Regional anesthesia for laparoscopy

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

Risk management in regional anesthesia: preface and comments

The benefits of regional anesthesia for surgical procedures, when compared with general anesthesia and/or systemic analgesia, include improved postoperative analgesia, an associated decrease in postoperative pain medication use, decreased nausea and vomiting, and quicker recovery and discharge from the hospital. Neurologic complications associated with regional anesthesia are extremely rare. Although rare, these complications may be reduced with new regional techniques such as the use of ultrasound or fluoroscopy, but further detailed research is needed. In regional anesthesia, rare but serious complications make it necessary to always consider the risk-benefit ratio. The articles discuss these issues and give advice on its effective and safe conduct.     

Regional anesthesia for ambulatory surgery

Ambulatory surgery is increasing at unprecedented rates with more complex procedures being performed. This article reviews the benefits of the use of regional anesthesia during ambulatory surgeries. Regional anesthesia, by putting the anesthetic at the surgical site, provides ideal conditions for ambulatory surgery and provides a smooth, predictable post-operative course.     

Benefits, risks, and best practice in regional anesthesia: do we have the evidence we need?

For more than 25 years, regional anesthesia has challenged anesthesiologists to determine whether it offers real benefits in terms of patient outcome from major surgery, compared with general anesthesia. Although there is good evidence that regional analgesia offers superior pain relief to systemic opioid analgesia, evidence to support improved outcome from surgery remains elusive. Although many publications appear to support the hypothesis, others show no benefit, and the lack of properly conducted, large studies makes it difficult to draw any evidence-based conclusions in favor of regional anesthesia. Given that all major regional techniques have the potential to cause significant risks to patient outcome, it is incumbent on all anesthesiologists to balance the intended benefits against the significant adverse events associated with regional techniques. We are beginning to develop an evidence base for both the benefits and risks of regional anesthesia, when used for specific patient groups and for specific surgical procedures. This presentation looks at some of the evidence and examines how it can be used to develop guidelines for best practice.     

区域阻滞麻醉与老年患者术后神经系统功能、病死率关系的研究进展

背景 区域阻滞麻醉应用于老年患者手术日益增多,其对老年患者术后神经系统功能、病死率的影响有待总结. 目的 通过文献综述,分析区域阻滞麻醉对老年患者术后神经系统、病死率的影响. 内容 讨论区域阻滞麻醉与老年患者术后神经系统功能,包括术后谵妄、认知功能障碍、脑卒中以及与病死率之间的关系. 趋向 区域阻滞麻醉可以减少老年患者术后肺部并发症,减少术后早期认知功能障碍,与全身麻醉相比,具有一定优势.区域阻滞麻醉是否能降低老年患者术后病死率、心血管并发症发生率、谵妄发生率、围手术期脑卒中发生率尚有待于进一步研究.     

General and/or regional anesthesia for vascular surgery. A retrospective evaluation.

Two hundred sixty three patients for extrathoracic vascular surgery of the arterial vessels, were evaluated retrospectively in order to assess the role of regional anesthesia in this group. In 33.8% regional anethesia with or without some form of suppletion was considered to be the anesthetic of choice. Regional anesthesia is especially indicated in those patients admitted for intractable ischaemic pain. As an anesthetic for the surgical procedure, it should be considered as a choice possibility as good as general anesthesia and in some cases as a better one.     

Regional anesthesia does not significantly change surgical time versus general anesthesia—A meta-analysis of randomized studies

Background and Objectives. The major determinant of variable operating room costs is surgical time. A number of factors contribute to surgical time. This study was designed to determine whether regional anesthesia decreases surgical time when compared with general anesthesia over several surgical procedures. Methods. A search was conducted for clinical trials that reported surgical times and which compared outcomes from regional versus general anesthesia. A meta-analysis of these trials was completed to determine whether, on average, among many surgeons and surgical procedures, the use of regional anesthesia affects surgical time. Confidence intervals were calculated and random effects meta-analysis was used to pool results. Results. Twenty-six studies (with 1,874 patients) were used in the meta-analysis. Regional anesthesia does not significantly decrease surgical time versus general anesthesia (mean general minus regional difference was 1.7 minutes, 95% confidence interval −0.5 to 3.9 minutes). Conclusions. Overall, the use of regional anesthesia does not significantly decrease surgical time.     

麻醉及相关学科在发展中国家的现状：一项赞比亚共和国的全国性调查

背景世界上很多外科手术是在发展中国家进行的。为了改善急症患者和危重患者的生存率，必须确定发展中国家麻醉实施存在的基本问题和麻醉面临的需求。本次调查研究者评估了目前赞比亚共和国麻醉以及相关学科（包括危重症医学、急诊医学以及疼痛治疗）的现状。方法向在赞比亚共和国卫生部注册的87所可行大或小型外科手术的医院发放问卷，问卷包括111个问题，分为5组，分别涉及：医院总体信息、麻醉、重症监护、急诊医学及疼痛治疗。结果对其中68所医院的问卷进行统计学分析（78％）。手术种类中最常见的是妇产科、腹部外科手术。氯胺酮分离麻醉是最常用的全身麻醉方法（50％）。全身麻醉患者中10％进行气管插管，大部分（78％）医院麻醉实施由非注册医师完成。68所医院中只有5所（7％）回信称配备重症监护室，共有29个床位服务整个国家。麻醉医师基本不参与急诊工作和疼痛治疗。结论赞比亚共和国的麻醉医学极不发达，缺乏医疗相关资源。     

Regional anesthesia for orthopedic procedures: What orthopedic surgeons need to know

Regional anesthesia is an integral component of successful orthopedic surgery. Neuraxial anesthesia is commonly used for surgical anesthesia while peripheral nerve blocks are often used for postoperative analgesia. Patient evaluation for regional anesthesia should include neurological, pulmonary, cardiovascular, and hematological assessments. Neuraxial blocks include spinal, epidural, and combined spinal epidural. Upper extremity peripheral nerve blocks include interscalene, supraclavicular, infraclavicular, and axillary. Lower extremity peripheral nerve blocks include femoral nerve block, saphenous nerve block, sciatic nerve block, iPACK block, ankle block and lumbar plexus block. The choice of regional anesthesia is a unanimous decision made by the surgeon, the anesthesiologist, and the patient based on a risk-benefit assessment. The choice of the regional block depends on patient cooperation, patient positing, operative structures, operative manipulation, tourniquet use and the impact of post-operative motor blockade on initiation of physical therapy. Regional anesthesia is safe but has an inherent risk of failure and a relatively low incidence of complications such as local anesthetic systemic toxicity (LAST), nerve injury, falls, hematoma, infection and allergic reactions. Ultrasound should be used for regional anesthesia procedures to improve the efficacy and minimize complications. LAST treatment guidelines and rescue medications (intralipid) should be readily available during the regional anesthesia administration.     

Physiologic changes during laparoscopy

The short-term benefits of minimal access techniques include less pain, early mobilization, and shorter hospital stay. Nonetheless, significant data have accumulated regarding the complications associated with laparoscopic techniques, including those that are unique to laparoscopic surgery such as bile duct injury and disruption of major blood vessels. Other problems such as myocardial ischemia and respiratory acidosis are associated with the cardiopulmonary effects of pneumoperitoneum and systemic CO2 absorption. These physiologic changes, although tolerated by healthy patients, could have particular adverse consequences for infirm and critically ill patients. It would appear that minimizing IAP during insufflation decreases the risk of potentially marked cardiovascular changes and regional blood flow alterations. In turn, this could arguably decrease the risk of perioperative myocardial events, or organ dysfunction or failure. Laparoscopy in the critically ill patient is questionable because the role is not established. An ICU patient has little to gain from the benefits of early mobilization. Conversely, in the presence of raised ICP or borderline organ function, the physiologic changes associated with pneumoperitoneum and laparoscopy could have profound detrimental effects.     

Comparison of postoperative pain in patients receiving interscalene block or general anesthesia for shoulder surgery.

A retrospective review of 114 patients who underwent elective shoulder surgery from January 1, 1995 to December 31, 1996 was performed. Eighty-eight patients received general anesthesia and 26 patients received regional anesthesia (interscalene block). There were no differences in surgical and anesthesia time and time to hospital discharge between groups. Patients who received regional anesthesia had a shorter recovery room stay (63 +/- 25 minutes versus 85 +/- 33 minutes [P.002]) and required less intraoperative fentanyl (174 +/- 96 microg versus 379 +/- 193 microg [P<.0001) and morphine in the recovery room (2 +/- 3 mg versus 6 +/- 7 mg [P=.006]). A higher percentage of patients who received regional anesthesia had a lower pain rating at 4 hours. Regional anesthesia for shoulder surgery decreases pain and facilitates recovery in the immediate postoperative period.     

Peripheral catheter techniques

With ultrasound, continuous peripheral nerve blocks (CPNBs) are one of the most recent developments in regional anesthesia in children. CPNBs are now used more widely in children because more suitable materials have been marketed, allowing complete, and prolonged postoperative pain control. Their use after orthopedic procedures in children and treatment for complex regional pain syndrome in adolescents has demonstrated the benefits. Perineural catheters have also shown their superiority over other techniques of continuous regional anesthesia in terms of side effects. The efficiency and the safety of these techniques may facilitate early ambulation with improved pain management, treatment at home with disposable pumps, and improved rehabilitation of children. Studies on large cohorts of patients published to date have failed to highlight any severe complications in their use compared with other adult studies. Accidents owing to systemic toxicity are very unlikely if the recommended maximum dose is not exceeded. The safety of continuous regional anesthesia techniques in children relies on the use of low-concentration l-enantiomer solutions (ropivacaine or levobupivacaine) accompanied by low plasma concentrations of local anesthetics, limiting the risk of systemic toxicity of these molecules. CPNB can ensure strong and lasting analgesia in hospital or at home.     

Upper extremity nerve blocks for the trauma patient

Regional anesthesia can provide a number of benefits for the patient with upper extremity injury but requires careful consideration of several problems unique to the trauma victim. When planning the approach to the brachial plexus, both the site of injury as well as associated conditions, such as the presence of a cervical immobilization device, become important. The practitioner should learn several approaches to the plexus as well as supplemental blocks at the wrist. The use of a nerve stimulator or portable ultrasound device may improve success in patients with difficult landmarks. Intravenous regional anesthesia remains an effective alternative to brachial plexus block for short surgical procedures. Copyright © 2002 by W.B. Saunders Company     

Awake Thoracic Surgery— Is it Worth the Trouble?

Awake thoracic surgery is performed by regional anesthesia techniques in spontaneously breathing, fully conscious patients to avoid side-effects of general anesthesia, fasten recovery, and reduce morbidity, particularly in high-risk patients. Results of ongoing experience are promising, and this novel surgical approach has been successfully applied to several thoracoscopic procedures, including management of pleural effusion, wedge resections, lung volume reduction surgery, bullectomy, and thymectomy. In this article, the historical background, main pathophysiology features of the surgical pneumothorax, and the various regional anesthesia techniques as well as reported results are reviewed and critically discussed.     

Perioperative Schmerztherapie bei opioidgewöhnten Patienten

In this review article the special anesthesiological problems of opioid tolerance and surgical interventions will be presented. These affect patients with a long-term opioid therapy of chronic pain, addicts with long-term substitution therapy and addicts with current or previous heroin addiction (“clean”). For all patient groups a guarantee of continuous and adequate analgesia (avoidance of fear and increasing patient compliance), exploiting suitable regional anesthesia or regional analgesia procedures when possible, and prevention of a physical opioid withdrawal syndrome have utmost priority. The necessary optimization of perioperative pain therapy only succeeds when based on a thorough preoperative examination of the clinical history which subtly inquires into the drug taking habits with respect to opioids and associated medications. Systemic and/or regional analgesia procedures are possible. Regional procedures are more effective for analgesia. Systemic analgesia procedures do not basically differ from those routinely used for patients without opioid tolerance. However, higher doses of opioids are necessary as well as individual titration according to needs. Special conditions apply to patients previously addicted to opioids (clean) when they are to be operated on. Non-opioids are sufficiently effective for low level pain and opiates can be avoided. Opioid therapy with inclusion of a non-opioid is necessary following major operations or for severe postoperative pain, even as i.v. patient-controlled analgesia (i.v. PCA) if needed. For these patients a relapse to addiction can be provoked by insufficient administration of analgesics, not by pain management including opioids.     

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

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

Regionalanästhesie bei Patienten mit Infektionen oder Immunsuppression

Regional anesthesia is the most effective procedure for acute pain therapy. Whether neuraxial and peripheral blocks in patients with pre-existing infectious conditions, immune deficits or other risk factors increase the risk of additional infections is unclear. Analyzing the available literature currently seems to indicate that the incidence of severe infectious complications is generally low. Diabetes, steroid therapy or malignant diseases are apparently present in many cases in which infections associated with regional anesthesia and analgesia have been described. A strict contraindication in patients with pre-existing systemic or local infections seems unjustifiable. A clear and documented risk-benefit ratio in these patients is mandatory.     

Propofol and thiopental for intravenous induction in neonates: Study protocol for a dose-finding trial

Background

Propofol and thiopental are commonly used induction agents in neonatal anesthesia. Even though both hypnotics have been used off-label for many years, pharmacological knowledge regarding these agents is scarce in neonates. The significant variability in neonates' body composition, organ function, and maturation makes pharmacological studies highly relevant albeit challenging. As a result, there is currently limited data about the anesthetic induction dose of thiopental and propofol in neonates. In addition, a knowledge gap exists concerning the pharmacodynamics of induction doses.

Objective

To determine the median effective anesthetic induction dose of propofol and thiopental in neonatal patients of different gestational and postnatal ages and evaluate the pharmacodynamics of the anesthesia induction doses on the neonatal systemic and cerebral hemodynamics.

Methods

This is a single-center, prospective, open-label, interventional, dose-finding study, including neonatal patients from birth up to 28 postnatal days undergoing general anesthesia for surgical or diagnostic procedures. The patients will be stratified according to their gestational and postnatal age and allocated to one of the two trial arms: anesthesia induction with propofol or anesthesia induction with thiopental. We will use Dixon's up-and-down method to estimate the median effective anesthesia induction dose of both agents in neonates of different gestational and postnatal ages. In addition, we will study the relationship between anesthesia induction doses and changes in systemic and cerebral hemodynamics.

Discussion

Alterations in the systemic and cerebral regional hemodynamics secondary to anesthesia induction may be harmful in neonates, especially premature and critically ill newborns, due to their immature organ systems, reduced physiological reserves, and impaired cerebral autoregulation. Perfusion homeostasis is considered one of the significant and modifiable determinants of anesthesia-related neurocognitive outcomes. Therefore, dose-finding and safety pharmacological studies of the anesthetic induction agents in neonates are urgently needed and acknowledged as a high priority by the European Medicine Agency. Estimating adequate induction doses to ensure optimal depth of anesthesia while avoiding systemic and cerebral hemodynamic disturbances will help ensure safe anesthesia and potentially improve anesthesia-related outcomes in this group of patients. Trial registration: EudraCT (EudraCT Identifier: 2019-001534-34), 05.07.2022.     

Interscalene brachial plexus block anesthesia for upper extremity surgery

Use of the interscalene brachial plexus block for upper extremity anesthesia in a primarily rheumatoid population is reviewed in 88 cases. The interscalene approach described by Winnie was used. Anesthesia was effective in 93% of the cases. Failure to achieve anesthesia was more likely to occur in surgical procedures on the distal upper extremities. The technique allowed effective and reliable anesthesia throughout the upper extremity, including the shoulder. Problems associated with other forms of upper extremity regional anesthesia, such as tourniquet pain, pneumothorax, systemic anesthetic toxicity, and inadequate duration of anesthesia, were not encountered. Difficulties with more distally based block administration due to decreased shoulder motion were obviated.