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PubMed2005

Monitored anesthesia care and loco-regional anesthesia. Vascular surgery use.

Association of locoregional techniques such as deep and superficial cervical block, lumbar epidural and/or peripheral blocks, and conscious sedation with hypnotic drugs (propofol 1-3 mg/kg/h or midazolam 2-4 mg/h) and/or opiates drugs (sufentanil 5-10 mcg or remifentanil 0.05-0.1 mcg/kg/min) is actually, the gold standard for vascular surgery. Our personal experience is based on 328 patients submitted to carotid endarterectomy, aneurysm repair and peripheral surgery.

Analgesia↗
PubMed1985

Comparison of the effects of general and regional anesthesia for cesarean section on neonatal neurologic and adaptive capacity scores.

Fifty-two neonates delivered by elective cesarean section were evaluated using the Neonatal Neurologic and Adaptive Capacity Scores. Twenty of the mothers received general anesthesia, 14 received epidural, and 18 received spinal anesthesia. All mothers receiving regional anesthesia were prehydrated with 1000 ml of lactated Ringer's solution and were given oxygen via a transparent face mask. All mothers undergoing general anesthesia received thiopental for induction followed by N2O-O2 (4 L:4 L) and 0.5% enflurane until delivery of the baby. All mothers were healthy, not in labor, and were scheduled for elective cesarean section. All neonates weighed 2500 g or more, had Apgar scores of 7 or more at 1 and 5 min, and had normal acid base and blood gas data. Neonates delivered with general anesthesia scored significantly lower on some of the test items for adaptive capacity, passive tone, active tone, primary reflexes, and total scores at both 15 min and 2 hr of age (P less than 0.05) than those delivered with either epidural or spinal anesthesia. Neonates delivered with epidural anesthesia scored lower than those delivered with spinal anesthesia on supporting reaction and motor activity at 2 hr of age (P less than 0.05). All neonates had high scores at 24 hr, at which time there were no significant differences between the three groups.

Adaptation, Psychological↗
PubMed1974

Local-regional anesthesia during childbirth: effect on newborn behaviors.

Administration of local-regional anesthesia during norgnal deliveries was correlated significantly with newborn behaviors as evaluated by the Brazelton neonatal assessment scale. Three days after birth, infants whose mothers received local-regional anesthesia were more irritable and motorically less mature than those infants whose mothers were not medicated.

Anesthesia, Conduction↗
PubMed1999

Adding clonidine to lidocaine for intravenous regional anesthesia prevents tourniquet pain.

UNLABELLED: Tourniquet pain often complicates the use of the pneumatic tourniquet during surgical procedures performed under IV regional anesthesia. Clonidine-containing local anesthetic solutions have better analgesic properties than plain solutions when used for spinal, epidural, or peripheral blocks. We tested the hypothesis that the addition of clonidine may improve the quality of IV regional anesthesia, especially tourniquet tolerance. Forty patients were allocated randomly in a double-blinded, randomized study to receive 40 mL of 0.5% lidocaine and either 1 mL of isotonic saline or clonidine (150 microg). A double-cuffed tourniquet was kept inflated until patients complained of pain, leading to release of the distal cuff. Pain at the tourniquet site, at the surgical site, and in the distal part of the arm was rated on a visual analog scale (VAS) and a verbal rating scale (VRS) every 15 min during tourniquet placement and every 15 min for 1 h after tourniquet deflation. Motor blockade, sedation, arterial pressure, and heart rate were also recorded. VAS and VRS scores were significantly lower in the clonidine group 30 and 45 min after tourniquet inflation. The tolerance for the distal tourniquet was also significantly longer in the clonidine group (median [range]: 22 [10-40] vs 10 [5-20] min; P < 0.05); motor blockade was comparable between the two groups. Pain was not different in the two groups after tourniquet release. The clonidine group experienced a higher degree of sedation. We conclude that clonidine improves tourniquet tolerance when added to a local anesthetic solution. IMPLICATIONS: A 150-microg dose of clonidine added to lidocaine improved tourniquet tolerance during IV regional anesthesia.

Adrenergic alpha-Agonists↗
PubMed2006

How to teach regional anesthesia.

PURPOSE OF REVIEW: The demand for peripheral nerve blocks and neuroaxial blocks from both patients and surgeons has increased over the last few years. This change in attitude towards regional anesthesia is prompted by the insight that adequate perioperative pain management leads to earlier ambulation, shorter hospital stay, reduced cost and increased patient satisfaction. To avoid serious complications of these techniques structured residency programs need to be available. RECENT FINDINGS: Until 2004, the Residency Review Committee for Anesthesiology in the United States required a minimum of 50 epidurals, 40 spinals and 40 peripheral nerve blocks during residency. Similarly, the German Society for Anesthesia and Intensive Care required 100 neuroaxial blocks and 50 peripheral nerve blocks. In 2004 the American Society of Regional Anesthesia and Pain Medicine endorsed standardized guidelines for regional anesthesia fellowships which regulate the administrative, equipment and educational demands. SUMMARY: This review introduces the reader to the different teaching methods available, including cadaver workshops, three-dimensional videoclips, video filming, ultrasound guidance and acoustic assist devices as well as demonstrating their advantages and disadvantages. Moreover, an overview is given of future residency training programs, which integrate administrative, material and educative demands as well as the teaching means into the daily clinical routine.

Anesthesia, Conduction↗
PubMed1993

Should student nurse anesthetists be required to administer regional anesthesia?

Although millions of anesthetics are administered by Certified Registered Nurse Anesthetists (CRNAs) every year, all CRNAs are not trained in the actual administration of regional anesthesia. Some individuals believe that all students should receive this instruction while enrolled in nurse anesthesia education programs. This belief has resulted in the Council on Accreditation of Nurse Anesthesia Educational Programs being encouraged to adopt an accreditation requirement for the administration of regional anesthesia by students. Clinical experience in administration would supplement experience in managing regional anesthetics and didactic instruction that students do receive. This study identified the current practices in nurse anesthesia programs related to the administration of regional anesthesia by students and reasons for supporting or opposing an accreditation requirement.

Accreditation↗
PubMedDate not supplied

[Pediatric regional anesthesia: rational approaches and practical aspects].

Regional anesthesia in children is to be carried out with due consideration for anatomy, physiology (specifically, neurophysiology), pharmacology of local anesthetics, and detailed knowledge of pediatric protocols of numerous regional blockades. Age-specific differences in the pharmacokinetics of local anesthetics should be borne in mind when choosing safe doses and protocols. The pharmacokinetic factors may involve the risk of toxic reactions to local anesthetics. The protocols of central neuroaxial blockades in children are characterized by certain differences, concerning the indications, anatomic reference points, choice of special equipment, doses, and schemes of administration.

Age Factors↗
PubMed2005

Regional anesthesia in hip surgery.

UNLABELLED: Historically, general anesthesia has been the "gold standard" for surgeons and patients when major hip surgery is being done. The recent introductions of improved techniques and catheters for continuous peripheral nerve blocks have made regional anesthesia more attractive to patients and surgeons. We focus on current trends and future directions in perioperative pain management for major orthopaedic procedures done on the hip. The use of epidural or spinal anesthesia during major hip surgery has been linked to a reduced risk of perioperative complications like deep venous thrombosis, less deterioration of cerebral and pulmonary functions in patients who are at high risk for complications, and overall reduced blood loss. In addition, continuous peripheral nerve blocks showed effective and safe postoperative pain control, allowing for lower opioids consumption, improved and earlier rehabilitation, and high patient satisfaction. Accurate patient selection and patient education are fundamental for the success of any regional anesthesia technique. Modern regional anesthesia for major hip surgery includes the use of a single shot and continuous epidural injections, single-shot and continuous spinal injection, continuous lumbar plexus blockade, and continuous peripheral blockade of the femoral and sciatic nerves. Continuous peripheral nerve blocks represent an adjunctive, effective, and safe technique for postoperative pain control after total hip arthroplasty. Future directions in postoperative pain control include the creation of a comprehensive system that supervises the use of continuous peripheral nerve blocks outside the acute inpatient setting for few days following the surgical procedure. LEVEL OF EVIDENCE: Therapeutic study, Level V (expert opinion). See the Guidelines for Authors for a complete description of levels of evidence.

Anesthesia, Epidural↗
PubMed1999

Control of shivering under regional anesthesia in obstetric patients with tramadol.

PURPOSE: Tramadol in a dose of 1 mg x kg(-1) iv is effective in the treatment of shivering after general anesthesia. The current study aimed to investigate (1) whether tramadol was equally effective for shivering under regional anesthesia in obstetric patients and (2) whether effective treatment could be achieved with lower doses. METHODS: In a randomised, double-blind study, 36 obstetric patients who shivered during Cesarean section under regional anesthesia and who requested anti-shivering treatment were allocated to one of three groups for iv treatment: Group T0.5 received tramadol 0.5 mg x kg(-1) (n = 12), Group T0.25 tramadol 0.25 mg x kg(-1) (n = 13) and Group NS normal saline 0.05 ml x kg(-1) (n = 11). Treatment efficacy was evaluated subjectively by the parturient as no improvement, slight improvement, or marked improvement. The attending anesthesiologist who was blinded also independently noted the time elapsed from treatment to the time shivering subsided. Side effects such as nausea, vomiting or sedation and Apgar scores of the newborn were also noted. RESULTS: Eighty percent of parturients in Group T0.5 and 92% in Group T0.25 were judged by observers to have shivering controlled compared with 27% in Group NS (P < 0.001). The response rates of Group T0.5 and Group T0.25 were not different. There was no increased incidence of side effects in the treatment groups. CONCLUSION: We conclude that tramadol iv was effective in the treatment of intraoperative shivering during regional anesthesia for Cesarean section. There was no demonstrable difference in response rate or incidence of side effects between the two doses of 0.5 mg x kg(-1) and 0.25 mg x kg(-1).

Adult↗
PubMed2005

Regional anesthesia in children.

The future of regional anesthesia in children is to continue to use current techniques, but also to search for ways to make them easier to employ. The potential development of safe local anesthetic agents with much longer durations, will serve to facilitate improvements in the techniques and styles of practice. The advances in minimally invasive surgical techniques do not mean that regional techniques will not be necessary, but will result in an adaptation of techniques. Peripheral nerve blockade and local wound infiltration can still be used and in some instances, may be very appropriate.

Analgesics, Opioid↗
PubMedDate not supplied

Lack of peripheral analgesic effect of low-dose morphine during intravenous regional anesthesia.

OBJECTIVE: To determine whether 1 mg morphine injected intravenously in conjunction with prilocaine has any effect on postoperative pain and analgesic requirement during intravenous regional anesthesia. METHODS: This was a randomized, double-blind study that included 37 patients undergoing carpal tunnel operations of the hand under intravenous regional anesthesia. Either 1 ml of morphine or 1 ml of physiologic saline diluted to 5 ml with 5% glucose was injected into the isolated exsanguinated arm. This was followed by 3 mg/kg of 0.5% prilocaine (total volume, 30-50 ml). Pain was assessed at 30, 60, 90, and 120 minutes, and 8, 24, and 48 hours after the end of the operation using a linear visual analog scale (VAS). The total number of analgesic tablets consumed in the first 48 hours were also counted. RESULTS: No difference was found in the VAS pain scores between the groups at any of the time periods studied. The postoperative analgesic requirement was similar in both groups. CONCLUSION: The authors conclude that 1 mg morphine showed no effect on postoperative pain or analgesic requirements when given in conjunction with prilocaine during intravenous regional anesthesia.

Adult↗
PubMed2006

Addition of cisatracurium to lidocaine for intravenous regional anesthesia.

STUDY OBJECTIVE: To determine the onset and regression time of motor and sensory block, and the quality of anesthesia and postoperative analgesia by the addition of cisatracurium to local anesthetic solution in small doses in intravenous regional anesthesia. DESIGN: Prospective, randomized, double-blind study. SETTING: University hospital. PATIENTS: 40 ASA physical status I and II patients undergoing elective hand surgery. INTERVENTIONS: Intravenous regional anesthesia was achieved using 3 mg/kg lidocaine diluted with saline to a total volume of 40 mL in the control group or 0.01 mg/kg of cisatracurium plus 3 mg/kg lidocaine diluted with saline to a total volume of 40 mL in the cisatracurium group. MEASUREMENTS: The onset and the regression time for sensory and motor block were recorded. Quality of anesthesia, intraoperative, and postoperative analgesic requirements were noted. Mean arterial pressure and heart rate were recorded every 5 minutes. MAIN RESULTS: The onset time of sensory and motor block in the cisatracurium group was shorter than in the control group, and the difference was statistically significant. The quality of anesthesia was better in the cisatracurium group than in the control group, and the difference was statistically significant. There was no difference between the two groups with respect to sensory block regression time. Motor block regression time was statistically longer in the cisatracurium group than in the control group. Analgesic requirement was greater in the control group than in the cisatracurium group. CONCLUSION: The addition of cisatracurium to lidocaine in intravenous regional anesthesia shortened the sensory and motor block onset times, improved the quality of anesthesia, and decreased analgesic requirements without causing clinical side effects.

Adult↗
PubMed1996

Epidemiology and morbidity of regional anesthesia in children: a one-year prospective survey of the French-Language Society of Pediatric Anesthesiologists.

We report the results of a prospective study on the practice of pediatric regional anesthesia by the French-Language Society of Pediatric Anesthesiologists (ADARPEF) during the period from May 1, 1993 to April 30, 1994. This study was designed to provide data concerning the epidemiology of regional anesthesia and its complications in a totally anonymous way. Data from 85,412 procedures, 61,003 pure general anesthetics and 24,409 anesthetics including a regional block, were prospectively collected. Central blocks (15,013), most of which were caudals, accounted for more than 60% of all regional anesthetics. Peripheral nerve blocks and local anesthesia techniques represented only 38% of regional blocks and Bier block was used only 69 times. Central and peripheral nerve blocks were performed in all pediatric age groups with some intergroup differences. Most blocks were performed under light general anesthesia (89%), confirming the fact that regional anesthetics are used as techniques of analgesia rather than anesthesia. Complications were rate (25 incidents involving 24 patients) and minor, and did not result in any sequelae or medicolegal action. Peripheral nerve blocks and local anesthesia techniques were generally safe. The overall complication rate of regional anesthesia was 0.9 per 1000, but because all complications occurred with central blocks, the complication rate of central blocks is in fact 1.5 per 1000 with significant variations in different age groups. This prospective study, based on a large and representative series of pediatric anesthetics, establishes the safety of regional anesthesia in children of all ages. It provides new insights on the practice of regional blocks and reveals that complications are rare and minor as they occur most often in the operating room and are readily managed by experienced anesthesiologists with resuscitative equipment at hand. The extremely low incidence of complications (zero in this study) after peripheral nerve blocks should encourage pediatric anesthesiologists to use them more often when they are appropriate, in the place of a central block.

Adolescent↗
PubMed1989

Comparison of sedative infusions during regional anesthesia--methohexital, etomidate, and midazolam.

Using a randomized, double-blind study design, the intra- and postoperative sedative effects of three intravenous central nervous system depressants were compared in 64 patients during regional anesthesia. After establishing regional anesthesia, methohexital 59 +/- 29 mg IV, etomidate 12.6 +/- 8 mg IV, or midazolam 3.7 +/- 1.5 mg IV (mean dose +/- SD) were infused in a titrated fashion over 5-15 minutes to achieve similar end points of sedation. This level of sedation was then maintained with a variable-rate infusion of either methohexital 180 +/- 65 mg/hr, etomidate 32 +/- 12 mg/hr, or midazolam 7.5 +/- 4 mg/hr (mean dose +/- SD) To maintain a stable level of sedation, changes in the maintenance infusion rate were required more frequently with methohexital (4.6 +/- 3 times) than with etomidate (2.6 +/- 2 times) or midazolam (2.7 +/- 3 times). Decreases in oxygen saturation below 95% were more frequent with midazolam than with methohexital and etomidate, while recall of intraoperative events was less frequent after midazolam. Observer evaluations found less sedation in the methohexital and etomidate groups than in the midazolam group during the early postoperative period. However, the patients' evaluation of residual sedative effects (e.g., postoperative sedation visual analogue scores) and discharge times from the recovery room were similar in all three groups. Nevertheless, patients given midazolam had significantly greater impairment of performance on the digit-symbol substitution test in the early postoperative period than did patients given either methohexital or etomidate.

Adult↗
PubMed2000

Regional anesthesia and issues of coagulation status.

Regional anesthesia has generally been accepted as safe and is associated with a relatively low incidence of neurological injury. In 1993, the Food and Drug Administration approved the use of low molecular weight heparin for perioperative thromboprophylaxis. In the past 5 years, there has been an alarming increase in the number of intraspinal hematomas and neurological injury associated with its use in patients undergoing neuraxial anesthesia. This article reviews the coagulation cascade, the various laboratory studies used to assess the coagulation system, and issues related to neuraxial block in the patient with perioperative anticoagulation therapy. The various anticoagulant drugs and their potential to cause intraspinal hemorrhage are addressed with special attention paid to low molecular weight heparin. Finally, recommendations for managing the patient who receives these drugs is presented.

Anesthesia, Local↗