The Thorax

General surgical procedures of the thorax are now generally restricted to the chest wall. Thus, the general surgeon performs operations for pathologic conditions Figure 24-32 Technique of regional anesthesia for thyroid surgery. Note that bilateral deep cervical plexus block is essential to anesthetize the structures that will be stretched by retractors. In addition, skin infiltration in the area of the incision helps to minimize bleeding. (From Raj P Clinical Practice of Regional Anesthesia....

Monitoring Of Respiratory Function

When combined technique of light general anesthesia, regional anesthesia, and sedation is used, a pulse oximeter is mandatory, especially in patients with a history of sleep apnea or snoring, significant obesity, and orofacial or neck disturbances. The pulse oximeter can determine the moment when the O2 saturation falls. To prevent this undesirable situation, respiratory rate interval monitoring can be used to detect the effect of opioids on the respiratory center. Apnea alarms are also useful...

Cancer Treatmentrelated Pain

Up to a third of women develop pain as a result of treatment of breast cancer.173 The pain is often described as a general burning and aching sensation referred to the axilla, the medial upper arm, the chest, or all of these areas. There may be paroxysmal episodes of shooting and lancinating pain. In addition, some women report phantom breast pain, mainly in the nipple. The pain may be exacerbated with arm movement, leading to a frozen shoulder as the patient attempts to

Outcome Studies Of Interpleural Analgesia In Cancer Pain

Interpleural analgesia may also be a useful addition to systemic analgesic medications in the treatment of moderate or severe cancer pain. There have been published reports of successful results from interpleural analgesic therapy for both nonmetastatic and metastatic cancers of the gastrointestinal tract, including the pancreas, kidney, breast, and lung as well as lymphoma, sarcoma, histiocytoma, and myeloma.11 1113 113 11531 11511 11551 11561 This evidence describing the use of interpleural...

Upper Extremity Blocks

Studies of perineural steroid injection, generally combined with local anesthetic, for the treatment of carpal tunnel syndrome were examined by Abram.143 Initial efficacy was found in multiple studies to range from 77 to 92 . However, many studies that followed patients for at least 1 year found continued benefit in only 13 to 22 . A prospective, randomized, double-blinded, placebo-controlled study measuring the short-term efficacy of steroid versus saline injection into the carpal tunnel was...

Epidural Steroid Injections

Epidural steroid injections (ESIs) have been used for low back and radicular pain for almost 50 years.13 Today they rank as one of the most common interventional procedures performed by pain management specialists. ESIs are primarily indicated as part of a nonoperative approach to the treatment of spinal and radicular pain. Pages first described his technique for accessing the epidural space via a paramedian approach in 1921s The technique involved the use of loss of resistance to the needle as...

Outcome Studies For Superior Hypogastric Plexus Block

Presacral neurectomy has been performed for years as a treatment for chronic pelvic pain. 82 Presacral neurectomy involves a surgical resection of the superior hypogastric plexus by either an open or a laparoscopic approach. Large retrospective series and case reports describe successful relief of pain in approximately 60 to 80 of patients with chronic noncancerous pelvic pain. 82 83 84 More recently, a randomized, controlled study compared a conservative surgical approach with presacral...

Adrenal And Renal Hormones And Catecholamines

In studies using rather large volumes of bupivacaine (0.5 ) and a well-described neural blockade, the intra- and postoperative increases in plasma cortisol, aldosterone, and renin, as well as catecholamines, have been inhibited. Although no systematic studies are available, rather large doses of bupivacaine seem to be necessary to achieve eradication of these stress parameters. -Lipotropic - Endorphin t ACTH4 GHI AVPJ-TSHt LH FSH* Prolactin t Testes ovaries Testosterone Estradiol...

Allergic Reactions

Allergic reactions to local anesthetics may occur. Reputedly, allergic reactions are more likely to occur with ester-linked local anesthetics than with amide-linked ones. Methylparaben, a preservative sometimes added to local anesthetic solutions, may cause allergic-type reactions. Cutaneous and respiratory reactions are the most common indicators of anaphylaxis. There is little information about whether or not toxic responses to local anesthetics are age dependent. Preliminary data from...

Amide Local Anesthetics

In contrast to the ester-linked drugs, the amide-linked local anesthetics must be transported by the circulation to the liver before biotransformation can take place. The two major factors controlling the clearance of amide-linked local anesthetics by the liver are (1) hepatic blood flow (delivery of the drug to the liver) and (2) hepatic function (drug extraction by the liver). Factors that decrease hepatic blood flow or hepatic drug extraction result in an increased elimination half-life. For...

Assessment Of Chronic Pain

In the early 1970s, chronic pain began to gain special attention as a discrete clinical syndrome that required diagnosis and treatment in special clinics involving interdisciplinary teams. The need for robust measurement tools and techniques led investigators to research and develop reliable and valid instruments for assessing chronic pain. For instance, an algometer was one of the many devices invented to measure chronic pain by comparing it with acute pain induced by a brief electric current...

Brachial Plexus Block

In 1884, less than a year after the discovery of the anesthetic properties of cocaine, William Halsted performed the first regional blockade of the brachial plexus. His technique involved surgical exposure of the plexus in the neck with subsequent intraneural blocking of individual nerves.143 Effectively providing complete anesthesia to the upper extremity, the procedure itself was, at times, nearly as extensive as the surgery for which it was being provided. Unfortunately, an addiction to...

Branko M Weiss Eli Alon

Outcome and Seven Pillars of Quality Avedis Donabedian 13 asserted that the seven pillars, or attributes, that define quality in healthcare13 are (1) efficacy (ability to bring improvements) (2) effectiveness (degree to which the care could attain the level of improvement that studies of efficacy have established as attainable in the clinical practice) (3) efficiency (if two approaches are equally efficacious or effective, the less costly one is the more efficient) (4) optimality (relationship...

Cardiovascular Disease

The diagnosis and treatment of congenital heart disease has improved markedly over the past several decades, leading to an increased number of pregnant women with congenital heart disease. The sympathectomy associated with neuraxial techniques acutely decreases systemic vascular resistance and myocardial preload. This sudden change may not be well tolerated in women with stenotic valvular lesions, asymmetrical septal hypertrophy, or right-to-left shunts. In contrast, patients with left-to-right...

Central Nervous System Toxicity

CNS symptoms of local anesthetic toxicity usually occur before cardiovascular changes. In humans, the first signs of CNS toxicity include drowsiness progressing to numbness of lips, slurring of speech, agitation, tinnitus, diplopia, fine tremors, and grand mal seizures large doses produce generalized CNS depression (an isoelectric electroencephalogram EEG ). Ironically, there is no evidence that epileptics have a heightened susceptibility to the CNS toxicity of these drugs. In fact, local...

Cervical Facet Joints

The anatomy of the cervical facet joints is considerably different from that of the lumbar region. Although they are still composed of the superior articular process of the vertebra below and the inferior articular process of the vertebra above, their capsular anatomy, orientation, and biomechanics differ significantly from their lumbar counterparts. The configuration of the joints also depends on the cervical level that is being addressed, as upper cervical segments differ substantially from...

Cervical Nerve Roots

Selective blockade of the C3 to C8 nerve roots is performed in the same manner. The patient is placed in the supine position with the head in the neutral position. After obtaining an anteroposterior (AP) fluoroscopic view of the cervical spine, the C-arm is positioned obliquely until the neuroforamina are clearly visualized. The proper angle causes the ipsilateral vertebral laminae to appear as a string of beads. A skin wheal is raised with local anesthetic just posterior to the posterior...

Clinical Research

Introduction and Historical Perspective It is the purpose of this chapter to review some of the clinical research in regional anesthesia as it relates to current developments in surgery and pain management. These advances in clinical research are related to the use of drugs, administration techniques, and equipment. Many of these developments are far from recent, and it is important to place them in historical perspective to understand the development of regional anesthesia. The origins of...

Subarachnoid and Epidural Anesthesia

Subarachnoid Anesthesia

MIGUEL ANGEL REINA JOSE DE ANDR S ANDRES L PEZ The meninges envelop the brain and spinal cord and consist of three membranes (external to internal) dura mater, arachnoid, and pia mater, respectively. Tn association with their cellular and fibrillar components, these membranes constitute an organ in their own right. The cellular and fibrillar components in turn are morphologically and physiologically implicated in the mechanical, immunologic, and thermal protection of the brain and spinal cord....

Trigeminal Ganglion Procedures

Nimbus Radiofrequency Needle Fluoroscopy

The trigeminal ganglion, which is an intercranial structure located just proximal and lateral to the foramen ovale, has three branches ophthalmic, maxillary, and mandibular. These are primarily sensory branches, except for the third division. This third division, the mandibular branch, exits through the foramen ovale and has motor branches that are involved in mastication. The procedures that anesthesiologists are involved in center around the different target sites that lend themselves to...

Vertebroplasty

Vertebroplasty is the percutaneous augmentation of a vertebral body using polymethylmethacrylate. Polymethylmethacrylate (PMMA) was first introduced in 1970 by Charnley for orthopedic use in total hip replacements.13 In 1984, Deramond and associates113 in France performed percutaneous bone augmentation using PMMA. They placed the PMMA in the cervical vertebra of a 50-year-old woman who had a C2 vertebral hemangioma with a long-term complaint of neck pain. The patient reported complete pain...

Choice Of Regional Anesthesia

Deep cervical plexus block may be used on the side of the surgery and superficial cervical block on the opposite side. In addition, the accessory nerve can be blocked by injecting 2 to 3 mL of local anesthetic in the upper third of the sternomastoid muscles. Cervical epidural block may be used for carotid surgery. ABDOMINAL AORTIC ANEURYSM Management of patients undergoing abdominal aortic surgical procedures represents a major challenge to the anesthesiologist. The typical patient with aortic...

Chronic Pain After Trauma

Pain persisting beyond the normal recovery period, and often greatly exceeding what might be anticipated relative to the residual pathology, can be considered chronic post-traumatic pain. Although it is widely assumed that psychological factors become increasingly important as acute pain becomes chronic, it is perhaps less well appreciated that a number of pathophysiologic changes also occur in both central and peripheral pain pathways. Consequently, the response of patients with chronic pain...

Cocaine

Cocaine occurs in abundance in the leaves of the coca shrub and is an ester of benzoic acid and methylecgonine. Ecgonine is an amino alcohol base closely related to tropine, the amino alcohol in atropine. It has the same fundamental structure as the synthetic local anesthetics. Pharmacologic Actions and Preparations The clinically desired actions of cocaine are the blockade of nerve impulses as a consequence of its local anesthetic properties, and local vasoconstriction secondary to inhibition...

Complications

Monitoring of Efficiency of the Block. Akinesia of the extraocular muscles is tested by observing whether the patient can move the eye in the four opposite directions (up, down, right, and left). The patient is asked to squeeze the eye to check the orbicularis oculi paralysis. Because the superior oblique muscle is anatomically located outside the muscle cone, it may not be completely paralyzed after a retrobulbar block. If the patient is asked to look downward, an intorsion movement of the eye...

Complications in Regional Anesthesia

The act of placing an epidural catheter may determine some of the complications with epidural anesthesia. The most common complication from placement of epidural catheters is accidental dural puncture with resultant postdural puncture headache (PDPH). Large surveys encompassing 51,000 epidural catheter placements performed during the past three decades suggest that the incidence of dural puncture is 0.16 to 1.3 . Subsequent development of PDPH depends on several factors and ranges from 16 to 86...

Continuous Spinal Anesthesia

Seven years after Bier's landmark work on the administration of cocaine via lumbar puncture, Henry Percy Dean, a British surgeon, introduced a modification of the technique called continuous spinal anesthesia.123 Unfortunately, many of his colleagues who attempted the procedure encountered difficulties such as needle trauma and breakage. Therefore, the technique fell into disfavor, as can be evidenced by the lack of citations referring to continuous spinal anesthesia in the English language...

Cosmetic Indications

Essential hyperhidrosis and excessive facial blushing can be so disabling to some individuals that they seek surgical redress in the form of sympathectomy. These two symptoms can be considered as physical manifestations of social phobic reactions, which are psychiatric conditions with criteria contained in the Diagnostic and Statistic Manual. It has even been considered ethically sound to perform endoscopic transthoracic sympathectomy for selected patients with social phobia resistant to...

D

Individual, group, and family psychotherapy 2. Cognitive-behavioral therapies 3. Biofeedback and relaxation techniques IV. Specific types of painful conditions to be included in the fellow's educational program A. Pain associated with cancer, including issues of death and dying, palliative care, and hospice care B. Postoperative and post-trauma pain C. Pain associated with nervous system injuries D. Pain associated with chronic disease V. Regional pain syndrome to be included in the fellow's...

General

Spinal cord stimulation has been found to be effective for neuropathic pain in general and is less often used for either visceral or somatic pain. The neuropathic pain entities include sympathetic-dependent pain thus, spinal cord stimulation is often considered as a first-line treatment for intractable pain caused by nerve damage resulting from repeated back operations, epidural scarring, or arachnoiditis. It is also useful for peripheral nerve injury syndromes such as stump pain, phantom pain,...

Head And Neck

Pain related to a malignant neoplasm of the head and neck poses one of the most challenging pain management problems because of the overlapping sensory innervation of the area. Most of the pain can be managed with medical regimens however, neural blockade can be a very effective addition. 194 1951 Sensory innervation of the head and neck arises from cranial nerves V, VTT, TX, and X, and dorsal roots of the second, third, and fourth cervical nerves. Sympathetic innervation derives from the T1...

Head And Neck Surgery

Common general surgical operations around the head and neck include thyroid and parathyroid surgery, operations on the lymphatic system, and surgery for lesions of the scalp and neck, including drainage of abscesses and removal of cutaneous and subcutaneous tumors. The scalp is supplied anteriorly by branches of the ophthalmic section of the trigeminal nerve the supraorbital nerve, the supratrochlea nerve, and the auriculotemporal nerve. Posteriorly, the scalp is supplied by branches of the...

History

Epidural steroid administration has been a long-standing component of the treatment of patients with numerous spine-related painful conditions. In 1925, Viner 51 reported his experience with caudal injection of procaine, Ringer's solution, normal saline, or liquid petrolatum in the treatment of sciatica. All patients were reported to be nearly free of symptoms at follow-up. Evans,13 in 1930, reported his treatment of patients with unilateral sciatica with caudal injection of procaine and...

Info

These effects occur beyond a certain threshold, and their severity increases with increasing exposure to ionizing radiation. Examples of stochastic effects are cancer and genetic alterations. These effects can be produced at low absorbed doses of ionizing radiation. Radiation protection practices are therefore twofold (1) to prevent the development of nonstochastic diseases by setting dose equivalent limits well below the threshold limit, which ensures that these limits will not be reached even...

Intrathecal Pump Delivery Systems

As stated earlier in this chapter, intraspinal drugs can be delivered externally through externalized epidural or intrathecal catheters or delivered internally through implanted pump systems. Because external delivery systems are discussed in another chapter, our discussion in this chapter is focused on implanted drug delivery systems. The first drug delivery system approved for the delivery of intraspinal analgesics was the Infusaid model 400 pump, which is no longer in production. The...

James E Heavner

Block of voltage-gated sodium channels by local anesthetics injected near peripheral nerves produces sensory and or motor block. Binding of opioids to opioid receptors, especially receptors, produces analgesia. Inhibition of the enzyme cyclooxygenase (e.g., by aspirin) prevents sensitization of nociceptors. This and other information fundamental to the management of acute and chronic pain is a result of clinical and basic research that has progressively built on prior knowledge. In this...

L2 Communicating Ramus

Percutaneous facet denervation and percutaneous partial rhizotomy have traditionally been the minimally invasive RF techniques used in the treatment of back pain. Recent advances in knowledge of the innervation of the anterior vertebral compartment have led to the development of performing RF lesions close to the exiting segmental nerves, with the aim of interrupting part of the afferent impulses from the anterior mechanical compartment. Based on anatomic considerations, the following technique...

Lateral Popliteal Sciatic Block

Using anatomic studies performed by Vloka and colleagues193 and Zetlaovi and associates, the patient is asked to slightly flex the knee, which enhances palpation Figure 20-52 Sciatic nerve block Lateral popliteal approach. Figure 20-52 Sciatic nerve block Lateral popliteal approach. of the groove between the vastus lateralis and biceps femoris muscles. After the groove is identified, the leg is straightened. Where the lateral line from the patella intersects the groove is the point of needle...

Local Anesthetics For Eye Surgery

Anesthesia of the cornea and conjunctiva can be obtained readily by topical application of local anesthetics. However, most of the local anesthetics described earlier are too irritating for ophthalmologic use. The Figure 13-18 Structurally similar to procaine the difference is that it lacks the terminal diethylamino group. Figure 13-18 Structurally similar to procaine the difference is that it lacks the terminal diethylamino group. Figure 13-19 The most frequently used local anesthetics in...

Local Anesthetics For Skin And Mucous Membranes

Some anesthetics are either too irritating or too ineffective to be applied to the eye. However, they are useful as topical anesthetic agents on the skin, mucous membranes, or both. These preparations are effective in the symptomatic relief of anal and genital pruritus, poison ivy rashes, and numerous other acute and chronic dermatoses. They are sometimes combined with a glucocorticoid or antihistamine and are available in a number of proprietary formulations. Dibucaine (Nupercainal) is a...

Lumbar Facet Pain

Intravertebral Anesthesia

The implications of the lumbar facet joint as the primary and sole source of pain have been debated. In the lumbar region, the prevalence of facet joint pain has been determined to range between 7.7 and 75 . 13 rn m m m ra The diagnosis of zygapophyseal joint pain on clinical grounds is challenging. Historically, a patient who had a clinical presentation of low back pain and a normal neurologic examination was diagnosed with an arthropathy of a lumbar zygapophyseal joint. However, provocative...

Mechanism Of Action

Regional Anesthesia Mechanism

Glutamate and aspartate are arguably the major excitatory transmitters in the vertebrate central nervous system, whereas GABA is a major inhibitory transmitter. The cell surface receptors that mediate the effects of glutamate release can be found at most excitatory synapses throughout the central nervous system. These receptors they are divided into the slow, G-protein-coupled metabotropic receptors and the fast, ligand-gated ion channels (ionotropic receptors). The latter class is again...

Methodology Issues In Evaluating Chronic Pain

The primary problem in evaluating chronic pain is to define relevant outcome measures that can provide an estimate of success of treatment consistent with the therapeutic procedure. Caution needs to be exercised in collecting, analyzing, and interpreting outcome data because of two important conceptual concerns. First, there are no satisfactory objective indicators of pain that are universally applicable and acceptable. Second, every outcome is prone to some degree of error during design,...

P Prithvi Raj Molly Johnston

A nerve block facility where regional anesthesia and advanced interventional techniques are performed should provide a comfortable and relaxing area for patients who are scheduled for nerve blocks. Adequate space, equipment, and comfortable environment are imperative to ensure proper preparation and care of the patient undergoing such procedures. Radiologic localization is indicated when difficulty is anticipated because of poor landmarks or anatomic anomalies, when deep nerves or plexuses are...

Perineal Pain

The differential diagnosis of perineal pain associated with primary or metastatic tumor is extensive. Pain of neuropathic origin may occur from invasion of the lumbar spinal cord, spinal roots, sacral plexus, and individual peripheral nerves. Phantom rectal pain has also been described. 11861 The perineum consists of the area between the ischial tuberosities, extending from the pubis to the coccyx. The area is divided into two triangles, which are the urogenital triangle anteriorly and the anal...

Pharmacodynamics Of Central Nervous System Toxicity

In humans, blood levels of lidocaine associated with the onset of seizures appear to be in the range of 10 to 12 g mL. At these blood levels, inhibitory pathways in the brain are selectively impeded, and facilitatory neurons can function unopposed. The seizures that result appear to originate in the amygdala and hippocampus.173 With lidocaine, prodromal symptoms appear before the onset of seizures and usually include slow speech, jerky movements, tremors, and hallucinations. Although these...

Preeclampsia

Hypertension in pregnancy is one of the leading causes of maternal complications and death in many countries.12 12 112 m ta ta ism ra ra The detailed discussion on the diagnostic and therapeutic aspects of preeclampsia as well as the anesthetic considerations are provided elsewhere in the anesthesia literature.1222 1222 1222 1222 Regional anesthesia could be advantageous if its use is adapted to or avoided owing to specific risks associated with preeclampsia, such as thrombocytopenia and...

Procedures For Pain Relief

Nerve blocks are capable of providing excellent analgesia, with minimal systemic effect, in a limited area of the body. Peripheral nerve blocks are simple to perform, provide excellent analgesia, and have a good record of safety. In general, appropriate blocks exist for almost all areas of the body. Often, however, there is no single technique that is effective, and a multimodal approach is necessary. Pain Control for Patients at the Intensive Care Unit A number of procedures can prevent pain...

Quality Of Acute Pain Management In The Prevention Of Chronic Pain

As previously mentioned, there is increasing evidence that the quality of acute pain management is an important factor in the subsequent development or prevention of chronic pain after trauma. Melzack and colleagues1911 reported that patients with persistent postsurgical pain tended to be older individuals for whom lower doses of analgesics had been initially prescribed, resulting in ineffective analgesia in the early postoperative days. Pain persisted for a longer period in these individuals...

References

Kay B Caudal blockade for postoperative pain relief in children. Anaesthesia 29 610, 1974. 2. Arthur DS Postoperative thoracic epidural analgesia in children. Anaesthesia 35 1131, 1980. 3. Blaise G, Roy WL Postoperative pain relief after hypospadias repair in pediatric patients Regional vs systemic analgesics. Anesthesiology 65 84, 1986. 4. Dalens B, Tanguy A, Haberer JP Lumbar epidural anesthesia for operative and postoperative pain relief in infants and young children. Anesth Analg 65 1069,...

Renal And Perirenal Surgery

The kidney can be approached through lumbar, thoracoabdominal, or transabdominal incisions. For the lumbar approach, the patient is in the lateral position with the operative side up and the kidney elevator beneath the 12th rib. Flexion of the table causes the muscles of the loin to be taut, and elevation of the kidney bridge makes more space available between the 12th rib and the ilium when the incision is made ( Fig. 24-21 ). This position may be uncomfortable for a conscious patient but may...

Roy Greengrass Susan Steele Gene Moretti Stewart Grant Steven Klein Karen Nielsen

It is important that any patient who is to undergo a regional anesthesia procedure for surgery be adequately evaluated preoperatively for physical status and anatomic anomaly present at the site where the block is to be performed. The responsibilities of physicians and assistant nurses and the organization of a nerve block facility are described in detail in Chapter 11 . In this chapter, somatic peripheral nerve blocks such as cervical plexus blocks, blocks of the brachial plexus and its...

Side Effects Of Vasoconstrictors

Vasoconstrictors are added to local anesthetics to increase the duration of action of the block and to serve as intravascular markers. The two most common vasoconstrictors are epinephrine and phenylephrine. Epinephrine is usually added to the local anesthetic in a dosage of 5 g mL, or 1 200,000. This can be achieved by adding 0.1 mL of a 1 1000 solution of epinephrine to 20 mL of local anesthetic. Phenylephrine is typically added to local anesthetics in a 1 20,000 concentration. Dosages of...

Spinal Analgesia

Spinal analgesia refers to the use of opioids and analgesic concentrations of local anesthetics to produce pain relief by either intrathecal or epidural administration. The epidural route has been used much more extensively for postoperative pain control. Reasons include popularity of the technique along with, or in combination with, light general anesthesia during surgery willingness to leave an epidural catheter in place for extended periods to maintain analgesia familiarity with...

Superior Hypogastric Plexus

Several authors1411 11151 11161 have described techniques for neurolytic block of the superior hypogastric plexus. The structure is diffuse and in a fashion analogous to that of blocks of the celiac plexus, is best blocked with neurolytic solutions. Previously, presacral surgical neurectomy was performed for some pelvic pain states.1701 1113 Laparoscopic approaches were subsequently developed and reported to be successful in treating pelvic pain that had not responded to medical treatment.1113...

Supraclavicular Plumb Bob Technique

The patient's head is turned slightly to the contralateral side. The patient is asked to raise the head slightly off the table so that the lateral border of the clavicular head of the sternocleidomastoid muscle can be identified as it inserts onto the clavicle. This point is marked as the entry point. After skin preparation, an insulated needle is inserted at the entry site as if it were a weight (plumb bob) under gravitational pull (i.e., in a parasagittal direction) ( Fig. 2026 ). If...

Surgery On The Lower Third Of The Face

Surgery of the lower third of the face requires a block of the mandibular nerve. Mandibular nerve block can be done anywhere from the foramen ovale to the mental foramen for surgery of the mandible, lower teeth, or superficial operations of the mandibular region. This block is useful for minor reduction of mandibular fractures or extraction of teeth. Dentists prefer intraoral routes, whereas anesthesiologists commonly use the extraoral route at the coronoid notch. The first two divisions of the...

Surgery On The Middle Third Of The Face

Anesthesia of the maxillary nerve and its subdivisions is indicated for dental pain management and surgical procedures. By using techniques of local infiltration, nerve blocks, and field blocks, these areas can quite easily be anesthetized. The following blocks can be performed on the maxillary nerve and its following branches (1) supraperiosteal, (2) infraorbital, (3) nasopalatine, (4) greater palatine, and (5) posterosuperior alveolar. Anatomy. The maxillary (second) division of the...

Surgery On The Upper Third Of The Face

The trigeminal nerve is the largest of the cranial nerves. It contains both sensory and motor fibers ( Fig. 24-13 ). General somatic afferent fibers convey both exteroceptive and proprioceptive impluses ( Fig. 24-14 ). Somatic exteroceptive impulses carried by the trigeminal nerve include touch, pain, and thermal senses. These impulses are transmitted from the skin of the face and forehead, the mucous membranes of the nasal surfaces and oral cavity, the teeth, the anterior two thirds of the...

Table 184 Total Dose And Maternal And Fetal Blood Levels Of Bupivacaine

Semilateral Position

CSE block Group A (Mean s.e. mean) Epidural block Group B (Mean s.e. mean) Maternal blood concentration (rig g) From Rawal N, Schollin J, Wesstrom G Epidural versus combined spinal epidural block for cesarean section. Acta Anesthesiol Scand 32 6166,1988 *Mean total dose of 8 mg for spinal block in addition to mean total dose of 32.0 mg for epidural block. *Mean total dose of 8 mg for spinal block in addition to mean total dose of 32.0 mg for epidural block. Figure 18-13 This figure shows the...

Table 256 Epidural Versus Spinal Anesthesia For Cesarean Delivery

Higher incidence of patchy, one-sided blocks Risk of systemic local anesthetic toxicity Unintentional intravenous injection may cause systemic toxicity Dose too small to cause systemic toxicity after intravenous injection Possible with unintentional subarachnoid injection or overdose epidural injection Less likely because of small drug dose Patient preparation for regional anesthesia for cesarean delivery includes the administration of aspiration prophylaxis and an intravenous bolus of...

Table 302 Commonly Used Contrast Solutions

Prevent excessive mixing with cerebrospinal fluid, which may be removed in amounts equal to the contrast amount to be injected to prevent distention of subarachnoid spaces. prevent excessive mixing with cerebrospinal fluid, which may be removed in amounts equal to the contrast amount to be injected to prevent distention of subarachnoid spaces. Indications for Radiologic Imaging Plain films are ideal for identification of bony defects, such as fractures, osteoporosis, and tumors, and for...

Table 451 Differential Diagnosis Of Local Anesthetic Reactions

Immediate convulsion and or cardiac toxicity Injection into vertebral or carotid artery may cause convulsion after administration of small dose Onset with 5 to 10 min. of irritability, progressing to convulsions Tachycardia, hypertension, headache, apprehension Rapidly reversible with elevation of legs

The Birth of Regional Anesthesia

The decisive step in the development of regional anesthesia was taken by C. Koller (1858-1944), a young Viennese physician who had been working for some time in S. Stricker's experimental pathology laboratory, and who also devoted himself to the study of ophthalmology ( Fig. 1-5 ). Both these circumstances were of importance, because Koller became familiar with experimental methods and also had personal experience with the need for using local anesthesia when operating on the eyes. He had...

The First Spinal Anesthetic

James Corning ( Fig. 2-1 ), a New York City neurologist, heard in 1885 of the local anesthetic properties of cocaine, which had been discovered by the Viennese ophthalmologist, Carl Koller, in 1884. 3 Corning began a series of experiments to determine whether local medication of the spinal cord was within the range of practical achievement. He reasoned that cocaine might be the ideal agent to treat neurologic disease if applied in the vicinity of the venae spinales of the cord. If it were...

The Thyroid Region

This region derives its primary nerve supply from superficial branches of the cervical plexus. Injection of local anesthesia at the midpoint of the posterior margin of the sternocleidomastoid muscle provides anesthesia in this area. Infiltration subcutaneously and under the superficial fascia is necessary. Additionally, somatic nerves accompany the superior thyroid artery to the superior pole of the thyroid gland, requiring injection above the superior pole of the thyroid. In the anesthetic...

Tonsillectomy

There is always a controversy as to whether local or general anesthesia is preferable or safer for tonsillectomy. This chapter is not the place for answering that question. Only the technique of providing regional anesthesia is described here. Agren and colleagues evaluated 38 patients randomly assigned for tonsillectomy with either local or general anesthesia.1241 The parameters compared were time in the operating room, duration of the operation, perioperative hemorrhage, number of ligatures...

Trial Stimulation

When the needle enters the foramen ovale, the patient is ready for trial stimulation. In many patients, the third division is affected. The mandibular nerve has some motor fibers. If the nerve is stimulated at 2 Hz with 0.1 to 1.5 volts, the muscle contraction of the lower mandible is observed. This is also a method for verifying that the needle has passed through the foramen ovale and is in the retrogasserian rootlets. If the first and second divisions are affected, there should be no motor...

Upper Intraabdominal Procedures

Satisfactory anesthesia for upper intra-abdominal surgery requires anesthesia and relaxation of the abdominal wall, which is supplied by the 5th through the 12th intercostal nerves and blockade of the pain fibers that pass through the celiac plexus and are derived from the 5 th through the 12th thoracic sympathetic ganglia. These conditions can be fulfilled by central blockade using spinal or epidural anesthesia, or by peripheral nerve block, which is the intercostal or paravertebral block...

Intravenous Local Anesthetics

The effect of intravenously administrated local anesthetics on postoperative pain and endocrine metabolic responses is minimal.13 PERIPHERAL INFILTRATION INSTILLATION OF LOCAL ANESTHETICS IN THE WOUND Application of local anesthetics at the wound site may modify the injury response by a dual mechanism inhibition of an afferent neural stimulus and a reduction in afferent firing because of the anti-inflammatory effects of local anesthetics.13 Although instillation or infiltration of the wound...

Efficacy Of Peripheral Nerve Block

By interrupting neural input into the CNS, peripheral nerve blocks may also minimize the surgical stress response after surgery. For instance, patients receiving regional anesthesia (interscalene block) for shoulder surgery have significantly lower serum epinephrine levels in the immediate postoperative period.122 Unlike those receiving general anesthesia, patients receiving regional anesthesia (retrobulbar block) for cataract surgery do not have a significant increase in catecholamines,...

Table 463 Overview Of Immune Function

Preservation of lymphocyte and natural killer cell activity I Cell-mediated (T lymphocyte) and humoral (immunoglobulin) response Possible potentiation by stress response Cortisol and epinephrine may reduce neutrophil chemotaxis and decrease NK cell activity. 3 Also, perioperative administration of morphine diminishes NK cell and lymphocyte activity. In animal studies, morphine induces a decrease in lymphoid organ weight and inhibits ability to combat active infections. Immunosuppression is not...

Postdural Puncture Headache

PDPH is a complication of spinal or epidural anesthesia. It must be differentiated from other causes of postpartum headache. The incidence of PDPH is approximately 1 after dural puncture with a 25-G pencil-point spinal needle. The incidence of unintentional dural puncture during induction of epidural analgesia or anesthesia also is approximately 1 . Of these patients, 75 to 90 develop PDPH.1 1123 Treatment of PDPH depends on the severity of the symptoms. Mild headaches that do not interfere...

Electrophysiology Of Peripheral Nerve Stimulators

Before the middle of the 19th century, nerve fiber conduction was thought to be instantaneous. In 1850, von Helmholz,8 in a classic series of experiments with an isolated nerve muscle preparation, demonstrated the temporal nature of nerve fiber conduction and paved the way for the elucidation of most of the relevant physiology of peripheral nerve stimulation. Of particular importance is the relationship between the strength and duration of the current and the polarity of the stimulus. There is...

Table 501 Etiological Classification Of Neuropathic Pain Syndromes

Peripheral nerve injury Trauma Surgical Compression or traction injuries Nonsurgical Nerve entrapment Carpal tunnel syndrome Tarsal tunnel syndrome Cubital tunnel syndrome Radial tunnel syndrome Meralgia paresthetica (lateral femoral cutaneous nerve) Thoracic outlet syndrome Metabolic diseases Diabetic neuropathy Uremia Amyloidosis Multiple myeloma Hypothyroidism Beri-beri Fabry's disease Infectious Lyme disease Guillain-Barre syndrome Autoimmune Polyarteritis Systemic lupus erythematosus...

Sympathetic Blockade For Neuropathic Pain

(See Chapter 33 on sympathetically maintained pain.) Sympathetic nerve blocks have been widely used in the treatment of multiple forms of neuropathic pain, and their role has been reviewed extensively by Boas.- Despite its historical role in the treatment of complex regional pain syndromes (CRPS), convincing evidence is lacking to support the use of sympathetic blockade in other neuropathic pain states. For example, although evidence exists that sympathetic blocks can effectively treat acute...

Peripheral Nerve Blockade

Peripheral nerve blockade is an essential tool in the management of acute and chronic pain. It is useful in the treatment of procedure-related pain (e.g., laceration repair, fracture reduction, IV catheter insertion), traumatic pain (e.g., postoperative pain, femur fracture), and in the diagnosis and management of complex regional pain syndromes (e.g., sympathetic nerve blocks). Additionally, regional anesthetic techniques are very useful when general anesthesia or systemic analgesics cannot be...

Development Of An Acute Pain Nurse Service

It is becoming increasingly clear that simpler and less expensive models must be developed if the aim is to improve the quality of postoperative analgesia for every patient who undergoes surgery. The organization should also include patients who undergo outpatient surgery. Furthermore, in countries with state-financed health services and budgetary restraints, the overstaffed U.S.-style anesthesiology-based comprehensive, multidisciplinary, postoperative pain control teams appear unrealistic for...

Lumbosacral Plexus And Its Branches

Minimal monitoring should include continuous regulation of blood pressure, ECG, and level of consciousness. If the patient receives any sedative or narcotic medications during the block, a pulse oximeter should be used. A peripheral nerve stimulator can greatly enhance the success rate of a sciatic nerve block by helping to avoid significant patient discomfort. The extent of the block can be assessed by examining motor function, which is primarily governed by a somatic...

Table 283 Causes Of Postmastectomy Patn And Symptoms

Keep the arm in a flexed position close to the chest wall. The intercostobrachial nerve has been reportedly injured in 80 to 100 of mastectomy patients undergoing axillary dissection and has been described as the cause of the axillary and upper arm pain.73 Phantom breast pain occurs in 10 to 64 of women, with most of the phantom pain and sensations reported in the nipple. This is because the nipple is the most highly innervated breast tissue. It is supplied by the fourth intercostal nerve.173...

Anterior Approach To The Sciatic Nerve

The anterior approach to the sciatic nerve relies on the path of the sciatic nerve between the ischial tuberosity and the greater trochanter of the femur ( Fig. 21-9 ). The patient lies supine with the leg in a neutral position. After a sterile preparation and drape, two parallel lines are drawn with a perpendicular dropped between them. The first line follows the inguinal ligament from the anterosuperior iliac spine to the pubic tubercle. A perpendicular line is drawn from the intersection of...

Posterior Approach To The Sciatic Nerve

The posterior approach to the sciatic nerve identifies the sciatic nerve at the same level as the anterior approach described earlier. In this setting, the patient is placed in the lateral position, with the upper leg flexed at the hip. At the midpoint of a line drawn from the ischial tuberosity to the greater trochanter, a short bevel needle is inserted with a nerve stimulator attached (length 25 mm under 10 kg, 50 mm until 25 kg, 100 mm over 25 kg). The depth at which twitches are seen...

Lateral Approach To The Sciatic Nerve

The patient position is supine and if possible, the leg is slightly rotated externally. The point of puncture is located on the lateral aspect of the thigh, 1 to 2 cm, below the greater trochanter, depending on the patient's age. The needle is inserted perpendicular to the long axis of the limb in the horizontal plane and directed toward the position bordering the femur and the ischial tuberosity. If the needle touches bone, it is withdrawn and reinserted more dorsally under the femur. The...

Sciatic Nerve

The sciatic nerve can be blocked by a variety of approaches. The block can be done in conjunction with blocks of the femoral nerve, the obturator nerve, and the lateral femoral cutaneous nerve to provide lower extremity anesthesia or postoperative analgesia. Block failure can be a significant problem. Ecchymosis or hematoma may occur and nerve injury with persistent dysesthesia has been noted. These side effects may occur whether the block is done in the anterior, posterior, or lithotomy...

Randomized Controlled Trials

Dilke and associates193 conducted a double-blind, randomized trial on 100 patients with degenerative disc disease and unilateral sciatica with neurologic deficit. Patients received either 80 mg of methylprednisolone in 10 mL saline, or 1 mL of normal saline injected into the interspinous ligament. Patients from these comparable groups who received epidural steroids manifested improvement judged by decreased use of analgesics. A significantly larger number of patients had clear pain relief at...

Ophthalmic Nerve And Orbit Anatomy

The globe of the eye is a sphere 20 to 30 mm in diameter ( Fig. 20-8 ). The globe sits within a bony pyramid with a square base that tapers to a tight apex the orbit. The orbit ranges from 40 to 50 mm in depth in Levator palpebrae superioris m, Superior oblique m, Superior rectus m. Medial rectus rn. Optic n. Inferior rectus m. Inferior oblique rn. Maxillary sinus Figure 20-8 The extraocular muscles, which can move the eye in all directions. The extraocular muscles include four recti muscles...

Clinical Applications Of Brachial Plexus Block

Approach The Brachial Plexus

More proximal surgical procedures usually use more proximal brachial plexus approaches (e.g., interscalene block for shoulder procedures). Clinical applications of interscalene block include all shoulder surgical procedures, including arthroscopic and open procedures,1201 management of frozen shoulder,123 repair of humeral fracture,1221 elbow procedures, carotid endarterectomy, vascular shunts, chronic pain syndromes, pain of the arm and forearm, and cancer pain management. Supraclavicular, 123...

Susan R Anderson

Infusion techniques in the epidural space as well as on the peripheral nerves are now commonly used for treatment of acute and chronic pain. For acute pain, continuous regional infusion has been found to be beneficial for trauma, after surgery, and in acute medical conditions. Similarly, for chronic pain, the technique has been useful in the rehabilitation of patients with chronic back pain and in relieving pain from reflex sympathetic dystrophy, peripheral neuropathy, and cancer. Continuous...

Conclusion

Raj Infraclavicular

Compared with IV PCA, PCEA is a relatively new technique that may offer adequate analgesia with a lower opioid dosage. PCEA provides greater control and higher patient satisfaction than CI. There is also a potential decrease in dose-dependent side effects with use of PCEA. The clinical advantages of PCEA may outweigh the greater cost and invasiveness of the technique. More data need to be analyzed, however, so that the best choice among IV PCA, CI, and PCEA may be made for analgesia in patients...

Inflammatory Bowel Disease

Tanelian performed a neurolytic celiac plexus block for a 4-year-old boy with rapidly progressive, painful, cryptogenic inflammatory bowel disease.123 The child had undergone many bowel resections. His disease was deemed fatal, but the course of the illness was unpredictable. The child's pain was refractory to high-dose parenteral opioids. A neurolytic celiac plexus block performed under fluoroscopic guidance produced no analgesia. A second celiac plexus block performed under computed...

Intrathecal Phenol

The patient is placed in the lateral position, with the affected extremity downward. The patient should be rolled backward into a 45-degree oblique position. This maintains the posterior roots in the lowermost position. A spinal needle should then be placed into the intrathecal space at the vertebral interspace of the dermatome to be blocked. A volume of up to 0.5 mL of 5 to 10 phenol may be administered at a slow rate. It is recommended that a tuberculin syringe be used and that increments of...

Lower Limb Peripheral Nerve Blocks

Spinal or epidural anesthesia is usually chosen when regional anesthesia is being considered for lower limb surgery. An alternative to central neural blockade is the combined femoral and sciatic nerve block. The sciatic nerve block component is technically more difficult, and, therefore, it is not widely used. In a study of 40 patients undergoing unilateral total knee replacement, Lau and coworkers1901 (Taiwan) compared spinal anesthesia with combined femoral (3-in-1) and sciatic nerve block....

Lumbar Dorsal Root Ganglia

Dorsal Root Ganglia

If prognostic blockades of the posterior (facets) and anterior (discs) compartments have been negative and the pain is located in the lower limb, then selective radicular blocks can be considered. It is common for a patient also to report lumbar pain, and the determination must be made whether to treat mechanical lumbar pain with referred pain to the limbs, or pain caused by spinal nerve pathology. Once a referred mechanical origin of the pain has been ruled out, diagnostic blockades of spinal...

Table 461 Overview Of The Neuroendocrine Stress Response

Hypermetabolic, catabolic state Catabolic hormones Heart rate blood pressure Serum glucose Protein catabolism Possible potentiation of postoperative hypercoagulability and immunosuppression Inhibition of the stress response Complete (peripheral procedures) Partial (abdominal or thoracic procedures) Attenuation or prevention of postoperative increase in catabolic hormones after surgical insult includes a general increase in catabolic hormones, such as catecholamines, Cortisol, renin,...

Morbid Obesity

Obesity accentuates many of the physiologic and anatomic changes of pregnancy. For example, there is less pulmonary reserve because functional residual capacity is smaller and oxygen consumption is higher than in the nonobese parturient. Similarly, cardiac output and blood volume are increased in obese individuals. There is a higher incidence of comorbidity (e.g., hypertension and diabetes mellitus), and a higher incidence of difficult airway. Obese parturients are more at risk for...

Denervation Of Cervical Facets C26

Although chronic spinal pain often has a complex mechanical or radicular etiology, sympathetic involvement may dominate the pain condition, producing individual clinical profiles in which more than one structure is involved in the pain syndrome. The treatment of cervical pain syndromes poses challenges for the clinician. Effective alleviation of pain, although a difficult task, is achieved in over 80 of cases, in experienced hands. During the last decade, much work has led to new approaches for...

Peripheral Nerve Blocks

In a nonrandomized prospective study of regional anesthetic blocks reported by Arner and associates,112 38 consecutive patients with neuralgias were treated with various local anesthetic peripheral nerve blocks. Etiologies included entrapment syndromes as well as surgical and traumatic nerve damage, and all patients had demonstrable sensory dysfunction. The peripheral nerves blocked included ilioinguinal, iliohypogastric, saphenous, superficial peroneal, intercostal, suprascapular, and lateral...

Denervation Of Lumbar Facets

The dorsal spine compartment is innervated by the medial and lateral branches of the dorsal ramus. The articular facets are innervated by the medial branch of the dorsal ramus of the superior segment and one or more segmental levels. The multisegmental organization of spinal innervation has an effect on spinal pain therapy because, in the absence of a technique for selectively producing a lesion of the sinuvertebral nerve in the treatment of dorsal compartment or articular facet syndromes, the...

Blockade Of The Obturator Nerve

The obturator nerve has both motor and sensory components. The anterior division provides sensory innervation to the medial aspect of the distal thigh. The posterior division provides sensation to the medial aspect of the distal thigh as well as to the hip and knee joints. The obturator nerve also provides motor innervation to the thigh adductors. Clinical applications of obturator block include use as an adjunct with lateral femoral cutaneous, femoral, and sciatic nerve blocks for surgical...

Procedure

The nurse will phone each outpatient the day after his or her surgery or procedure. If unable to contact the patient on the first day postsurgery postprocedure, the nurse will phone the second day postsurgery postprocedure. Patients who have Friday surgery dates will be contacted the following Monday. B. The nurse will chart a postprocedure phone call note based on the information received and any instructions given to the patient, including any referrals made on the patient's chart. C....