difusi&#243;n proximal y la distal se observ&#243; con mayor frecuencia en el grupo intraneural &#40;proximal&#58; 86 vs&#46; 14&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#46; Distal&#58; 43 vs&#46; 4&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En base a nuestro estudio experimental concluimos que la inyecci&#243;n de un peque&#241;o volumen &#40;1<span class="elsevierStyleHsp" style=""></span>ml&#41; permite discriminar la disposici&#243;n de la aguja intraneural vs&#46; perineural en un porcentaje elevado de casos&#46; Por ello&#44; sugerimos que esta &#171;dosis test&#187; debe de considerarse en los algoritmos de seguridad si queremos reducir la incidencia de inyecci&#243;n intraneural&#46;</p></span>"
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            "titulo" => "Material y m&#233;todos"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Silva Herrera RE&#44; Serr&#225; Sandoval A&#44; Gonzalez Venegas M&#44; de Lara Gonz&#225;lez S&#44; Gracia J&#44; Sala-Blanch X&#46; Evaluaci&#243;n del &#225;rea de secci&#243;n del nervio mediano tras la inyecci&#243;n intraneural o perineural&#46; Rev Esp Anestesiol Reanim&#46; 2019&#59;66&#58;122&#8211;128&#46;</p>"
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            "apendice" => "<p id="par0115" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0045"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Box-plot showing the differences between pre- and post-injection cross-section in both groups&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Box-plot showing the changes in nerve area observed in each group &#40;post-injection vs&#46; pre-injection difference&#41; in absolute numbers &#40;cm<span class="elsevierStyleSup">2</span>&#41; &#40;A&#41; and as a percentage &#40;B&#41;&#46;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">ROC curve showing the correlation between the percentage increase in cross-section area following administration of 1<span class="elsevierStyleHsp" style=""></span>ml volume and intraneural administration of the same volume&#46;</p>"
        ]
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Anatomical cross-section of the forearm showing the intraneural &#40;A&#41; vs&#46; perineural &#40;B&#41; injection of solution&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "fig0030"
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        "mostrarFloat" => true
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Ultrasound image of the median nerve&#46; Image A shows the intraneural injection&#46; The continuous line delimits the cross-section of the nerve&#46; Image B shows the perineural puncture&#46; The dotted line delimits the cross-section of the nerve&#46;</p>"
        ]
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Area in square centimetres &#40;cm<span class="elsevierStyleSup">2</span>&#41;</th></tr><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intra pre&nbsp;\t\t\t\t\t\t\n
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