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Regional anesthesia represents a selective approach in shoulder surgery. The following technics can be used: brachial plexus block, cervical epidural and intra-articular anesthesia. The advantages of each technique are discussed.
OBJECTIVES: Intravenous regional anesthesia (i.v.r.) is a safe, effective technique for surgery on the upper extremities, but it provides no postoperative analgesia. The aim of this study was to evaluate the analgesic efficacy of ketorolac during and after surgery with i.v.r. induced by lidocaine. PATIENTS AND METHODS: A double blind, placebo-controlled clinical trial. Twenty-six patients undergoing elective surgery on the upper extremities under i.v.r. were studied. In the anteroom of the operating theater, an anesthesiologist prepared the anesthetic solution to be administered from two syringes. One contained 3 mg/kg of 0.5% lidocaine (0.6 ml/kg). The second syringe (2 ml) contained 1 ml of 0.9% saline solution for the control group or 1 ml with 30 mg of ketorolac for the treatment group. A second anesthesiologist received the patient in the operating theater and used the syringes provided to induce the blockade. After releasing the pneumatic tourniquets we assessed the appearance of postoperative pain on a visual analog scale over the first 24 hours. The dats were compared using parametric (Student t test) and non parametric tests (Mann-Whitney U test and Fisher's exact test). RESULTS: No significant differences in the characteristics or hemodynamic parameters analyzed were found between the two groups. Nor did we find any differences in analgesia during surgery. Ten of the 13 patients (77%) in the control group required analgesia within the first two hours, whereas none of the patients in the treatment group required analgesia during that time (p < 0.0001). There were no statistically significant differences between the two groups in the total amount administered altogether, both during and after surgery. No local or systemic side effects were observed.
The behavior of 105 patients randomly assigned to receive either general or regional anesthesia and who underwent one of three types of surgery (hysterectomy, prostatectomy, or joint replacement) was assessed before, immediately after, and 3 mo after surgery. Psychologic status was assessed by the Sickness Impact Profile, the SCL-90-R, and a Metamemory Questionnaire. Cognitive functioning was measured by a battery of ten psychomotor, memory, and skilled performance tasks. Physical health was scored by the ASA classification of physical status, a health index, postoperative complications ratings, and a self-rated measure of the patient's health. There were cognitive differences across surgery groups due to age and gender variability among the patients; however, the type of anesthesia produced no difference in behavior. Both the physical and mental health indices showed improvement from the preoperative to the postoperative periods. General anesthesia appears to pose no risk to mental function and recovery beyond that associated with regional anesthesia and surgery.
STUDY OBJECTIVE: To assess the efficacy and safety of intravenous (i.v.) dexmedetomidine, an alpha-2 agonist, as a premedication before i.v. regional anesthesia. DESIGN: Randomized, double-blind, placebo-controlled study with two parallel groups. SETTING: Day-case surgery unit, Department of Surgery, Turku University Hospital, Turku, Finland. PATIENTS: 30 healthy ASA physical status I outpatients scheduled for minor hand surgery with i.v. regional anesthesia. INTERVENTIONS: Patients were assigned to one of two groups to receive either dexmedetomidine 1 microgram/kg i.v. (n = 15) or saline placebo i.v. (n = 15) 10 minutes before exsanguination and inflation of a tourniquet. Regional blockade was induced with 0.5% lidocaine 3 mg/kg (maximum 200 mg). Additional fentanyl 1 microgram/kg intraoperatively and oxycodone 0.05 mg/kg postoperatively were administered for analgesia if needed. MEASUREMENTS AND MAIN RESULTS: Dexmedetomidine preoperatively induced 16% to 20% decreases in systolic blood pressure (p < 0.001), diastolic blood pressure (p < 0.001), and heart rate (p < 0.001), which were mainly abolished within the 4-hour postoperative follow-up period. A clinically significant decrease in arterial oxygen saturation was not observed. The subjective intensity of pain during tourniquet inflation was similar in both groups, but fewer intraoperative (p = 0.009) opioid analgesics were needed in the dexmedetomidine group. Dexmedetomidine decreased sympathoadrenal responses: plasma norepinephrine concentration decreased to one-fourth of the baseline level (p < 0.001), and one of its main metabolites, 3,4-dihydroxyphenylglycol, decreased by 27% (p < 0.001). Dexmedetomidine also prevented an increase in plasma epinephrine concentration following tourniquet inflation (p = 0.003). Dexmedetomidine induced subjective sedation (p = 0.002), but the Maddox Wing test did not show any statistically significant differences between the groups. General effectiveness was graded superior in the dexmedetomidine group (p < 0.001). CONCLUSIONS: Dexmedetomidine is an effective premedication before i.v. regional anesthesia because it reduces patient anxiety, sympathoadrenal responses, and opioid analgesic requirements.
BACKGROUND: The war in Iraq has resulted in a high incidence of severe extremity injury requiring multiple surgical procedures and extensive rehabilitation. We describe the use of advanced regional anesthesia to meet this significant medical challenge. METHODS: From March 2003 to December 2004, 4,100 casualties have been evacuated to Walter Reed Army Medical Center (WRAMC). Of 1,400 inpatients, 750 have been battle-injured with 500 having extremity injuries. Of these, 287 (57%) received surgical care incorporating regional anesthesia including single-injection peripheral nerve blocks and continuous peripheral and epidural infusion catheters. Wounding, surgical, anesthetic, and outcomes data have been prospectively collected. RESULTS: Over 900 operations (mean 4+/-2/patient) were performed on 287 casualties prior to arrival at WRAMC, and 634 operations (mean 2+/-1/patient) were performed at WRAMC. Thirty-five percent of this cohort was amputees. In the study group, 646 advanced regional anesthesia procedures, including 361 continuous peripheral nerve blocks (CPNBs), were performed with a mean catheter infusion time of 9 days (1-34). Catheter-related complications occurred in 11.9% of casualties and were technical or minor in nature. Catheter-related infection rate was 1.9%. In 126 casualties with indwelling CPNB catheters, a significant decrease in pain score over 7 days was apparent (mean 3.7+/-0.2 to 2.2+/-0.2, P<0.001). CONCLUSION: Advanced regional anesthetic techniques allowed for safe perioperative surgical anesthesia and analgesia in the management of the modern combat casualty.
STUDY OBJECTIVE: To compare the intraoperative effects and recovery characteristics when either midazolam or propofol was used for sedation during local or regional anesthesia. DESIGN: Open-label, randomized study with blinded observer assessing recovery data. SETTING: Outpatients undergoing elective surgical procedures under local or regional anesthesia at Stanford University Hospital, Stanford, California. PATIENTS: Sixty-eight consenting, unpremedicated ASA physical status I, II, or III patients. INTERVENTIONS: After achieving adequate analgesia with local anesthetic solutions, patients were administered a loading dose of either midazolam (4.2 +/- 1.4 mg) or propofol (69 +/- 23 mg) followed by a variable-rate maintenance infusion equal to 8.6 +/- 5.4 mg/h or 265 +/- 185 mg/h, respectively, to maintain a stable level of sedation during the operation. MEASUREMENTS AND MAIN RESULTS: Intraoperative assessments included level of sedation, as well as cardiovascular and respiratory status, at 1- to 5-minute intervals during the operation. Postoperatively, recovery of cognitive and psychomotor function was assessed using analog scales and the digit-symbol substitution test. The overall quality of intraoperative sedation was similar in the two sedative treatment groups. Although midazolam produced less pain on injection and more effective intraoperative amnesia, use of propofol was associated with less postoperative sedation, drowsiness, confusion, clumsiness, and amnesia, as well as more rapid recovery of cognitive function. However, discharge times were similar in the two sedative treatment groups. CONCLUSIONS: Propofol infusion is a clinically useful alternative to midazolam for sedation during ambulatory surgery under local or regional anesthesia.
BACKGROUND AND OBJECTIVES: The major determinant of variable operating room costs is surgical time. A number of factors contribute to surgical time. This study was designed to determine whether regional anesthesia decreases surgical time when compared with general anesthesia over several surgical procedures. METHODS: A search was conducted for clinical trials that reported surgical times and which compared outcomes from regional versus general anesthesia. A meta-analysis of these trials was completed to determine whether, on average, among many surgeons and surgical procedures, the use of regional anesthesia affects surgical time. Confidence intervals were calculated and random effects meta-analysis was used to pool results. RESULTS: Twenty-six studies (with 1,874 patients) were used in the meta-analysis. Regional anesthesia does not significantly decrease surgical time versus general anesthesia (mean general minus regional difference was 1.7 minutes, 95% confidence interval -0.5 to 3.9 minutes). CONCLUSIONS: Overall, the use of regional anesthesia does not significantly decrease surgical time.
UNLABELLED: One thousand questionnaires concerning the techniques and complications of intravenous regional anesthesia (IVRA) were sent to 900 American and 100 Canadian anesthesiologists. Of the 321 respondents, 86% perform IVRA regularly. A wide variation in device-related and clinical aspects was found, ranging from acceptable to falling outside published guidelines. Anesthesiologists perform a median of four upper-limb IVR procedures per month, most often using 50 mL of lidocaine 0.5% at tourniquet pressures of 250 mm Hg or 100 mm Hg greater than the systolic blood pressure. Forearm, thigh, and calf IVRA are occasionally used. Complications, reported infrequently in the literature, were reported by respondents, including mistaken deflation of the cuff; dysphoria, dizziness, or facial tingling; seizures; cardiac arrests; and deaths. Although there was no correlation between complications and deviation from traditional practice, we recommend that IVRA be performed following recognized protocols by anesthesiologists who are familiar with the technique and trained to treat its potential complications. We recommend a protocol for IVRA. IMPLICATIONS: Intravenous regional anesthesia is a widely used anesthetic technique. A survey of 321 American and Canadian anesthesiologists indicates a wide variation in technique. Despite no correlation between complications and technique, the authors recommend that recognized protocols be used for this technique.
Regional anaesthesia is today a well established method for providing pain control in children. We must consider two kinds of problems: problems unique to paediatric population and problems that are the same in adults. A good knowledge of paediatric anatomy is mandatory for regional anaesthesia. Physiology in newborn and infants differ from older children and adults; metabolism and clearance of drugs, local anaesthetic included, are reduced so that we have a narrow therapeutic window and an increased toxicity. Moreover, the risk of inadvertent intravascular injection exists and can be minimized only with adequate monitoring along the performance of block. The availability of new local anaesthetics enantiomers such as ropivacain and levobupivacain, can add safety to regional anaesthesia and the addition of adjuvants like clonidine and ketamine contribute to the reduction of risks connected with toxicity. Performance of a block during anaesthesia is safer than when performed in an awake child.
OBJECTIVE: To compare the clinical outcomes for patients with carotid artery stenosis with advanced age, diabetes mellitus, atherosclerotic coronary vascular disease, and contralateral internal carotid artery occlusion who underwent carotid endarterectomy (CEA), using regional anesthesia, with the outcomes for patients without these risk factors. METHODS: A prospective series of 600 CEAs performed using regional anesthesia was analyzed. All patients were surgically treated under the direction of one neurosurgeon, in an academic medical center. Clinical outcome measures were any stroke, death, or cardiac morbidity within 30 days after surgery. All patients were monitored until a clinical end point was reached and/or 6 weeks had elapsed after surgery. The incidence of adverse clinical outcomes among the suspected high-risk patients was compared with the incidence for the entire series using contingency-table analysis (chi2 and Fisher's exact tests). RESULTS: Fifteen strokes (2.5%), three cardiac complications (0.5%), and two deaths (0.3%) occurred within 30 days after CEA. None of the suspected risk factors was associated with a significantly (P < 0.05) increased risk of perioperative morbidity or death. CONCLUSION: CEA using regional anesthesia can be performed for patients with advanced age, diabetes mellitus, atherosclerotic coronary vascular disease, and contralateral internal carotid artery occlusion, with acceptably low perioperative morbidity rates.
Ambulatory surgery is increasing at unprecedented rates with more complex procedures being performed. This article reviews the benefits of the use of regional anesthesia during ambulatory surgeries. Regional anesthesia, by putting the anesthetic at the surgical site, provides ideal conditions for ambulatory surgery and provides a smooth, predictable post-operative course.
Various anesthetic and surgical techniques have been recommended with or without cerebral function monitoring in attempts to reduce the risk of carotid endarterectomy, but there is no consensus as to the ideal method for performing this procedure. General anesthesia is now the most common anesthetic technique used, but of 337 carotid endarterectomies performed by the author's service from 1981 through 1985, 305 (91%) were conducted with regional anesthesia. This paper presents the morbidity and mortality rates for those patients. There were two perioperative transient ischemic attacks (0.66%), two perioperative strokes (0.66%), and two perioperative deaths (0.66%). No patient in the series suffered a myocardial infarction within 30 days after endarterectomy. This series demonstrates that carotid endarterectomy can be performed with good results using regional anesthesia, which facilitates intraoperative cerebral function monitoring. Regional anesthesia is associated with a very low incidence of postoperative hypertension and perioperative myocardial infarction.
OBJECTIVE: To determine the prevalence of fetal acidemia associated with regional anesthesia for elective cesarean delivery in healthy paturients with uncomplicated singleton term pregnancies. METHODS: This was an epidemiologic study using the data base of the Swiss obstetric study group (Arbeitsgemeinschaft Schweizerischer Frauenkliniken). After the exclusion of cases with extraneous factors that may have affected the health of the neonate, we analyzed the umbilical artery pH, Apgar score, and other neonatal outcome measures after cesarean delivery with reference to the anesthetic technique. RESULTS: From 1985 to 1994, 327,763 deliveries, including 40,858 (12.47%) by cesarean, were registered in the data base. Of these, 5806 patients fulfilled the study criteria. The study population included 1002 spinal, 2155 epidural, and 2649 cases of general anesthesia. The frequency of fetal acidemia (pH less than 7.10) was significantly increased in the spinal-anesthesia group (odds ratio [OR] 4.67; 95% confidence interval [CI] 2.73, 8.01) and in the epidural group (OR 2.39; 95% CI 1.42, 4.04) compared with the general-anesthesia group. CONCLUSION: The rate of fetal acidemia is significantly increased after regional anesthesia. This risk must be judged in light of the risks inherent with general anesthesia.
BACKGROUND AND OBJECTIVES: Controversy regarding the use of regional anesthesia in parturients with chorioamnionitis stems from concern that, in bacteremic patients, anesthetic technique may result in infectious complications because of "seeding" of the epidural or subarachnoid space. This study attempts to evaluate the outcome of the parturient with chorioamnionitis based on anesthetic technique. METHODS: Data on chorioamnionitis was collected by review of all obstetric deliveries over a 1-year period with respect to type of anesthetic administered, blood culture results, antibiotic administration, and outcome. RESULTS: Three hundred nineteen women with chorioamnionitis were identified from a total of 10,047 deliveries over a 1-year period. Bacteremia was found in eight of these patients, three of whom received epidural anesthesia. None had received antibiotics before induction of anesthesia. No infectious complications related to anesthetic technique were found. Mean temperature and leukocyte counts were not significantly different between bacteremic and nonbacteremic groups. CONCLUSIONS: Although the total number of patients in this study is small, there is no evidence that regional anesthesia was detrimental to patients with chorioamnionitis. Factors such as leukocyte count and temperature elevation may not be predictive in identifying the bacteremic subgroup of patients.
Diazepam is widely used as a sedative for loco-regional anesthesia. The venous irritation and long duration of action and hangover may be a drawback. We compared 8-chloro-6-(2-fluorophenyl)-1-methyl-4H-imidazo[1,5-a] [1,4]benzodiazepine (midazolam, Ro 21-3981, Dormicum), a new water-soluble benzodiazepine, with diazepam for cardio-respiratory changes, onset time, duration of action, amnesia and venous irritation after a single i.v. shot in loco-regional anesthesia.
IMPLICATIONS: We report our experience with ketorolac/lidocaine IV regional anesthesia (Bier block) (IVRA) in two adolescents with complex regional pain syndrome 1. IVRA resulted in complete resolution of symptoms.
Thrombelastography (TEG), a less commonly available technique used to assess hemostatic function, has recently gained popularity. Analysis of TEG yields qualitative information about platelet function, thromboplastin generation and their interaction with the intrinsic cascade to form a stable clot. Additional information is obtained about fibrinogen and Factor XIII levels as well as the fibrinolytic system. TEG has been shown to be more sensitive and accurate than traditional coagulation tests at both predicting and treating coagulopathies. We report here three cases in which TEG was used to assess hemostatic function in patients at risk for bleeding prior to the induction of regional anesthesia. In all three cases, traditional tests were inadequate to predict the safe practice of regional anesthesia. TEG provided this information and regional anesthesia was successfully employed.
BACKGROUND AND OBJECTIVES: The purpose of this study was to compare the effectiveness of three local anesthetic agents for intravenous regional anesthesia in the upper limb. Side effects and plasma concentrations of the drugs in the doses administered for IVRA were also studied. METHODS: Thirty patients in ASA groups I and II received intravenous regional anesthesia for surgery of the upper limb. In a double-blind prospective study, they were randomly allocated to receive one of three local anesthetics: articaine, lidocaine, or prilocaine. Patients received 40 mL of a 0.5% solution of the local anesthetic. The onset time of sensory block was assessed by pinprick and the extent of motor block was was scored as 0-3. Plasma concentrations of local anesthetics were determined in all patients from serial arterial blood samples drawn at predetermined times before and after tourniquet release. RESULTS: The onset time of sensory block was significantly shorter (2.5 minutes) in the articaine group than in the lidocaine group (11.1 minutes) or the prilocaine group (10.9 minutes) (Scheffe, P < .05). Development of motor block was equal in all three groups (score 2). Estimation of plasma concentrations by high performance liquid chromatography showed that the peak level in all 30 patients was reached immediately after release of the tourniquet; plasma concentrations thereafter gradually declined. Maximum concentrations of articaine, lidocaine, and prilocaine were, 1.85, 8.5, and 4.4 micrograms/mL, respectively. No signs of local anesthetic toxicity of the cardiovascular or central nervous systems were seen. CONCLUSION: Articaine had the fastest onset of sensory block and the lowest peak plasma concentration of the three local anesthetics when used for intravenous regional anesthesia.