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Postoperative Discomfort due to Peripheral Residual Nerve Blocks in Outpatients who had Carpal Tunnel Surgery-Juniper Publishers
Introduction: The purpose of this study was to compare the discomfort due to residual blocks between distal and proximal blocks.
Methods: The study was conducted on a pool of ambulatory patients who had undergone open surgery for carpal tunnel release under peripheral blocks. Patients returned home 2-3hours after surgery. On the third postoperative day. They were called, and asked to determine the discomfort caused by residual obstruction after discharge from the hospital, on a verbal scale (absent, minor, slight, very important and very important). According to the degree of discomfort, we separated the patients into two groups that were compared with Fisher exact tests and Student's t-test.
Results: Between November 2006 and January 2008, 185 patients were contacted on Day 3 and analyzed (105 distal BP and 80 proximal BP).The age, sex, body mass index, the dominant side and the operated side, smoking, postoperative pain scores did not differ between groups. The muscolocutaneous nerve was blocked in 24 (22.9%) patients who had a distal peripheral nerve block (distal BP) and in 63 (78.8%) of those who have had a proximal block (proximal BP) (p <0.001). Overall, the distal BP induced less discomfort than promixal BP (P = 0.041).
Discussion: This difference could be due to the larger territory of the proximal BP. But the clinical impact of this malaise seems limited since in both groups, 70 to 80% of patients reported no discomfort or minor discomfort.
Keywords: Peripheral blocks; Carpal tunnel syndrome; Postoperative discomfort; Surveillance; Monitoring
Methods: The study was conducted on a cohort of ambulatory patients having undergone open surgery for carpal tunnel release in peripheral blocks. Patients went home 2-3hours after surgery. On the third postoperative day. They were called, and were asked to determine the discomfort caused by residual obstruction after discharge from the hospital on a verbal scale (absent, minor, slight, very important and very important). According to the degrees of discomfort, we separated the patients into two groups and compared the two using the Fisher exact test and Student's t-test.
Results: Between November 2006 and January 2008, 185 patients were contacted three days after their release and analyzed (105 distal PNBs and 80 proximal PNBs). Age, gender, body mass index, ASA score, postoperative pain scores were not different between groups. The musculocutaneous nerve was blocked in 23% of distal PNBs and in 81% of proximal ones (p<0.001). Overall, distal PNBs induced less discomfort than proximal PNBs (p=0.041). Nevertheless, 20% of patients with distal PNBs express mild to very important discomfort, versus 30% of patients with proximal PNBs (p=0.124).
Discussion: Despite dramatic differences in anaesthetised and paralysed territories between the two groups, wrist PNBs induce only slightly less postoperative discomfort due to residual block than proximal PNBs. Therefore, the clinical impact of this discomfort seems limited since in both groups, 70 to 80% of patients reported no or minor discomfort.
1]. Peripheral nerve blocks were the techniques anesthetics frequently used. They provide good surgical conditions and a better risk-benefit. Two types were first disclosed for this surgery. This would be the nerve block at the wrist  and nerve blocks at the brachial plexus or the humeral canal or axilla . The choice of technique depends on the operators and indications but they are comparable to anesthesia level. The main nerves to block in carpal tunnel release surgery, are the median, ulnar and often the musculocutaneous. There is talk of proximal peripheral block (PPB) when the nerves are blocked at the axilla and distal peripheral block when they are located at the elbow and wrist.
Whatever the technique, blocks allow street aptitude before the total lift of the block . Nearly all patients go home with the residual effects of anesthesia . We did not find any similar study on the blocks at the wrist. In addition, the discomfort of residual blocks at the brachial channel have not been compared with those of the blocks at the wrist.
The aim of our study was to evaluate discomfort from distal and proximal residual blocks in ambulatory patients undergoing carpal tunnel release surgery.
6]. Before making the incision, the surgeon was tested the incision site with the tip of the scalpel or pinching the area with dissection forceps. When necessary, they completed the LRA by intraoperative local infiltration of lidocaine 1%.
The average duration of tourniquet was similar with 13.19±3.01mn for the wrist group and 12.96±2.98mn proximally. Table 1 summarizes the distribution of the population by type of anesthesia. The peroneal nerve was significantly blocked proximally 63(78.8%) against 24(22.9%) P<0.0.001. Figure 2 &1 showed that overall the LRA is well tolerated with 17(9.2%) of the genes greater than 3. The proximal blocks gene was significantly higher than the wrist blocks 4(3.9%) against 13(16.3%) p = 0.04?
As many risk factors may be considered in the occurrence of post operative discomfort. A study done in the US shows that the incidence of postoperative complications of peripheral nerve blocks was not modified by the use of ultrasonography . Surgery could also cause discomfort. Uroš Ahčan  showed in a comparative study between the conventional technique and by macroscopic endoscopic visualization of the entire transverse carpal ligament a significant reduction in post operative discomfort after carpal tunnel surgery. This technique could avoid injuries subcutaneous palmar nerve terminal branch of the musculocutaneous. He further asserts that there are several individual anatomical variations which are difficult to predict.
The density of skin nerve endings that criss-cross from the hand to the trunk further increases the risk of injury. Another explanation for the post-block discomfort is the etiology underlying several pathologies with nerve damage may favor the occurrence of post operative discomfort after LRA . The most cited were tenosynovitis in rheumatoid arthritis, nonspecific chronic tenosynovitis or fibrosis, radius fracture in the wrist, Colles' fracture, carpal arthrosis, scaphoid nonunion, the wrist trauma, diabetes mellitus, thyroid disease, pregnancy, birth control pills, lymph nodes, muscle hernia or lipomas in the carpal tunnel. Anesthesia consultation still does not diagnose preexisting nerve injuries. Even when the diagnosis is made, there is no direct correlation between the etiology and nerve damage.
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For more articles in Journal of Anesthesia & Intensive Care Medicine please click on: https://juniperpublishers.com/jaicm/index.php
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Seeking help with stats assessment of fidelity of a treatment course
I am helping with a methods assessment of a 3-arm study. I am trying to determine how to do a statistical assessment of the fidelity of the behavioral treatment courses that we administered to a group of participants. To summarize, we had 3 different treatments, all of which were slightly different versions of an 8-week course based on Cognitive Behavioral Therapy. The instructors set out an agenda for each class (week 1 through week 8), with about 8 items on each agenda (e.g. item 1: welcome; item 2: do exercise ABC; item 3: discuss exercise ABC, etc.), in advance. The agendas were crafted such that all 3 arms were equivalent in structure, with differing content. We had interns in each class rate whether or not the instructor administered each planned agenda item (score of 0 if it didn't happen; score of 1 if it did happen).
My mentor suggested using Cohen's kappa to measure inter-rater agreement between 2 raters, with one rater being the instructor (who's rating is always a 1) and one being an intern (who may have rated 1 or 0). As I'm working on this approach, I'm at a bit of a loss. I don't think my scenario fits the assumptions of Cohen's kappa because I am comparing the instructor's plan to the intern's rating of compliance, rather than comparing 2 independent ratings of the same set of items. In fact, I can't even generate the Cohen's kappa in PASW because, the program tells me, "the Instructor Rating is a constant"! I haven't been able to figure out what type of statistical test would be optimal to assess fidelity to a plan that was set out in advance.
It is also entirely possible that Cohen's kappa does make sense to use in this context, and perhaps I am missing something obvious?
Please let me know if I've left out any information that is necessary! I am a student, still working on building my knowledge of stats, so any resources, search terms, examples, or advice would be very much appreciated :)