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...

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...

Superior Hypogastric Plexus

Pelvic pain states can be modified by neurolysis of the superior hypogastric plexus.143 Afferent nociceptive fibers originate in various pelvic viscera form a midline plexus in the retroperitoneum, extending from the lower third of the fifth lumbar vertebral body to the upper third of the first sacral vertebral body. These afferent fibers then pass centrally via the sympathetic nerves, trunks, ganglia, and rami. Previously, surgical presacral neurectomy was performed for some pelvic pain...

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...

Superior Hypogastric Plexus Block

Superior hypogastric plexus blockade was first described in 1990 as a treatment for cancer-related pelvic pain.173 This nerve block was performed using a fluoroscopically guided posterior approach, very similar to the posterior approach to the blockade of the celiac plexus or lumbar sympathetic trunk. Because the iliac crests of the pelvic bone can be an anatomic barrier to proper needle placement, computed tomography (CT) has been used to guide superior hypogastric plexus blocks.173 123 153...

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...

Aids To Block Performance

In patients with difficult anatomy (e.g., morbidly obese), in whom the interscalene groove is difficult to palpate, the interscalene groove may be located by drawing lines laterally from the cricoid and along the lateral border of the clavicular head of the sternocleidomastoid muscle as described. Where these lines intersect, a mark should be made 2 cm laterally along the line from the cricoid. The insulated needle should be inserted at this mark perpendicular to skin planes, and slightly...

Aids To Nerve Location By Radiologic Imaging

Lanz and Theiss056 reported that the brachial plexus block near the first rib at the level of the trunks and divisions provided the most reliable efficacy. Despite this advantage, the use of the approach near the first rib is limited because of the risk of pneumothorax.053 0581 0591 Eliciting paresthesias is also important to obtain a high degree of success.13 1621 However, paresthesias are uncomfortable for patients and may result in nerve injury.0631 0641 0651 0661 063 To perform the brachial...

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...

Anesthesia

CHAN To achieve consistently successful outcomes with regional anesthesia, practitioners must have adequate knowledge and experience. Increasing pressure on both trainers and trainees, combined with the complexity of modern general anesthetic agents, has caused anesthetic trainees to become less familiar and thus less confident in the practice of many regional anesthetic techniques. Often, it is easier to give a general anesthetic, especially when faced with...

Ankle Block

The ankle block is useful for surgical procedures of the foot. However, for procedures requiring high tourniquet pressures, more proximal techniques should be considered. There are five nerves that innervate the foot. The number of nerves blocked for any particular procedure depends on the site of the surgery and whether or not a tourniquet will be used. Four of the nerves are branches of the sciatic nerve the fifth, the saphenous nerve, is the terminal branch of the femoral nerve ( Figs. 20-55...

Aseptic Meningitis

Few reports have documented aseptic meningitis after subarachnoid steroid injections.123 1123 Even fewer have been reported after epidural steroid injections.1143 The syndrome is characterized by fever, nausea, headaches, and neurologic signs, including burning pain in the lower extremities, convulsions, and confusion after spinal steroid injections. CSF studies may reveal pleocytosis, roughly proportional to the steroid dose given,1123 elevated protein, and low glucose. Cultures are negative...

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...

Behavioral Medicine

Incorporation of cognitive behavior therapy in the medical care of chronic low back pain patients in a controlled, randomized study caused patients to experience less pain, better control, more pleasure, less avoidance, and less disability. Relaxation and imagery were primary components of therapy.1 Although some contend that cognitive behavior programs help regardless of whether the patients are treated individually or as a group, others claim that inpatient or full-time intensive treatments...

Bladder Surgery

Cystoscopic procedures done for diagnosis or surgical manipulation are relatively minor procedures and may even be performed on an outpatient basis. Spinal, lumbar epidural, caudal, or transsacral block provide entirely satisfactory analgesia. Urethral instrumentation, especially in females, can be performed with topical anesthesia with 2 lidocaine jelly without much discomfort to the patient. Conduction anesthesia to achieve a level of T9 is equally satisfactory, and the choice of drug depends...

Blood Supply Of Nerve Roots And Dorsal Root Ganglia

In the cervical spinal cord, the anterior and posterior radicular arteries supply the nerve roots. These radicular arteries are classified further as either proximal or distal. The proximal radicular artery is a branch from the anterior or posterior spinal artery, while the distal radicular artery is a direct branch of the vertebral artery and enters the dural root pouch on the anterior surface of its respective root.19 115 A ganglionic artery supplies the cervical DRG, which is often a direct...

Brachial Plexus And Branches

Fractures of the upper extremity, especially at the elbow and wrist, are common injuries during the summer months when children are outside playing on jungle gyms and riding skateboards. These patients are often brought for treatment in the late afternoon or early evening, having eaten just before the traumatic event. Surgery focuses on reduction and realignment procedures with hardware insertion and casting. Use of a sedative may complicate the anesthetic considerations of a full stomach. In...

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...

Caudal Block

Caudal Anesthesia Landmarks

This is the most useful pediatric block, because it is widely applicable and technically simple. Indeed, caudal anesthesia is very easy to administer to a child rather than an adult in whom the caudal block is often difficult and occasionally impossible. The caudal block can provide analgesia for surgery up to and including the umbilicus. This technique can be used successfully in neonatal rectal surgery.123 The anesthetic agent is injected through the sacral hiatus, which is formed by failure...

Cckb

CCK-B, cholecystokinin-B NMDA, N-methyl-D-aspartate. clinical use of opioids in the epidural or subarachnoid space in order to ameliorate acute and chronic pain. Analgesia that is seen after epidural or spinal administration of opioids, in contrast to regional anesthesia with local anesthetics, is not associated with sympathetic nervous system denervation, is dose related, and is specific for visceral rather than somatic pain. The main objective in using spinal opioids is to obtain a reduction...

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...

Central Neuraxial Techniques For Cesarean Delivery

The literature suggests that spinal, epidural, or combined spinal-epidural techniques can be used effectively for cesarean delivery. When compared to regional techniques, the literature indicates that general anesthetics can be administered with shorter induction-to-delivery times.1341 The ASA Task Force concluded that the literature is insufficient to examine the comparative merits of various regional anesthetic techniques, but fewer complications and improved maternal satisfaction result from...

Cervical Dorsal Root Ganglion

The accepted mechanism for producing analgesia by means of an RF-induced lesion is the destruction of nervous tissue and, consequently, the reduction of the nociceptive input. The RF lesion induced adjacent to the dorsal root ganglion (DRG), however, causes only transitory sensory loss, whereas the relief of pain may be of much longer duration. The pain relief could be explained by the selective action of heat on unmyelinated C fibers, but such a selective effect has not been confirmed by...

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...

Cervical Nerves Anatomy

Skin of a great proportion of the dorsal scalp, the neck, and the shoulders is supplied by sensory branches of the upper four cervical nerves ( Fig. 20-13 ). The dorsal rami of C2 to C4 supply the back of the neck and the scalp as the greater occipital nerve. The ventral rami of C1 to C4 form the cervical plexus. The deep branches supply the muscles of the neck and the diaphragm. The superficial cervical plexus pierces the posterior border of the sternocleidomastoid at its midpoint to fan out...

Cervical Spine

In the cervical spine, the posterior compartment, comprised of facet joints and intrinsic back muscles (semispinalis capitis, semispinalis cervicis, multifidus, and interspinalis), is innervated by the cervical posterior rami. The spinal nerve divides into anterior and posterior rami as it exits the foramen. After a short trajectoryof 2 to 5 mm, the posterior ramus divides into a medial and a lateral branch. In the cervical region, these branches are separated by the semispinalis capitis...

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....

Radiographic Imaging in Regional Anesthesia

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...

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...

Characteristics Of Diverse Radiofrequency Lesions

Facet denervation consists of producing an RF lesion of the medial branch of the posterior primary branch that innervates the zygapophyseal articulation. Although incorrectly called rhizolysis, because the root is not damaged, the term survives. The aim of the procedure is to interrupt completely the medial branch because the danger of causing sequelae by deafferentiation does not exist when a small area is innervated. The lesion is produced at 80 C for 60 seconds, when a temperature monitoring...

Chloroprocaine

2-Chloroprocaine (Nesacaine), an ester local anesthetic introduced in 1952, is a chlorinated derivative of procaine (see Fig. 13-12 ). Its major assets are its rapid onset and short duration of action and its reduced acute toxicity due to its rapid metabolism (plasma half-life approximately 25 s). Enthusiasm for its use has been tempered by reports of prolonged sensory and motor block after epidural or subarachnoid administration of large doses. Figure 13-12 Local anesthetic chemical structures...

Choice Of Anesthesia

In some centers, regional anesthesia is the prime choice for patients undergoing vascular surgery. This is because the sympathetic tone of the blood vessels is blocked by regional anesthesia, which maintains good perfusion at the site of operation as well as in distal tissues. Surgical procedures that can be performed with regional anesthesia alone are carotid endarterectomy, vascular surgery of the upper extremities (e.g., arterial surgery, Gore-Tex graft), aortogram, aortoiliac bypass graft,...

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...

Christopher J Jankowski

Complications from neuraxial anesthesia have been recognized since August Bier reported the first spinal anesthetic over 100 years ago.12 Fortunately, serious complications of neuraxial anesthesia remain rare but can be devastating when they occur. As morbidity and mortality from anesthesia and surgery continue to decline, the relative importance of these problems increases. Safe, effective practice of neuraxial anesthesia requires a detailed knowledge of the potential complications, their...

Christopher L Wu

Over the past two decades, a growing body of knowledge has accumulated from investigation of the effect of regional anesthesia and postoperative analgesia on patient outcomes. Use of regional anesthesia and analgesia results in many beneficial physiologic effects and is strongly associated with favorable outcomes in several organ systems (i.e., gastrointestinal and coagulation) however, the efficacy of regional anesthesia may not be as apparent in other areas, such as postoperative cognitive...

Christopher L Wu Md

Associate Professor of Anesthesiology, Critical Care Medicine, The Johns Hopkins University School of Medicine Director, The Johns Hopkins University Hospital, Efficacy of Neuraxial and Peripheral Nerve Blocks in Acute Pain Management MYRON YASTER MD Professor of Anesthesiology, Critical Care Medicine, and Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland Pediatric Pain Management

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...

Coagulopathy

Neuraxial anesthesia is contraindicated in the presence of a coagulopathy. Spinal hematoma may result in permanent neurologic damage if not diagnosed and decompressed within 6 to 12 hours after onset of symptoms.1323 Unfortunately, it is often difficult to assess whether patients with abnormal laboratory coagulation parameters have a clinical coagulopathy. In general, an international normalized ratio greater than 1.41113 or a prolonged aPTT are considered contraindications to neuraxial...

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...

Combination Of Opioid With Local Anesthetic

In an effort to combine the desirable analgesic properties of local anesthetics with those of epidural opioids, several investigators studied the concomitant use of morphine-bupivacaine epidural infusions for pain relief. 123 123 Studies have demonstrated either additive or synergistic analgesic activity between a variety of opioids and dilute concentrations of bupivacaine.123 123 1291 Such combinations appear to provide pain relief of greater magnitude than that attained with either an opioid...

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 Epidural Analgesia

Continuous or intermittent epidural analgesia using local anesthetics administered either alone or in combination with opioids blocks nociceptive impulses from entering the central nervous system and thereby provides profound analgesia without producing systemic sedation or hemodynamic changes (hypotension). Epidural analgesia has become the most commonly performed regional anesthetic technique for the intra- and postoperative management of children undergoing urologic, orthopedic, and general...

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...

Contraindications

Circumstances that make spinal anesthesia inadvisable include conditions that may potentiate bleeding into Figure 18-11 A, Anterior view with dermatomal distribution of the body wall. B, Posterior view with dermatomal distribution of the body wall. Figure 18-11 A, Anterior view with dermatomal distribution of the body wall. B, Posterior view with dermatomal distribution of the body wall. the central nervous system (blood dyscrasia, coagulopathies), which may cause infection of the meninges of...

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...

Definition Of Terms

The following terms are defined briefly in this section a more complete description of the characteristics of each type of facility appears in subsequent portions of this chapter. 1. Pain Treatment Facility. This generic term is used to describe all forms of pain treatment facilities without regard to personnel involved or types of patients served. Pain unit is a synonym for pain treatment facility. 2. Multidisciplinary Pain Center. This organization of healthcare professionals and basic...

Desirable Characteristics Of A Pain Clinic

A pain clinic should have access to and regular interaction with at least three types of medical specialties or healthcare providers. If one of the physicians is not a psychiatrist, a clinical psychologist is essential. 2. The healthcare providers should communicate with each other on a regular basis both about individual patients and about programs offered in the pain treatment facility. 3. There should be a director or coordinator of the pain clinic. If he or she is not a physician, there...

Desirable Characteristics Of Peripheral Nerve Stimulators

Many specialized PNSs are now commercially available, and most contain complex and sophisticated electronics that are far from the primitive machines of the early pioneers. The desirable features of PNSs have been elucidated by Galindo and by Ford and colleagues. 113 Table 17-7 lists the features PNSs should include for optimum efficiency. 1. The device should have a constant level of current output. This implies that the stimulator should have a high internal resistance. Because it is a...

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...

Development of Regional Anesthesia

The idea that drugs might diminish local pain not only by their action on the central nervous system but also by their direct effect on the nerve endings or on the nerves themselves was put to trial after syringes for injection were made available in the middle of the 19th century. Thus, ethyl alcohol, in relatively high concentrations (> 50 ), was used to treat patients with neuritis. The injection of alcohol into the affected nerve killed it, resulting in alleviation of the patient's pain....

Development of the Technique of Regional Anesthesia

In 1908, August Bier devised a very effective method of bringing about complete anesthesia and motor paralysis of a limb. He injected a solution of procaine into one of the subcutaneous veins that was exposed between two constricting bands in a space that had previously been rendered bloodless by an elastic rubber bandage extending from fingers or toes. The injected solution permeated the entire section of the limb very quickly, producing what Bier called d rect ve n anesthes a in 5 to l5...

Digital Nerve Block

This block is used for surgical procedures on the fingers. The digital nerves run at the dorsal lateral borders of the proximal phalanges. Digital vessels run with the digital nerves on the ventral and lateral aspects of the fingers. The common digital nerves divide the palmar and dorsal branches. Palmar digital nerves are branches of the medial nerve. Dorsal digital nerves are branches from the radial nerve and supply the back of the fingers. The patient's hand and affected finger should be...

Discussion

The limitation of this survey is that it reflects only the practice of regional anesthesia in the institutions that responded. The sample size was small, mainly because of the difficulty in obtaining the names and addresses of hospitals in different countries. There is no Asian directory or list of hospitals available that one could choose from. The Asia Oceanic Society of Regional Anesthesia mailing list was chosen because it was the most up-to-date list available, but many of the members had...

Distribution And Clearance

Fentanyl is highly lipid soluble and is rapidly distributed to tissues that are well perfused, such as the brain and the heart. Normally, the effect of a single dose of fentanyl is terminated by rapid redistribution rather than by elimination, in a manner very much akin to the effect of thiopental. However, prolongation of effect occurs after multiple or large doses of fentanyl (e.g., when it is used as a primary anesthetic agent) because elimination and not distribution determines the duration...

Effects Of Regional Anesthesia Techniques On The Neonate

General versus Regional Anesthesia and Neonatal Outcome The comparisons of regional versus general anesthesia for cesarean delivery are typically focused on the fetal status and neonatal outcome data, such as acid-base values, Apgar score, and ventilatory pattern, which may or may not represent the outcome. The studies in the 1970s and 1980s reported, variably, some or no differences in the neonatal status regarding the type of anesthesia given. In a 1975 to 1983 retrospective analysis, Ong and...

Efficacy Of Neuraxial Block

Although perioperative stress may result in many undesirable physiologic effects, the relationship between the stress response per se and the postoperative outcome is unclear, despite some evidence that diminishing stress improves patient outcomes.143 Neuraxial block, especially with local anesthetics, suppresses the stress response and may result in prevention of detrimental physiologic parameters, such as increases in blood pressure, heart rate, and oxygen consumption, which may lead to...

Efforts to Produce Analgesia Before the Discovery of Regional Anesthesia

Primitive man, seeing in illness and pain the work of evil spirits that had taken possession of the body, tried to get rid of such invaders by methods based on effects on the patient's imagination. Incantations, charms, amulets, special ceremonies, and faith in the power of medicine men and sorcerers made more or less deep impressions on the subject. In many cases, these methods probably contributed to the alleviation, or even abolition, of pain. A kind of local anesthesia was, therefore, able...

Epidural Block

Epidural block is an effective technique for intra- and postoperative pain relief. However, general anesthesia is almost always required if the epidural and surgical procedures are to be performed under satisfactory conditions. The greatest advantage of epidural block is the long-term analgesia after major surgery of the chest and abdomen and some orthopedic procedures.111 13 13 In these cases, a combination of light general anesthesia with endotracheal intubation and epidural anesthesia is...

Epidural Blood Patches

Few of the many treatments that have been suggested for PDPH are clearly beneficial. 35 Epidural blood patches have a long history of efficacy in treating PDPH. However, the mechanism by which they provide relief is unclear. Blood injected into the epidural space may act as a plug by sealing the dural defect as it clots. Alternatively, increased pressure from the blood within the epidural space may stop the CSF leak. Neither of these theories explains the nearly immediate relief that many...

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...

Femoral Nerve

Femoral nerve blocks are easily performed and can provide significant postoperative analgesia for femoral shaft fractures or other anterior thigh procedures. When combined with a sciatic nerve block, an obturator nerve block, and a lateral femoral cutaneous nerve block, lower extremity anesthesia can be obtained. Because of the proximity of the femoral nerve to the femoral artery, intravascular injection or hematoma formation may occur. Direct injury to the femoral nerve can result from...

Frequency And Voltagedependence Of Local Anesthetic Action

The degree of block produced by a given concentration of local anesthetic depends on how the nerve has been stimulated and on its resting membrane potential. Thus, a resting nerve is much less sensitive to a local anesthetic than one that is repetitively stimulated higher frequency of stimulation and more positive membrane potential cause a greater degree of anesthetic block. These frequency- and voltage-dependent effects of local anesthetics occur because the local anesthetic molecule in its...

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,...

General Considerations

The local anesthetic drug and dosage must be selected on the basis of expected duration of surgery and degree of motor blockade required. Superficial procedures such as removal of a subcutaneous tumor or repair of an uncomplicated inguinal hernia do not require intense, prolonged motor blockade, whereas the more extensive and lengthy procedures involving the deep muscle layers of the abdominal wall and the intra-abdominal structures must be accompanied by muscle relaxation. Information...

General Technical Considerations

Spinal Cord Transection Succinylcholine

As with any anesthetic, appropriate equipment must be at hand (and checked) to treat a patient with any potential complication. This means that an oxygen source and appropriately sized airway equipment (bag, mask, laryngoscope, endotracheal tube, laryngeal mask airway, and oral airway) must be readied in advance. Drugs to rapidly induce general anesthesia and paralysis (thiopental and succinylcholine) are required, as is a functioning source of suction. Before the administration of the regional...

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...

Hemmo A Bosscher Melvin G Gitlin Alan D Kaye

Chronic back pain, radiculopathy, and associated disabilities represent a significant health problem. Back pain is considered a major cause of absence from work and of long-term disability. The vast majority of patients suffering acute back pain recover spontaneously in several weeks. However, a significant fraction of these have recurrence of symptoms within a year. Many patients who have a relapse or whose back pain does not subside in time, and for whom surgery is not indicated, are...

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

Knapp (1884) 2 first used cocaine for retrobulbar block, but the technique failed to gain popularity until the 1930s, after the discovery of procaine.12 Atkinson2 described a cone injection technique, which became standard teaching ( Fig. 20-14 ). In the Atkinson method, the patient directs the gaze upward and inward however, this technique results in many complications,12 including damage to the optic nerve. To avoid contact with the orbital nerve, the needle should not pass more than 31 mm...

Honorio T Benzon Adrienne E Knight

Trauma is tissue damage caused by an extrinsic force.13 The stress response to trauma and the accompanying pain activate neurohumoral and physiologic processes ( Table 26-1 ). These responses result in hyperglycemia, lipolysis, protein catabolism, increased catecholamine and antidiuretic hormone levels, a hypercoagulable state, and immunosuppression. hj Trauma has direct and reflex-related effects on the cardiovascular, pulmonary, gastrointestinal, renal, musculoskeletal, and immunologic...

In Vitro Studies Of Cerebrospinal Fluid Loss Through Dural Lesions Produced By Different Needles

A number of authors, including Cruickshank and associates,173 Ready and colleagues,173 Janes and coworkers,173 Westbrook and colleagues, 1751 Morrison,183 and Holst and associates,153 have conducted in vitro studies of CSF loss through dural lesions produced by different needles. The aim of such research has been to indirectly determine the size of the dural lesions produced by different needles. The results measure the volumes of real or artificial CSF that escape through the dural lesions...

Inferior Dental And Lingual Nerve Blocks

The foramen is located in the center of the medial aspect of the ascending ramus of the mandible. The foramen is found by rolling the index finger over the concavity of the retromolar trigone. With the barrel of the syringe resting on the contralateral premolars, the needle is directed to a point just beyond the midpoint of the palpating finger. While anesthetic is injected, the needle is directed medially and more posteriorly for a distance of 1 to 2 cm. A column of 2 mL blocks both nerves.

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...

Intercostal Nerve

Pneumothorax is the complication usually associated with intercostal nerve blocks. The incidence of pneumothorax after intercostal nerve blocks is less than 1 . Cough or chest pain produced during intercostal block may indicate formation of a pneumothorax. Administration of oxygen followed by needle aspiration of the pneumothorax or chest tube placement may need to be done, depending on the size of the pneumothorax. Because of the proximity of the intercostal artery and vein to the nerve, rapid...

Intercostal Nerves

The intercostal nerve technique is indicated for surgery of the upper abdominal region in conjunction with celiac plexus block, for postoperative pain in thoracoabdominal surgery, and for trauma in the chest wall especially for fracture of the ribs and for neurolytic blocks. The spinal nerve in the paravertebral region divides into a dorsal branch, innervating the muscle and skin of the back, and ventral branch that forms intercostal nerves for the 11 intercostal spaces and the subcostal nerve...

Interpleural Block

Interpleural administration of local anesthetic for the control of pain was described initially by Reiestad in 1984 and has been the subject of several investigations in the past several years. Indications for the technique have expanded and include postoperative pain relief after thoracic and upper abdominal surgical procedures including cholecystectomy, nephrectomy, unilateral breast surgery, and gastric fundoplication. Additionally, the technique has been used for treatment of patients with...

Intracranial Operations

A local anesthetic for intracranial operations should ideally have a duration of 3 to 5 hours, because the procedure usually lasts that long. Lidocaine or ropivacaine without epinephrine produces anesthesia for about 1 hour however, when administered with 1 200,000 epinephrine, it may last 3 or more hours. Epinephrine also helps to control bleeding in this highly vascular area and slows the absorption of local anesthetic. The blood level rises more slowly, lessening the likelihood of systemic...

Intradiscal Electrothermal Coagulation

Intradiscal electrothermal annuloplasty (IDET) is a minimally invasive technique developed for the treatment of discogenic, nonradicular pain ( Fig. 19-1 ). Chronic unremitting low back pain caused by internal disc disruption is a very frustrating problem for the clinician. Treatment options have been limited to physical therapy and analgesics or surgical fusion, and both have marginal beneficial results.162 The IDET procedure involves introducing a flexible electrode into the painful disc....

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 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 T11 to T12 interspace for lumbar dermatomes and the L1 to L2 interspace for sacral dermatomes. A volume of up to 1.0 mL of 5 to 10 phenol may be administered at a slow rate. It is recommended that a...

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...

Jackknife Position

This position is used mainly for anorectal surgery with a hypobaric solution. Care must be taken with the patient's position during the procedure to avoid pressure points on the pelvis, thighs, or lower legs. The gloved anesthetist prepares the skin of the lumbar area with a bactericidal preparation, wiping off the excess solution. The field is draped with sterile towels. The appropriate interspace is located. Depending on the special anatomic features of the patient, the second, third, or...

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...