Info

From Auroy Y, Narchi P, Messiah A, et al. Serious complications related to regional anesthesia. Results of a prospective survey in France. Anesthesiology 87 479486,1997. Reproduced with permission. * Number of cases, (rate per 10,000) and (95 confidence interval). ' P < 0.05 epidural vs. spinal anesthesia. * Number of cases, (rate per 10,000) and (95 confidence interval). ' P < 0.05 epidural vs. spinal anesthesia. Pleym and Spigset concluded that the causal relationship between the...

Lower Extremity Blocks

Peripheral nerve blocks are employed to provide analgesia in patients with lower extremity trauma. Blockade of the femoral nerve is performed to provide pain relief and abolish muscle spasm in patients with fracture of the shaft of the femur. A lumbar plexus block or a combination of femoral, lateral femoral cutaneous, and obturator nerve blocks can be useful for surgery on the proximal femur and the femoral neck. A combined lumbar plexus block and sciatic nerve block provide anesthesia for...

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....

The Endogenous Opioid System

Opioid receptors are classified as 5, and k receptors ( Table 14-2 ). The classification of the effect of opioid agonists and antagonists on opioid receptors is shown in Table 14-3 . These opioid receptors belong to a superfamily of guanine (G) protein-coupled receptors that constitute 80 of all known receptors, including muscarinic, adrenergic, y-aminobutyric acid, and somatostatin receptors. or morphine-preferring receptors are principally responsible for supraspinal and spinal analgesia....

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...

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...

An American Twist

Although Europe was the birthplace of spinal anesthesia, two pioneering surgeons, F. Dudley Tait and Guido E. Caglieri, administered the first spinal anesthetic in America on October 26, 1899. Tait and Caglieri studied 7 cadavers, 11 patients, and an unknown number of cats, dogs, rabbits, guinea pigs, and horses in their efforts to further understand how lumbar puncture could benefit patients. Although they never clearly stated their reasoning, Tait and Caglieri were apparently trying to...

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...

Buttock And Low Back Pain

It is more difficult to treat pain that is axial (i.e., pain perceived in the middle to lower back) and buttock pain.'82 82 m aa dm m Dual-lead stimulation, again with either two catheter-type electrodes or one plate-type electrode with columns of contacts, can be effective. The rationale is that stimulation applied by both columns at the same time can provide denser and deeper stimulation to the axial fibers that are deep within the posterior midline aspect of the spinal cord. Some adjustment...

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

After absorption, local anesthetics may cause stimulation of the CNS, producing restlessness and tremor that may proceed to clonic convulsions. In general, the more potent the anesthetic, the more readily convulsions may be produced. Alterations of CNS activity are thus predictable from the local anesthetic agent in question and the blood concentration achieved. Central stimulation is followed by depression death is usually caused by respiratory failure. The apparent stimulation and subsequent...

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...

Radiographic Imaging in Regional Anesthesia

Radiographic Image Adequacy

Use of radiography in regional anesthesia and pain management has grown more important as the field has developed. Radiographic diagnostic tests such as plain films, computed tomography (CT), magnetic resonance imaging (MRI), and bone scans are frequently obtained to find simple fractures or degenerative joints, disc bulges, herniations, and spinal cord or nerve impingement. During the performance of many procedures, fluoroscopy or CT is used to place the nerve blocks with precision. Because of...

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...

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...

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...

Development Of Other Local Anesthetics

It was only natural that discoveries in organic chemistry, both analytic and synthetic, should have led to efforts to find preparations with good anesthetic properties and without the drawbacks of cocaine. Besides its highly acute toxicity and the risk of addiction (which came to play a greater role as time went by), cocaine is easily decomposed when the solution is sterilized. It is also expensive. As emphasized by Willstatter, the vegetable bases, such as cocaine, are often so complex that...

Eudynia And Maldynia

To discuss the topic of chronic pain (maldynia), one must understand acute pain (eudynia). The International Association for the Study of Pain (IASP) defines acute pain as an unpleasant sensory and emotional experience associated with actual and potential tissue damage and also describes pain in terms of tissue damage.12 The latter type of pain has biologic usefulness in that the experience locates body areas that are being attacked by external or internal noxious inputs, while activating fight...

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 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...

Hemodynamic Changes And Prevention Of Arterial Hypotension

The cardiovascular system undergoes a complex set of changes throughout pregnancy to provide ideal conditions for fetal growth, labor, and delivery, and to cope with maternal postpartum adaptation. Tndividual cardiovascular characteristics may range widely, and the adaptation should not be seen as uniform or (quantitatively, qualitatively, or chronologically) sufficient. Healthy and less healthy parturients are exposed to different degrees and qualities of cardiovascular adaptation, to 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...

Intraperitoneal Local Anesthetics

Eds And Local Anesthesia

In keeping with the idea that pain should be treated at the peripheral site, efforts have been made to elucidate the effect of intraperitoneal local anesthetics, but the results have been fairly negative with regard to both pain relief and modification of the surgical stress response.13 Figure 23-2 Neural blockade techniques that may influence the response to surgical injury. (From Kehlet H Endocrine-metabolic effects. In Raj PP ed Clinical Practice of Regional Anesthesia. New York, Churchill...

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...

L2 Communicating Ramus

Anterior Rami T11

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...

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...

Lumbar Plexus And Branches

Innervation of the skin, muscles, periosteum, and joints of the hip, thigh, and knee make the blockade of the lumbar plexus particularly useful in pediatric patients. Analgesia for lower extremity procedures in children frequently involves areas innervated by branches of the lumbar plexus. Procedures involving joint or bone realignment, especially with insertion of hardware, are common, particularly in a disabled child whose ability to sit upright in a wheelchair or to manage transfers from...

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,...

Ophthalmic Surgery

The majority of patients who need ophthalmic surgery are frequently at the extremes of age. Aged patients often suffer from multiple systemic diseases. In fact, the eye problem may be a reflection of ongoing systemic disease with multiple end-organ involvement. For example, if diabetic patients need surgery for diabetically caused advanced retinopathy, they may have coronary artery disease, peripheral vascular disease, cardiovascular disease, kidney disease, peripheral neuropathy, or autonomic...

P Prithvi Raj Molly Johnston

Room Requirement For Nerve Block

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...

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...

Postoperative Pathophysiology

Postoperatively, patients may exhibit alterations in several aspects of general mental status, such as cognitive function, and they may experience confusion, delirium, or dementia. Although mental function generally reaches a nadir between the second and fifth postoperative days, with recovery to preoperative levels by 1 week after surgery, delays in recovery of mental function are associated with poor patient outcomes.12 Along with physical parameters, cognitive functional measures are strong...

Preanesthesia Evaluation

Preoperative evaluation of the patient is extremely important because many ophthalmic patients are elderly and in poor health. They may have advanced coronary artery disease, hypertension, peripheral vascular disease, diabetes, renal insufficiency, arthritis, or chronic obstructive lung disease, and they may be receiving multiple medications. Many anesthesiologists are reluctant to administer general anesthetics to ophthalmic patients who are in poor general health, which may encourage the use...

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...

Preoperative Visit And Evaluation

The majority of patients who undergo vascular surgery have organ function changes secondary to aging and are on numerous medications. During the preoperative visit, specific answers should be obtained from the patient regarding events such as a history of transient ischemic attacks, myocardial infarction, congestive heart failure, renal failure, or angina. A brief examination may reveal an absent or diminished carotid or radial pulse. Absent or widely different pulse volumes and blood pressures...

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...

Pudendal Nerve Block

A pudendal nerve block is indicated for perineal surgery, such as obstetric vaginal procedures (vaginal delivery, forceps delivery) and for hemorrhoidectomy. To Cutaneous Branches of the Superficial Peroneal Nerve Great Saphenous Vtein -Mad. Malleolus- Figure 20-56 Transverse section through the ankle showing the needle placement for blocking the superficial and deep peroneal, saphenous, sural, and posterior tibial nerves. (From Raj PP Clinical Practice of Regional Anesthesia. New York,...

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...

Saphenous Nerve Block At The Knee

The saphenous nerve descends through the femoral canal to accompany the femoral artery into the adductor canal. It then becomes superficial by passing between the sartorius and gracilis muscles and passes anteroinferiorly to supply the skin and fascia of the anteromedial aspects of the knee, leg, and foot. The saphenous nerve is the only branch of the lumbar plexus (femoral nerve) below the knee. Thus, a saphenous nerve block at the knee combined with a sciatic block can be used for leg and...

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...

Spinal Anesthesia And Sedation

Benzodiazepines are commonly used for sedation and anxiolysis during regional anesthesia. Ketamine is widely used in many developing countries, either as a sole anesthetic agent or to provide additional analgesia for procedures done under local anesthesia. Tripathi and Saxena (India) compared the effects of a combination of diazepam and ketamine with diazepam and placebo in providing comfort to patients undergoing spinal anesthesia. One hundred patients were randomly divided into two groups....

Splanchnic Nerve And Celiac Plexus Neurolysis

Kappis originally described retroaortic and retrocrural placement of local anesthetic agents adjacent to the bodies of T12 to L2. This technique has been modified for neurolytic and RF procedures so that curved blunt needles or cannulae are introduced closer to the midline and follow a vertebra-hugging approach to the middle third of the vertebral bodies of T11 and T12. The anatomy is variable, and the wider spread of neurolytic agents may, theoretically, produce a more profound neurolysis....

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

Extraoral Infraorbital Block

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...

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 Lumbar Ganglia

The bilateral ganglionated chains run ventrolateral to the lumbar vertebrae, just anterior to the attachment of the iliopsoas fascia to the lumbar vertebrae. In fact, they lie in a groove between these two structures. The ganglia are quite variable in position and number and have been the focus of much study 139 113 because it is thought that for effective neurolysis the actual ganglia rather than the chain must be destroyed. Under the direct vision of an open or endoscopic approach, this might...

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...

Tibial Nerve Block

The tibial nerve lies under the flexor retinaculum at the midpoint between the medial malleolus and calcaneus. Figure 20-53 Saphenous nerve block at the knee. The needle is placed at the level of the patella on the medial condyle of the femur between the tendons of the sartorius muscle and the gracilis muscle. (From Raj PP Clinical Practice of Regional Anesthesia. New York, Churchill Livingstone, 1991, p 321.) Figure 20-53 Saphenous nerve block at the knee. The needle is placed at the level of...

Topical Anesthesia

Anesthesia of mucous membranes of the nose, mouth, throat, tracheobronchial tree, esophagus, and genitourinary tract can be produced by direct application of aqueous solutions of salts of many local anesthetics or by suspension of the poorly soluble local anesthetics. Tetracaine (2 ), lidocaine (2 -10 ), and cocaine (1 -4 ) are most often used. Cocaine is used only in the nose, nasopharynx, mouth, throat, and ear. Cocaine has the unique advantage of producing vasoconstriction as well as...

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...

Psoas Lumbar Plexus Block

The lumbar plexus was previously described as being between the quadratus lumborum and psoas major muscles. Current information, however, suggests that the lumbar plexus lies within the substance of the psoas major itself.173 This has been confirmed by a combined cadaver and computed tomography study.183 Cadaveric dissections have determined that the femoral nerve lies between the lateral femoral cutaneous and obturator nerves. Although the lateral femoral cutaneous nerve is in the same fascial...

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...

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...

Central Nervous System Monitoring

Conscious state monitoring is necessary to detect the impact of drugs, metabolic response, and or cardiovascular and respiratory changes. Propofol is frequently used to sedate patients, but methohexital, barbiturates, and other drugs, especially benzodiazepines, are also used. Sometimes fentanyl or remifentanil in variable doses is administered as a rescue analgesic during the operation, because often it is not possible to continue with regional anesthesia. Thus, the regional anesthetic...

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...