Principles of office anesthesia: part I. Infiltrative anesthesia

The use of effective analgesia is vital for any office procedure in which pain may be inflicted. The ideal anesthetic achieves 100 percent analgesia in a short period of time, works on intact or nonintact skin without systemic side effects, and invokes neither pain nor toxicity. Because no single agent meets all of these criteria, the physician must choose from the available armamentarium based on the anesthetic properties that are most desired. Infiltrative anesthetics are frequently chosen because of their proven safety record, low cost, ease of storage, widespread availability, and rapid onset of action. Allergy to local injectable anesthetics is rare, and when it occurs it is often secondary to the preservative in multidose vials. Anesthesia can be prolonged with the addition of epinephrine or the use of longer-acting agents. Buffering the local anesthetic with bicarbonate, warming the solution, and injecting slowly can minimize the pain of anesthetic injection. Complications are rare but include central nervous system and cardiovascular toxicity, or extreme vasoconstriction in an end organ, if epinephrine is used.     

Regional anesthesia for office procedures: part I. Head and neck surgeries

Although local anesthesia usually is used in surgical procedures, field or nerve blocks can provide more effective anesthesia in some situations. In a field block, local anesthetic is infiltrated around the border of the surgical field, leaving the operative area undisturbed. In field blocks, epinephrine may be added to the anesthetic to enhance vasoconstriction and prolong the duration of anesthesia. In a nerve block, anesthetic is injected directly adjacent to the nerve supplying the surgical field. A review of regional anatomy and the location of nerves and other important structures is essential before administering the injection. Systemic toxicity is rare with regional anesthesia and can be prevented by using the smallest dose possible and aspirating before the injection. Supraorbital, supratrochlear, infraorbital, and mental nerve blocks can provide adequate anesthesia in procedures on parts of the face. Field block also may be considered when operating on the ear or lips.     

Regional anesthesia for office procedures: Part II. Extremity and inguinal area surgeries

The hand can be anesthetized effectively with blocks of the median, ulnar, or radial nerve. Each digit is supplied by four digital nerves, which can be blocked with injections on each side of the digit. Anterior or posterior ankle blocks can be used for regional anesthesia for the foot. The anterior ankle block, which is used for procedures on the dorsum of the foot, involves blocking the saphenous nerve, and superficial and deep peroneal nerves. The posterior ankle block, which is used to anesthetize the sole of the foot, involves blocking the sural and posterior tibial nerves. Paracervical block is used for procedures on the cervix, such as loop electrocauterization or conization. Dorsal penile block has been the most commonly recommended anesthetic technique for neonatal circumcision. A safe and effective alternative is the application of anesthetic cream over the skin to be circumcised.     

Topical anesthesia in preendoscopic medication: spray versus lozenges.

Patients' acceptance of upper fiberpanendoscopy was significantly (p less than 0.001) better when topical anesthesia with oxybuprocaine was performed with a spray than with a lozenge.     

小梁切除术的表面麻醉效果

目的 探讨表面麻醉方法在小梁切除术中的有效性和安全性.方法 60例患眼随机分为两组,试验组30眼在表面麻醉下施行小梁切除术,对照组30眼在球后麻醉下施行小梁切除术,分析、观察其麻醉效果.结果 试验组和对照组麻醉效果差异无统计学意义(P>0.05),但球后出血、眼睑皮下出血、结膜下水肿等并发症发生率,试验组明显低于对照组(P<0.05).结论 表面麻醉是青光眼小梁切除术一种安全可靠的方法.     

Chronic shoulder pain: part II. Treatment

Chronic shoulder pain is a common problem in the primary care physician's office. Effective treatment depends on an accurate diagnosis of the more common etiologies: rotator cuff disorders, adhesive capsulitis, acromioclavicular osteoarthritis, glenohumeral osteoarthritis, and instability. Activity modification and analgesic medications comprise the initial treatment in most cases. If this does not lead to improvement, or if the initial presentation is of sufficient severity, a trial of physical therapy that focuses on the specific diagnosis is indicated. Combined steroid and local anesthetic injections can be used alone or as an adjuvant to the physical therapy. The site of the injection (subacromial, acromioclavicular joint, or intra-articular) depends on the diagnosis. Injections into the glenohumeral joint should be done under fluoroscopic guidance. Symptoms that persist or worsen after six to 12 weeks of directed treatment should be referred to an orthopedic specialist.     

Somatizing patients: part II. Practical management

Somatization is the experiencing of physical symptoms in response to emotional distress. It is a common and costly disorder that is frustrating to patients and physicians. Successful treatment of somatization requires giving an acceptable explanation of the symptoms to the patient, avoiding unwarranted interventions and arranging brief but regular office visits so that the patient does not need to develop new symptoms in order to receive medical attention. Antidepressants may be helpful in many patients, as well as cognitive psychotherapy when patients are willing to participate in it. Typical problems in managing such patients can be addressed by relying on the continuity established through regular visits to the same primary care physician.     

Osteoporosis: part II. Nonpharmacologic and pharmacologic treatment

Family physicians will frequently encounter patients with osteoporosis, a condition that is often asymptomatic until a fracture occurs. Treatment of the fracture can be initiated without further diagnostic testing. Thereafter, treatment of osteoporosis includes (1) prevention of further bone loss through weight-bearing exercise, tobacco and alcohol avoidance, hormone replacement therapy in women, and raloxifene and calcium supplementation; (2) treatment of fracture-related pain with analgesics and calcitonin; (3) building bone mass when feasible with alendronate; and (4) modifying behaviors that increase the risk of falls. Patients without fracture who are at risk for osteoporosis can also benefit from these preventive measures. Furthermore, women of all ages should be encouraged to maintain a daily calcium intake of 1,000 to 1,500 mg and to participate in weight-bearing exercise for 30 minutes three times weekly to reduce their risk of falls and fractures. Persons at risk should avoid medications known to compromise bone density, such as glucocorticoids, thyroid hormones and chronic heparin therapy.     

Heart failure and treatment: part II. Perianesthesia management.

Heart failure is a clinical syndrome not limited to age or ethnicity. Patients with heart failure, compensated and uncompensated, may present for emergency or planned surgery. Patient outcomes depend on the knowledge and nursing care of the perianesthesia nurse. An understanding of the types of heart failure, etiology, pathophysiology, hemodynamic factors, and treatment will assist the nurse in making decisions that will affect the clinical course. Evidence-based practice will facilitate the perianesthesia nurse in reducing morbidity and mortality in this patient population.