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PubMed2002

New drugs, new techniques, new indications in pediatric regional anesthesia.

The use of regional anesthesia in children represents one of the most effective methods for perioperative analgesia and postoperative pain control. Things have been dramatically changed in the last two decades due to the appearance of new safer drugs and new tools; moreover new techniques were introduced showing their efficacy. In this paper we briefly describe the efficacy of new local anesthetics and adjuvants; we review the use of continuous peripheral blocks and other not very diffused techniques of regional anesthesia.

Adjuvants, Anesthesia↗

PubMed1993

[Intravenous regional anesthesia of the arm].

Intravenous regional anesthesia is a well established technique since the start of this century. It is easy to perform, with rapid onset of analgesia and safe to practice, when proper patient monitoring (ECG, intermittent blood pressure monitoring, oxygen delivery by nasal insufflation) is established and a local anesthetic solution with low systemic toxicity (e.g. prilocaine) is used. When choosing this technique of regional anesthesia it is an important condition, that the operative procedure has to be finished before the tourniquet of the upper arm is released. Immediately after this cuff-release and recirculation of the arm analgesia will diminish. When using prilocaine or mepivacaine as local anesthetic drug a complete surgical analgesia of 30 up to 45 min can be achieved. Long-acting local anesthetics should not be used because of their increased systemic toxicity under the aspect of drug wash-out at the end of the procedure or in terms of inadvertent cuff release. The site of action of intravenous regional anesthesia has been controversial, since adequate clinical investigations with contrast media and radio isotopes proved, that the principal site of action is at the peripheral nerve endings.

Anesthesia, Conduction↗

PubMedDate not supplied

The public's fears about and perceptions of regional anesthesia.

BACKGROUND AND OBJECTIVES: The public is not well informed about matters relating to regional anesthesia. Previous studies concerning regional anesthesia have involved patients, surgeons, and anesthesiologists. This study is the first in-depth survey of the attitudes of the general public toward a number of commonly perceived fears about regional anesthesia. METHODS: A province-wide telephone survey was conducted in Alberta, Canada. The sample surveyed was representative of the adult population of the province and included an equal balance of urban and rural participants. General and regional anesthesia were defined, a scenario involving major knee surgery was described, and participants were asked to choose between regional and general anesthesia. Respondents were then questioned so their attitudes toward commonly perceived fears associated with regional anesthesia could be assessed. RESULTS: A total of 1,216 people were surveyed. A preference for regional or general anesthesia was not expressed in this scenario. Approximately 27% of respondents were very concerned about permanent paralysis, back injury, perioperative pain, seeing the surgical procedure, and the prospect of a needle in the back. Only 6% of individuals were concerned about headaches. CONCLUSIONS: The public's fears and conceptions about regional anesthesia are greatly distorted. The anesthesia community has not been successful in keeping the public informed about regional anesthesia. Future anesthesia-related educational programs should address the concerns of the public about anesthesia matters, particularly regional anesthesia.

Adult↗

PubMed1996

[Cost effectiveness of local regional anesthesia in a remote area].

Loco-regional anesthesia techniques are considered as a simple and economic solution to problems posed by anesthesia in developing countries. However the cost benefits of some techniques are reduced by cardiovascular effects that affect the quantity and nature of peroperative vascular filling usually necessary during general anesthesia. The purpose of the present study was to ascertain the relative costs of these methods by comparing the quantity of crystalloid solution and blood administered during loco-regional anesthesias and general anesthesias in a general hospital center in Africa. In a retrospective cohort of 1050 consecutive patients operated on in the Surgery and Gynecology/Obstetrics Departments of the A. Sice Hospital in Pointe Noire (Congo), 495 included in a study comparing perimedullary anesthesia and general anesthesia. The total volume of solution and blood administered to the patients during the procedure was studied in function of the type of anesthesia and surgery performed. Results showed that the amount of crystalloid solution administered during peridural and spinal anesthesia tended to be higher. This difference was significant only for prostate surgery. Use of epidural anesthesia did not increase the quantity of fluid modified gelatin and blood transfused in this series. It was also observed that 55% of patients who underwent peridural anesthesia required further intravenous anesthesia as opposed to 18.8% of patients who underwent spinal anesthesia. These findings indicate that loco-regional anesthesia performed under standardized conditions does not significantly change the quantity and nature of preoperative filling usually necessary during general anesthesia. Thus these techniques can be considered as cost-effective in developing countries even though the long period necessary for practitioners to learn them results in a transient increase in cost. A prospective study by surgical groups with experience using loco-regional anesthesia is needed to confirm this study.

Adolescent↗

PubMedDate not supplied

The training and careers of regional anesthesia fellows--1983-2002.

BACKGROUND AND OBJECTIVES: The education and subsequent careers of regional anesthesia fellows have not been examined but may provide insight into improving future fellowship training and/or the future of the subspecialty. METHODS: Regional anesthesia fellows educated during a 20-year period (1983-2002) were asked to complete a comprehensive survey that detailed their training, current professional setting, and use of regional anesthesia, and how they foresee the future of regional anesthesia. A separate survey of academic anesthesiology chairs assessed the role of and need for regional anesthesiologists in teaching departments. RESULTS: Twelve regional anesthesia fellowship programs in the United States and Canada provided contact information on 176 former fellows. The survey response rate from those practicing in North America was 49% (77/156). Two of the 12 responding institutions have trained 68% of regional anesthesia fellows. Of respondents, 61% are or have been in academic practice. Regional anesthesia remains an integral part of most respondents' current practice, as evidenced by significant use of regional techniques, active involvement in subspecialty societies, and participation in continuing medical education programs. Academic chairs indicate that fellowship-trained regional anesthesiologists play important roles in resident education and are in demand by academic departments. CONCLUSIONS: This report details how regional anesthesia fellows from 1983 to 2002 were trained and how they currently practice and examines their insights regarding the strengths and weaknesses of past and future regional anesthesia education.

Adult↗

PubMedDate not supplied

Comparison of remifentanil and propofol infusions for sedation during regional anesthesia.

BACKGROUND AND OBJECTIVES: Patients treated with regional anesthesia often require concomitant medication for comfort and sedation. Propofol is widely used for this purpose. Remifentanil, a new ultra-short-acting opioid, exhibits at low doses distinct sedative properties that may be useful for supplementation of regional anesthesia. This study compared the effectiveness of remifentanil and propofol infusions for providing sedation during regional block placement and surgery. METHODS: In an open, prospective trial, 28 patients were randomly allocated to receive continuous infusions of remifentanil (6 microg/kg/h) or propofol (3 mg/kg/h) for sedation during spinal or axillary regional anesthesia. Infusion rates were titrated to maintain a sedation level > or = 2 as assessed with the Observer's Assessment of Alertness Scale. Vital signs were measured continuously, during and for 2 hours after ending study drug infusion. RESULTS: Similar scores for comfort and sedation were obtained in both groups during placement of the regional block and during surgery. Degree of sedation correlated with drug infusion rate of remifentanil (P < .002) but not for propofol. Respiratory rate decreased in the remifentanil group in absence of surgery (P < .05). Mean arterial pressure and heart rate were 20% lower in the propofol group (P < .05). Return to alertness occurred after 10 +/- 6 minutes in the remifentanil group and after 16 +/- 15 minutes in the propofol group. Similar incidences of hypotension, bradycardia, and nausea and vomiting were found in both groups, but intraoperative respiratory depression and nausea were more prominent in the remifentanil group. CONCLUSIONS: When titrated to the same sedation level, remifentanil provided a smoother hemodynamic profile than propofol during regional anesthesia. The frequent occurrence of remifentanil-induced respiratory depression requires cautious administration of this agent. The incidence of adverse reactions seen with both agents during and after their administration makes the management of such sedative infusion techniques difficult.

Adult↗

PubMed2006

Interscalene block anesthesia at an ambulatory surgery center performing predominantly regional anesthesia: a prospective study of one hundred thirty-three patients undergoing shoulder surgery.

Interscalene block (ISB) of the brachial plexus is frequently used for patients undergoing ambulatory shoulder surgery. We previously reported that the incidence of postoperative complaints (neurapraxia) after an ISB was low (3% at 2 weeks), but objective neurologic assessment was not included in the study. The present study combines subjective findings with both preoperative and postoperative objective sensory and motor assessments after an ISB. We prospectively evaluated 133 patients undergoing elective ambulatory shoulder surgery. ISB anesthesia was accomplished by use of 1.5% mepivacaine alone or in combination with bupivacaine (0.5%-0.75%) via a paresthesia technique and a 23-gauge needle. All of the blocks were performed by experienced anesthesiologists. The number of passes with the needle, site of paresthesia, ease of performing the block, and success of the ISB were recorded for each patient. Neurologic assessment was performed preoperatively and up to 2 weeks postoperatively by 1 of 4 health care professionals but not by the anesthesiologists who performed the ISB and included diminished sensation, localized nerve pain, Semmes-Weinstein monofilament pressure threshold sensibility, Weber static 2-point discrimination, and grip strength changes. Patients with postoperative changes were followed up until resolution of symptoms occurred. Successful surgical anesthesia was achieved in 98% of the patients. There was 1 major perioperative complication (0.7%), a seizure that occurred within 5 minutes of the ISB. Two (1.4%) complained of transient postoperative neurapraxias. Neither patient had any changes in objective sensory and motor measurements. Hence, there was no correlation between subjective complaints and objective findings in this study. This study demonstrates that, in the hands of anesthesiologists doing predominantly regional anesthesia, there is a 1.4% incidence of neurologic complications after an ISB. ISB is a safe and effective technique for patients undergoing ambulatory shoulder surgery when an anesthesiologist experienced with regional anesthesia is involved.

Adult↗

PubMed2006

The critically ill patient and regional anesthesia.

PURPOSE OF REVIEW: The review presents an overview of indications, limitations and practical aspects of regional anesthesia and analgesia in critically ill medical and surgical patients. RECENT FINDINGS: A Medline search from 1966 to 2006 with the search terms regional anesthesia, regional analgesia, critically ill and nerve blocks, as well as a search of the Cochrane Library, revealed no studies specifically designed to evaluate the use of regional anesthesia and analgesia in the intensive care unit setting. The available evidence is limited to case reports, cohort studies and expert opinions, and relies heavily on extrapolation from studies primarily designed to examine intraoperative management of surgical patients in whom an intensive care unit admission was part of the perioperative course. SUMMARY: Regional anesthesia and analgesia in the critically ill can help to improve respiratory function, bowel function, mental status and patient comfort secondary to its opioid-sparing effects. Limitations for the use of regional anesthetic techniques are mainly associated with bleeding risks, hemodynamic side-effects, difficulties in neurologic assessment and the potential of local anesthetic toxicity.

Analgesics, Opioid↗

PubMed1990

Regional anesthesia in the pediatric patient.

Pediatric regional anesthesia has been viewed less favorably in the past because it was often considered an extra and unnecessary procedure. Current anesthesia practice demonstrates that local anesthetic techniques are of great value either as the sole anesthetic or for postoperative analgesia in the pediatric population. This review of literature contrasts the anatomic, physiologic, and pharmacokinetic differences between the pediatric and adult populations regarding regional anesthesia. The advantages and special considerations of the pediatric population also are reviewed. Regional anesthesia in the pediatric patient population does have its benefits and should be considered as an option in the provision of anesthesia in the pediatric age group.

Anesthesia, Conduction↗

PubMed1985

Regional anesthesia in head and neck surgery.

Regional anesthesia in the head and neck area is a common and effective tool for the plastic surgeon. For short procedures, it offers the advantages of convenience and comfort to the patient. In many procedures, in addition, it offers advantages to the plastic surgeon over general anesthesia. A knowledge of anatomy of the course of the sensory nerves in the head and neck is essential to execute regional anesthesia. Some variability is always present. However, the most important factor in success is practice with a specific technique until it is mastered. No attempt was made in this article to provide an exhaustive reference to all acceptable forms of anesthesia. An attempt was made, however, to indicate one or two successful methods for each type of commonly used block so that when studied and practiced it can be expected to yield consistent results. Some repetition has been unavoidable because the intent has been to provide a relatively self-contained section for each block so that it may be as a reference without having to read the entire article. It is hoped that frequent practice will result in effective local and regional anesthesia in the head and neck area.

Anesthesia, Conduction↗

PubMed2000

A report of two hundred twenty cases of regional anesthesia in pediatric cardiac surgery.

The use of regional anesthesia (ie, epidural, spinal, or caudal) has been reported in a few small series of children undergoing cardiac surgery, but not in larger studies. In this retrospective, descriptive study, we report the results of the use of regional anesthesia in 220 pediatric cardiac operations. We reviewed the records of children receiving a regional anesthetic for cardiothoracic surgery at Stanford Medical Center between January 1993 and February 1997. All patients were targeted for early tracheal extubation. A variety of regional techniques were used. Time to extubation, control of pain, incidence of respiratory depression and other complications, and length of hospital stay were determined. There were no deaths. Eighty-nine percent of the patients were tracheally extubated in the operating room; 4.1% of whom required reintubation within 24 h. Ninety-five percent +/-2.5% of the patients had pain scores < or =4.0 at all intervals postoperatively. Adverse effects of regional anesthesia included emesis (39%), pruritus (10%), urinary retention (7%), postoperative transient paresthesia (3%), and respiratory depression (1.8%). The incidence of peridural hematoma was zero. The rate of adverse effects was lower in the thoracic catheter epidural approach as compared with various caudal, lumbar epidural, and spinal approaches. Hospital duration of stay was not effected by the presence of regional anesthetic complications. In this study, regional anesthesia was safe and effective in the management of pediatric patients undergoing cardiac surgery.

Adolescent↗

PubMed1992

Continuous intravenous regional anesthesia.

This study evaluates the effectiveness of continuous intravenous regional anesthesia for prolonged operations on the upper extremity. The factors evaluated include patient's sex and age, number of procedures performed, tourniquet on and off times, anesthetic doses, adjunctive drugs used, technical complications, and side effects. Seventy-two procedures were done on 34 patients. The first tourniquet time averaged 58 minutes. Off time averaged 10 minutes. Second tourniquet time averaged 33 minutes, and the mean total tourniquet time was 91 minutes. The mean first anesthetic dose was 275 mg. Mean second anesthetic dose was 128 mg. Mean total anesthetic dose was 402 mg. There were two (6%) technical complications and two (6%) patients had side effects. Continuous intravenous regional anesthesia offers the prolonged anesthesia of brachial plexus block or general anesthesia and the safety, reliability, and ease of intravenous regional anesthesia. Continuous intravenous regional anesthesia should be considered an alternative choice of anesthetic method in upper extremity surgery.

Adult↗

PubMed2005

Neuraxial anesthesia and low-molecular-weight heparin prophylaxis in major orthopedic surgery in the wake of the latest American Society of Regional Anesthesia guidelines.

In May 2003, the Second American Society of Regional Anesthesia Consensus Conference statement was issued partly in response to continued safety concerns over the use of regional anesthesia--in particular, neuraxial techniques--with low-molecular-weight heparin (LMWH) prophylaxis in major orthopedic surgery. As the 2003 Consensus statement makes clear, regional anesthesia may be used safely with LMWH prophylaxis. The key to optimizing patient safety, however, depends on a careful calibration of the total daily dose and the timing of the first and subsequent doses of the LMWH drug with the timing and management of the regional anesthetic procedure. Because the challenge of successfully providing regional anesthesia in the presence of LMWH thromboprophylaxis is a clinical one, anesthesiologists should do what they can to ensure that every member of the surgical team has an understanding of current literature and practice guidelines such as those recently published by the American Society of Regional Anesthesia.

Anesthesia, Conduction↗

PubMed1982

Onset and progression of intravenous regional anesthesia with dilute lidocaine.

Intravenous regional anesthesia was induced in seven healthy volunteers using dilute lidocaine solution. Onset and progression were documented by sequential detailed neurologic examinations and compared with changes following intravenous regional administration of normal saline. On average, lidocaine produced sensory loss earliest on the radial forearm and in the first dorsal web space, although the sequence of development of analgesia was variable, e.g., fingertip analgesia could occur before or after forearm sensory loss. Motor paralysis could precede or follow sensory loss in tissues supplied by the same peripheral nerve; the only consistent finding was persistence of strength in the flexor digitorum profundus of the little finger. The pattern of development of intravenous regional anesthesia was related to the anatomic distribution of the peripheral nerves; it is hypothesized that the primary mechanism of action is block of the small distal nerve branches.

Adult↗

PubMed2005

Intraoperative nausea and vomiting during cesarean section under regional anesthesia.

Nausea and vomiting during regional anesthesia for cesarean section are very common and unpleasant events. They cause significant distress to the patient and also interfere with the surgical procedure. They have multiple etiologies, which include hypotension, vagal hyperactivity, visceral pain, i.v. opioid supplementation, uterotonic agents and motion. The obstetric anesthesia literature has addressed these causative factors for nausea and vomiting individually, making it difficult for the anesthesiologists to have a comprehensive understanding of these important complications. This review highlights the anesthetic and non-anesthetic causes of intraoperative nausea and vomiting during regional anesthesia for cesarean section and the appropriate prophylactic and therapeutic management. Intraoperative nausea and vomiting can be best prevented by controlling hypotension, optimizing the use of neuraxial and i.v. opioids, improving the quality of block, minimizing surgical stimuli and judicious administration of uterotonic agents. Although prophylactic antiemetics have been advocated during cesarean sections, strict adherence to these practices can effectively lower the incidence of intraoperative nausea and vomiting without the requirement of antiemetic agents. Antiemetics, therefore, should be reserved for the prevention of intraoperative nausea and vomiting in high-risk patients and for the treatment of nausea and vomiting not responding to routine measures.

Adjuvants, Anesthesia↗

PubMed1988

The difficult airway in obstetric anesthesia: techniques for airway management and the role of regional anesthesia.

A case is presented illustrating the use of a continuous spinal anesthetic in a parturient with a difficult airway who required urgent cesarean delivery. Options for endotracheal intubation of a parturient with a difficult airway are reviewed. The role of regional anesthesia in this setting is discussed. The most appropriate methods for intubation of the obstetric patient are direct laryngoscopy, the lighted stylet, and fiberoptic endoscopy. Available data suggest that regional anesthesia, specifically continuous spinal anesthesia, may be a safe and effective option for management of a parturient with a difficult airway. Further investigation of this technique is merited.

Adult↗

PubMed2000

Regulation of proprioceptive memory by subarachnoid regional anesthesia.

BACKGROUND: Patient perception of limb position during regional anesthesia is frequently incorrect. The existing model ascribes this misperception, or phantom sensation, as a reversion to a fixed, slightly flexed, body schema. A model was developed to evaluate the influence of limb position changes on the incidence of incorrect or phantom sensations during regional anesthesia. METHODS: Forty American Society of Anesthesiologists physical status I-III adult patients undergoing genitourinary procedures under subarachnoid anesthesia were assigned to a lidocaine or bupivacaine treatment group and randomly assigned to one of four time groups (1, 4, 7, and 10 min). After blockade, patients were placed supine and blinded to limb positioning manipulations. One leg was flexed and the contralateral leg extended, with leg positions subsequently reversed at the assigned time point. At 10 min, patients were asked to identify the position of each leg. Percentage of incorrect response was analyzed using a logistic regression model with two independent variables: treatment and time. A supplemental study was undertaken to evaluate the observed difference in incorrect perceptions relative to flexed first versus extended limb first sequencing. RESULTS: The inability to perceive a change in limb position under regional anesthesia is dependent on the time after the block that the position change is initiated in relation to the onset characteristics of the local anesthetic. A phantom sensation of an extended leg position clearly exists. The flexed-first limb has a significantly higher incidence of incorrect or phantom perceptions. CONCLUSION: Proprioceptive memory involves a dynamic neuroplastic imprinting process that is influenced by limb or joint position prior to onset of regional anesthesia. This contrasts with previously held beliefs of a purely fixed body schema.

Adult↗

PubMed2006

Anesthesia and Prader-Willi syndrome: preliminary experience with regional anesthesia.

The constellation of neonatal hypotonia, developmental delay, hypogonadism and obesity caused by hyperphagia was first reported in 1956 and subsequently termed Prader-Willi syndrome (PWS). Genetic analysis has demonstrated abnormalities of chromosome 15. Anesthesia concerns of PWS include morbid obesity, the potential for difficulties with airway management, risk for perioperative respiratory failure, abnormalities in the central control of ventilation and temperature, rare reports of primary myocardial involvement, aggressive and at times violent behavior and glucose intolerance. For the first time, we report the use of regional anesthesia in four patients with PWS. A lumbar plexus catheter was used to provide postoperative analgesia in one patient while regional anesthesia (fasica iliaca block, spinal anesthesia, and lateral vertical infraclavicular block) was used to provide primary intraoperative anesthesia in three other patients while avoiding the need for general anesthesia. Previous reports of the anesthesia care of patients with PWS are reviewed and the potential perioperative implications of the sequelae of PWS are discussed.

Anesthesia, Conduction↗