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PubMed2001

Regional anesthesia for laparoscopy.

A variety of laparoscopic procedures can be performed on patients under regional anesthesia. Diagnostic laparoscopy in elective and emergency patients, pain mapping, laparoscopy for infertility, and tubal sterilization are some examples. The key benefits of regional anesthesia include less emesis, less postoperative pain, shorter postoperative stay, improved patient satisfaction, and overall safety. Regional techniques, such as rectus sheath blocks, inguinal blocks, and caudal blocks, are useful adjuncts to general anesthesia and facilitate postoperative analgesia. Other techniques, such as spinal and epidural anesthesia, and combination of the two, are suitable as a sole anesthetic technique for laparoscopy. The physiologic changes during laparoscopy in the awake patient appear to be tolerated well under regional anesthesia. It is reasonable to assume that with advances in instrumentation and surgical techniques, the role of laparoscopy will increase in the future. The benefits conferred by regional anesthesia make it an attractive option to general anesthesia for many patients and procedures. Successful implementation of regional anesthesia is an important determinant of how anesthesiologists, surgeons, and surgical facilities cope with new challenges. In the future, it could be possible to provide "walk-in/walk-out" regional anesthesia with a real possibility of fast tracking patients through the recovery process after ambulatory surgery. For maximal patient safety, however, facilities offering regional anesthesia must have appropriately trained anesthesia personnel and the equipment necessary for monitoring and providing full resuscitation in the event of complications or a need to convert to general anesthesia.

Anesthesia, Conduction↗

PubMedDate not supplied

Regional anesthesia for major vascular surgery.

The relative merits of general vs regional anesthesia for patients undergoing major vascular surgery has been the subject of debate over the past decade. Previous studies of regional vs general anesthesia often were deficient in experimental design and, therefore, did not produce definitive answers. Some of these deficiencies related to non-standardized, poorly conducted, and/or described general anesthetic techniques, nonstandardized methods of postoperative analgesia in the general anesthesia groups, and variations in preoperative cardiac status in the study groups. Furthermore, most studies did not conclusively demonstrate a cause and effect relationship between the proposed mechanisms of the beneficial effect of regional anesthesia and outcome. Recent studies, however, have claimed improvements in outcome following regional anesthesia in patients undergoing peripheral vascular procedures. The reported beneficial effects have included amelioration of the neuroendocrine stress response to surgery, improvement in pulmonary function, cardiovascular stability, enhancement of lower limb blood flow, reduction in the incidence of graft thrombosis, and a reduction in the thrombic response to surgery. Skeptics still question whether recent studies have the power to determine whether regional anesthesia decreases the incidence of cardiac and pulmonary complications following major vascular surgery. Furthermore, the issue of whether the beneficial effects of regional anesthesia on the incidence of graft thrombosis and the thrombotic response to surgery relating to intraoperative or postoperative regional anesthesia/analgesia, to regional anesthesia per se, or to the systemic effects of absorbed local anesthetics remains unresolved.

Anesthesia, Conduction↗

PubMed1998

Benchmarking the perioperative process: III. Effects of regional anesthesia clinical pathway techniques on process efficiency and recovery profiles in ambulatory orthopedic surgery.

STUDY OBJECTIVES: (1) To incorporate regional anesthesia options for common outpatient orthopedic surgery into clinical pathways; (2) to use the clinical pathway format and the Procedural Times Glossary published by the Association of Anesthesia Clinical Directors (AACD) as management tools to measure postoperative same-day surgery processes and discharge outcomes; and (3) to determine the effects of general, regional, and combined general-regional anesthesia on these processes and outcomes. DESIGN: Hospital database and patient chart review of consecutive patients undergoing anterior cruciate ligament reconstruction (ACLR) during academic years (AY) 1995-1996 and 1996-1997. Patient data from AY 1995-1996, during which no intraoperative anesthesia clinical pathway existed, served as historical controls. Data from AY 1996-1997, during which intraoperative anesthesia clinical pathways were used, served as the treatment group. SETTING: Ambulatory surgery center in a teaching hospital. MEASUREMENTS AND MAIN RESULTS: The records of 503 ASA physical status I and II patients were reviewed. 1996-1997 patients selected general anesthesia (+/- femoral nerve block) or epidural anesthesia, after which the remainder of the perioperative anesthesia process was standardized with respect to the drugs and equipment used. 1995-1996 patients did not necessarily have a choice in anesthesia technique and did not have a standardized perioperative anesthetic course with respect to specific drugs and supplies. Intervals described in the AACD Procedural Times Glossary, anesthesia drug and supply costs, and patient outcome variables (postoperative nursing interventions required and unexpected admissions), as influenced by anesthesia technique used, were measured. Combined general-regional anesthesia care for ACLR in 1996-1997, when compared with general anesthesia alone, led to increased pharmacy and materials costs and increased turnover time. However, patients with the combined technique showed improved recovery profiles and lower unexpected admission rates, and they required fewer nursing interventions for common postoperative symptoms. Patients receiving epidural anesthesia showed discharge outcomes similar to those patients receiving general anesthesia with femoral nerve block. Postanesthesia care unit bypass (fast-tracking) was more likely in clinical pathway regional anesthesia patients, when compared with the clinical pathway general anesthesia used. CONCLUSIONS: Clinical pathway regional anesthesia care for outpatient orthopedics may have a significant role in simultaneously containing costs and improving both process efficiency and patient outcomes.

Adult↗

PubMed2004

Strabismus after regional anesthesia for cataract surgery.

BACKGROUND: An adult strabismus clinic in a regional eye centre provided an opportunity to estimate the risk of postoperative diplopia from regional anesthesia after cataract surgery and to describe the management of these patients. METHODS: Retrospective cohort analysis. All cases were referred over a 22-month period (November 1997 to September 1999) for investigation of postoperative diplopia after cataract surgery. The surgical and anesthetic records were reviewed to determine the number and location of injections, and the volume and type of regional anesthesia. The evolution and management of patients' diplopia was studied prospectively. RESULTS: Twenty-one patients (12 women and 9 men aged 63 to 88 [median 76] years) were ascertained with postoperative diplopia. In 11 cases the right eye was affected, and in 10 cases, the left eye. Vertical diplopia occurred most commonly from inferior rectus restriction (16 cases). Three cases resolved without treatment, which indicated that the diplopia was transient. Four patients declined treatment, five required prism in eyeglasses only, and nine required strabismus surgery. One patient required surgery and prism in eyeglasses. Two patients required more than one strabismus operation to relieve the diplopia. For the period of data collection, we estimate the risk of nontransient postoperative diplopia from regional anesthesia as 2.6 cases per 1000 cataract procedures (95% confidence interval 1.9-4.7). INTERPRETATION: Patients should be forewarned of the risk of diplopia after cataract surgery with regional anesthesia. The treatment of the diplopia may require prism in eyeglasses or strabismus surgery or both.

Aged↗

PubMed2006

Orbital regional anesthesia: complications and their prevention.

Serious complications following orbital regional anesthesia are rare, but occur following both needle and blunt cannula (sub-Tenon's) techniques. Each technique of orbital regional anesthesia has its own risk/benefit profile. This article reviews the etiology, risk factors, treatment and prevention of complications of commonly used akinetic orbital blocks. Ophthalmologists and ophthalmic anesthesiologists must be prepared to deal with rare, but serious complications, that can occur with any technique of orbital regional anesthesia.

Anesthesia, Conduction↗

PubMed2005

Influence of obesity on surgical regional anesthesia in the ambulatory setting: an analysis of 9,038 blocks.

BACKGROUND: Regional anesthesia is increasing in popularity for ambulatory surgical procedures. Concomitantly, the prevalence of obesity in the United States population is increasing. The objective of the present investigation was to assess the impact of body mass index (BMI) on patient outcomes after ambulatory regional anesthesia. METHODS: This study was based on prospectively collected data including 9,038 blocks performed on 6,920 patients in a single ambulatory surgery center. Patients were categorized into three groups according to their BMI (<25 kg/m2, 25-29 kg/m2, > or =30 kg/m2). Block efficacy, rate of acute complications, postoperative pain (at rest and with movement), postoperative nausea and vomiting, rate of unscheduled hospital admissions, and overall patient satisfaction were assessed. Linear and logistic multivariable analyses were used to obtain the risk-adjusted effect of BMI on these outcomes. RESULTS: Of all patients 34.8% had a BMI <25 kg/m2, 34.0% were overweight (BMI 25-29 kg/m2), and 31.3% were obese (BMI > or = 30 kg/m2). Patients with BMI > or =30 kg/m2 were 1.62 times more likely to have a failed block (P = 0.04). The unadjusted rate of acute complications was higher in obese patients (P = 0.001). However, when compared with patients with a normal BMI, postoperative pain at rest, unanticipated admissions, and overall satisfaction were similar in overweight and obese patients. CONCLUSIONS: The present investigation shows that obesity is associated with higher block failure and complication rates in surgical regional anesthesia in the ambulatory setting. Nonetheless, the rate of successful blocks and overall satisfaction remained high in patients with increased BMI. Therefore, overweight and obese patients should not be excluded from regional anesthesia procedures in the ambulatory setting.

Adult↗

PubMed2002

Intravenous regional anesthesia with clonidine in the management of complex regional pain syndrome of the knee.

STUDY OBJECTIVE: To evaluate the safety and efficacy of administering intravenous regional anesthesia (IVRA) with clonidine in the management of complex regional pain syndrome (CRPS) of the knee. DESIGN: Prospective, non-blinded study. SETTING: University-affiliated pain management center. PATIENTS: 7 patients with the diagnosis of CRPS of the knee. The diagnosis of CRPS was made if a) patients had at least four of these symptoms: allodynia, hyperesthesia, edema, vasomotor changes, pain with a burning quality, sudomotor changes, joint stiffness, or temperature differences between extremities; b) patients had significant pain relief (>75%) after a lumbar sympathetic block. INTERVENTIONS: Each patient received IVRA with a solution containing clonidine 1 microg/kg in a total volume of 50 mL 0.5% lidocaine. IVRA clonidine (IVRA-C) was performed on each patient up to six times (maximum of once a week for six weeks). MEASUREMETNS: Pain was assessed using a verbal pain scale (VPS) between 0 and 10 before each IVRA-C treatment. Duration of pain relief was defined as the time during which the patients experienced no pain (VPS = 0). Continuous electrocardiogram (ECG) and pulse oximetry (SpO2) were monitored and blood pressure was recorded every 5 minutes for the first 60 minutes after tourniquet deflation. MAIN RESULTS: Five patients received complete pain relief with 4 to 6 IVRA-C blocks. The two remaining patients reached a therapeutic plateau from IVRA-C, but had persistent anatomic lesions contributing to the recurrence of their CRPS. No patient experienced hypotension (mean arterial pressure < or = 20% baseline), hypoxemia (SpO2 < or = 90%), bradycardia (heart rate < or =H 60 beats/min), or excessive sedation. CONCLUSIONS: IVRA-C is a useful treatment modality in the management of CRPS of the knee. Clonidine doses of 1 microg/kg appear to be well tolerated without significant side effects.

Adult↗

PubMed2000

Compartment syndrome following intravenous regional anesthesia.

PURPOSE: To present two cases of upper extremity compartment syndrome following intravenous regional anesthesia. CLINICAL FEATURES: Case 1: A 57-yr-old man presented for surgical release of a left-hand Dupuytren's contracture. The procedure was performed under iv regional anesthesia with 360 mg lidocaine and sedation with 150 microg fentanyl and 1.5 mg midazolam. Tourniquet time was 107 min at a pressure of 260 mmHg using three different tourniquet sites. Within minutes of tourniquet release, increased forearm muscle tension, hand anesthesia, pallor, and limited motor function developed. Serum CK and myoglobin levels rose. Myoglobinuria was present. Several fasciotomies and aggressive fluid therapy were performed. Patient made almost full recovery. Case 2: A 73-yr-old woman with controlled hypertension had Dupuytren fasciotomy of her right hand under iv regional anesthesia with 200 mg lidocaine and sedation using 75 microg fentanyl and 1.5 mg midazolam. Tourniquet time was 64 min at a pressure of 250 mmHg using three different tourniquet sites. The patient complained of pain at the iv site during injection of local anesthetic, third tourniquet inflation and after deflation of tourniquet. Thirty minutes after arrival in PACU, her fingers were bluish. She complained of pain and swelling of the forearm. Under general anesthesia, fasciectomy was performed. Myoglobin and CPK levels rose. CPK MB was high but troponin was negative. Three days later she developed pulmonary embolism. She was heparinized and subsequently discharged home. She recovered completely. CONCLUSION: Compartment syndrome may have a rapid and severe onset. Etiology of our cases is still not established. We postulate that increased tissue pressure may be the cause. The anesthesiologists must be aware of compartment syndrome during regional anesthesia.

Aged↗

PubMed2006

Ultrasound guidance in peripheral regional anesthesia: philosophy, evidence-based medicine, and techniques.

PURPOSE OF REVIEW: This article introduces the use of ultrasound to facilitate peripheral regional anesthesia. RECENT FINDINGS: Regional anesthesia, despite its well known clinical benefits, has not gained the popularity of general anesthesia. This is secondary to multiple shortcomings including a defined failure rate, lack of simplicity, and the potential for patient discomfort or injury. Many of the negative aspects of regional anesthesia evolve from the reality that current nerve-localization techniques are unreliable. Given the great variation in human anatomy it is not surprising that even the most veteran clinician can be challenged by techniques that demand anatomical assumptions. The recent use of ultrasound imaging for nerve localization is an innovative application of an old technology which addresses many of the shortcomings of current techniques. Specifically, ultrasound imaging allows the operator to see neural structures, guide the needle under real-time visualization, navigate away from sensitive anatomy, and monitor the spread of local anesthetic. SUMMARY: Ultrasound technology represents an ideal mechanism by which the regional anesthesiologist can attain the safety, speed, and efficacy of general anesthesia. Ultimately, it is the correct peri-neural spread of local anesthetic around a nerve that provides safe, effective, and efficient anesthetic conditions.

Anesthesia, Conduction↗

PubMed1990

Long-term cognitive and social sequelae of general versus regional anesthesia during arthroplasty in the elderly.

This study compared the effects of general and regional anesthesia on cognitive and psychosocial functioning in elderly persons. Sixty-four patients between 60 and 86 yr of age undergoing knee arthroplasty were randomly assigned to receive either general or regional anesthesia. A battery of psychometric tests, including the Satz-Mogel form of the Wechsler Adult Intelligence Scale-Revised, the Wechsler Memory Scale-Revised and the Sickness Impact Profile, and various neuropsychological measures were administered by a blinded observer just before surgery and again 3 months later. Analyses of covariance revealed improvements in most measures that were equivalent between groups. The results indicated that there were no cognitive or psychosocial effects of general or regional anesthesia after 3 months in elderly persons undergoing knee arthroplasty. In this patient population, general anesthesia poses no more risk to long-term mental function than regional anesthesia.

Aged↗

PubMed2002

Gaston Labat, John Lundy, Emery Rovenstine, and the Mayo Clinic: the spread of regional anesthesia in America between the World Wars.

The spread of regional anesthesia in America was greatly facilitated by the work of Gaston Labat. Recruited to work at the Mayo Clinic, Dr. Labat there published his seminal textbook, Regional Anesthesia, in which he laid out his techniques to the next generation of physician specialists, notably John Lundy, Ralph Waters, and Emery Rovenstine. It was Rovenstine who was responsible for creating the specialty of anesthesiology in the 1920s and 1930s. John Lundy continued Labat's work at the Mayo Clinic when Labat left for Bellevue Hospital in New York. There, while teaching, Labat further developed and refined his techniques for delivering regional anesthesia.

Anesthesia, Conduction↗

PubMed2002

Assessing sedation with regional anesthesia: inter-rater agreement on a modified Wilson sedation scale.

UNLABELLED: A valid and reliable means for measuring sedation during regional anesthesia would be valuable for both research and practice. Current methods of monitoring sedation include machine-, patient-, and observer-based assessment. The reliability of machine-based methods is limited at lower levels of sedation, whereas patient-based methods are impractical at higher levels. Observer-based methods offer the best alternative for assessing sedation during regional anesthesia; however, their reliability has not been adequately documented. We examined the interrater reliability of the Wilson sedation scale. Sedation was assessed by pairs of anesthesia care providers in 100 patients undergoing surgical procedures with regional anesthesia. On the basis of the findings, the scale was modified, and 50 additional patients were assessed. The study protocol called for a series of standardized stimuli administered by a research assistant. Raters were blinded to each other's ratings. Interrater reliability was assessed by using the kappa statistic, a measure of actual agreement beyond agreement by chance. When continuing checks on its operationalization and reliability are included, the modified Wilson scale provides a simple and reliable means by which to assess and monitor intraoperative sedation. IMPLICATIONS: We evaluated the interrater reliability of the Wilson scale for measuring sedation during regional anesthesia. Paired anesthesia care providers' ratings of patient sedation indicated very good interrater reliability in both the original scale and a modified version. The modified Wilson scale provides a quick noninvasive means of monitoring sedation during regional anesthesia.

Adolescent↗

PubMed2006

Ultrasonographic guidance in pediatric regional anesthesia. Part 2: techniques.

The benefits of regional anesthesia are well documented. The downsides of such techniques have been a significant failure rate and a potential for serious complications. Nearly, all regional blocks were first described as essentially 'blind' techniques. The development of high-resolution portable ultrasound (US) has made the use of US for regional anesthesia possible. Improved understanding of sonographic anatomy should lessen both the failure rate and the possibility of incurring serious complications. Natural caution has dictated that only a selection of blocks used in adults has been commonly used in pediatric practice, but with the aid of US, the repertoire of blocks for infants and children may be widened. The second part of this review will concentrate on the practice of both peripheral and central blocks.

Anesthesia, Conduction↗

PubMed2001

Ropivacaine 0.2% and lidocaine 0.5% for intravenous regional anesthesia in outpatient surgery.

BACKGROUND: A longer-acting local anesthetic agent, such as ropivacaine, may offer advantages over lidocaine for intravenous regional anesthesia. The objectives of this study were to evaluate whether the findings of volunteer investigations with intravenous regional anesthesia with ropivacaine (which have shown prolonged analgesia after release of the tourniquet) translates into improved pain control after surgery. METHODS: With Human Investigation Committee approval and a double-blind study design, 20 healthy patients with American Society of Anesthesiologists physical status I or II classification who were scheduled to undergo forearm and hand surgery were randomly assigned to administration of 40 ml of either 0.2% ropivacaine or 0.5% lidocaine for intravenous regional anesthesia. Evidence of central nervous system side effects, such as lightheadedness, tinnitus, and metallic taste, as well as cardiac arrhythmias, were evaluated and treated (if necessary) after local anesthetic administration, before and during surgery, and after release of the tourniquet until discharge from the postanesthesia care unit. Regression of sensory anesthesia in the nerve distributions of the forearm and hand was recorded. Verbal numerical pain scores were monitored and quantified until the patients were discharged to home from the postanesthesia care unit. Patient pain scores, side effect profiles, time to first oral intake, and total amount of oral analgesics were recorded 24 h postoperatively. RESULTS: Intravenous regional anesthesia with 0.2% ropivacaine and 0.5% lidocaine provided equivalent levels of surgical anesthesia. After release of the tourniquet, the first evidence for return of sensation in the distribution of the five peripheral nerves occurred later in the ropivacaine group (median, 20 min; range, 15-40 min) than in the lidocaine group (median, 1 min; range, 1-25 min). Verbal numerical pain scores were significantly lower at the time of admission, whereas during the remainder of the postanesthesia care unit stay and later at home, the difference in verbal numerical pain scores between the two groups was no longer statistically significant. CONCLUSIONS: Ropivacaine 0.2% may be an alternative to 0.5% lidocaine for intravenous regional anesthesia in the outpatient surgical setting. Longer-lasting analgesia in the immediate postoperative period may be due to a more profound and prolonged tissue binding effect of ropivacaine.

Adult↗

PubMed1992

Sedation and analgesia techniques for regional anesthesia.

The use of adjuvant drugs for regional anesthesia may be indicated for a variety of reasons. Some general patient considerations, indications for the commonly used sedatives and analgesics, and administration techniques for these agents for patients having regional anesthesia are discussed.

Analgesics↗

PubMed1999

Recent developments in regional anesthesia for ambulatory surgery.

The use of regional anesthesia techniques is increasing in popularity because they reduce the incidence of postoperative complications, including nausea, vomiting, and pain, and decrease the recovery time and hospital stay. This article reviews the recent developments in regional anesthesia techniques and the modifications necessary to adapt them for ambulatory surgery.

Journal Article↗

PubMed2004

Regional anesthesia and perioperative outcome: what is new?

PURPOSE OF REVIEW: This review of the most recent publications is aimed to look at the current developments regarding the effects of regional anesthesia on perioperative outcome. RECENT FINDINGS: The debate continues on whether regional anesthesia and analgesia improve outcome or not. Researchers are still divided in their views. While previous meta-analyses are more favorable, more recent trials are rather on the con side. In an attempt to lessen heterogeneity, meta-analyses have now incorporated data from more recent trials to perform subgroup analyses. Such analyses persistently show the same positive results. The established outcome effects of regional anesthesia are mostly due its ability to provide superior analgesia, its ability to reduce the perioperative stress response and subsequent physiologic perturbations, and its ability to reduce pulmonary complications. Its potential to prevent cardiac morbidity in patients undergoing coronary artery bypass grafting is investigated further by looking at valuable specific biological markers like troponin I and natriuretic peptides. Intrathecal opioids do not seem to improve outcome, unlike the intrathecal local anesthetics. The latter improve outcome presumably by blocking the surgical stress response. In contrast, opioids, non-steroidal antiinflammatory drugs and cyclooxygenase-2 inhibitors have been shown not to impact outcome presumably by not being able to interfere with the stress response. The safety and efficacy of epidural or spinal anesthesia for spinal surgery continue to be demonstrated by current studies. SUMMARY: Despite the controversies, the numerous potential benefits and advantages of regional anesthesia are keys to its continued popularity. With constant search for new scientific clues by improving experimental designs, valuable evidence slowly unfolds. Regional anesthesia certainly takes a leading role in the current trends for a multimodal approach of perioperative pain management.

Journal Article↗

PubMed1991

[Conversation during regional anesthesia].

From the psychological point of view, regional anesthesia is something special because the patient experiences his operation consciously. This means that the anesthetist is required not only to guarantee a safe anesthetic, but also to recognize the special needs of the patients, to enter into them adequately, and thus to support the patient's own strategies for coping with his situation. The question arises as to what extent the anesthetist's behavior meets the patient's psychological requirements. For this reason, the conversation between patient and anesthetist was monitored during 17 operations under regional anesthesia and investigated by means of a quantitative speech analysis. It was shown that the anesthetist clearly predominated in the course of the conversation: particularly during the time when the patient was preparing himself for the operation, it was the anesthetist who actively framed the communication by numerous questions and conversational activities while the patient responsively remains passive. The anesthetist spoke simply and clearly to the patient. Prime consideration was given to explaining the anesthetic procedure and the operation. There were not many attempts by the physician to also deal with the patient's psychic state. On the while, communication was concerned with the quick and easy performance of anesthesia. This was also demonstrated by the fact that conversation between the anesthetist and the patient was nearly absent during the operation.

Anesthesia, Conduction↗