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Chapter 52. Regional Analgesia in the Critically Ill

Which statement is true regarding epidural catheter use in critically ill patients?

A. The most common side effects of an epidural are hypertension and tachycardia.

B. Neurologic assessment always needs to be performed by evoked potentials.

C. Continuous infusion of local anesthetics causes more pronounced hemodynamic changes than intermittent bolus doses.

D. Coagulopathy or anticoagulation causes a serious bleeding risk while an epidural is in place.

E. Major indications for epidural catheters are chest trauma, thoracic and abdominal surgery, and paralytic ileus.

E is correct. Additional important indications are pancreatitis and intractable angina pain.

A is incorrect. The most common side effects of epidural blocks are bradycardia and hypotension related to sympathetic block.

B is incorrect. Discontinuation of continuous infusion allows neurologic assessment when necessary.

C is incorrect. Hemodynamic changes can be more pronounced with intermittent bolus dosing, in patients with hypovolemia, or in patients with reduced venous return secondary to high positive end-expiratory pressure ventilation.

D is incorrect. There is no hard evidence of increased risks of epidural bleeding with developing coagulopathy or therapeutic anticoagulation while an epidural catheter is in place. Nevertheless, the benefits of epidural analgesia should be weighed against the risk of this serious complication.

Which statement is true regarding peripheral nerve catheters in critically ill patients?

A. Continuous interscalene or cervical paravertebral blocks provide excellent analgesia for rib fractures.

B. An interscalene brachial plexus block results in the loss of hemidiaphragmatic function.

C. Guidance by eliciting paresthesia is the safest way for nerve blocks in the ICU.

D. Central neuraxial blocks in heavily sedated patients are good for junior resident training because of less anxiety.

E. A femoral nerve block provides good analgesia for a broken pelvis.

B is correct. Although phrenic nerve blockade has negligible effects in mechanically ventilated patients, it may impair weaning from mechanical ventilation in high-risk patients.

A is incorrect. In patients with altered mental status in whom opioid-based analgesic regimens might make neurologic evaluation difficult, excellent analgesia can be achieved for the shoulder or upper limb with continuous interscalene, cervical paravertebral, or infraclavicular approaches to the brachial plexus.

C is incorrect. Real-time ultrasound guidance for peripheral catheter placement might be especially beneficial in the sedated critically ill patient.

D is incorrect. Performance of ...

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