Combined regional and general anaesthesia

Combining regional and general anaesthesia can have many advantages, particularly in patients undergoing major thoracic, abdominal or orthopaedic surgery. The use of regional anaesthetic techniques in anaesthetized children is an accepted standard of care, because needle and procedure phobias are very common and can result in severe anxiety, an inability to cooperate and sudden unpredictable movement. Epidural local anaesthetics have the potential of attenuating sympathetic hyperactivity, maintaining bowel peristalsis, sparing the use of opioids, and facilitating postoperative feeding and out-of-bed activity. Catheter techniques allow excellent and prolonged postoperative analgesia using epidural or peripheral nerve blocks. However, the superiority of regional techniques for hip fracture surgery and carotid endarterectomy has been disputed in several recent studies. As part of the combination technique, epidural block may in fact decrease blood flow in free flap surgery by a steal phenomenon, and increase intrapulmonary shunting during one-lung ventilation. The present review focuses on the use of a combination of regional and general anaesthesia for a variety of surgical procedures. It also compares the two anaesthetic techniques in elderly patients. The review is based on studies published during the past year.     

Pain relief after major ankle and hindfoot surgery with repetitive peripheral nerve blocks: A feasibility study

Background

Major ankle and hindfoot surgery (e.g., ankle, triple and subtalar arthrodesis) typically causes severe postoperative pain, especially the first two postoperative days. Current modalities of postoperative analgesic treatment often include continuous peripheral nerve blocks of the saphenous and sciatic nerves via catheters in order to extend the duration of pain- and opioid-free nerve blockade to 48 h. Unfortunately, the 48 h-efficacy of continuous infusion via a catheter is reduced by a high displacement rate. We hypothesised that one-time repetition of the single injection peripheral nerve blocks would provide effective analgesia with a low opioid consumption the first 48 postoperative hours.

Methods

Eleven subjects preoperatively received a popliteal sciatic and a saphenous single injection nerve block with a protracted local anaesthetic mixture. Surgery was performed under general anaesthesia. The one-time repetition of the single injection nerve block was carried out approximately 24 h after the primary nerve block. The main outcomes were pain and cumulative opioid consumption during the first 48 postoperative hours.

Results

Nine of the 11 (82%) patients had effective analgesia without opioids during the first 48 postoperative hours. Two patients each required a single dose of 7.5 mg of oral morphine equivalents after 43 h.

Conclusion

One-time repetition of single injection saphenous and sciatic nerve blocks consistently provided effective analgesia practically without opioids for 48 h after major elective ankle and hindfoot surgery.     

Analgésie postopératoire par voie locorégionale chez l'adulte: techniques perimédullaires et périphériques. Indications,effets indésirables et surveillance

Regional analgesia is a very effective way to treat postoperative pain. Lumbar and thoracic epidural analgesia are well adapted to major abdominal and thoracic surgery. Nevertheless, respiratory side effects induced by opioids are potentially severe and an adequate monitoring is essential. In orthopaedic surgery, perineural blocks are the best technique to manage postoperative pain and perineural catheters may be used. The importance of intra-articular analgesia, simple and safe, is not fully understood. The association of a local anaesthetic inducing a minor motor block and a strong sensitive block (bupivacaine, ropivacaine), with an opioid seems to be the best pharmacologic choice regarding quality of analgesia and safety. Benefits of postoperative regional analgesia on mortality and morbidity are not demonstrated. Medical and nursing staff and specialized units should improve quality of postoperative regional analgesia as well. General guidelines for the practice of regional anaesthesia must be closely followed.     

Distal nerve blocks of the lower limb

This article describes the distal nerve blocks which are usefulfor ankle (popliteal and saphenous nerve block) and foot (ankleblock) surgery. Metatarsal nerve blocks, i.v. regional anaesthesia(Bier's block) and local anaesthetic infiltration for arthroscopyare not considered.     

Continuous peripheral nerve blocks in children

In recent years, regional anaesthesia in children has generated increasing interest. Continuous peripheral nerve blocks have an important role in the anaesthetic arsenal, allowing effective, safe and prolonged postoperative pain management. Indications for continuous peripheral nerve blocks depend on benefits/risks analysis of each technique for each patient. The indications include surgery associated with intense postoperative pain, surgery requiring painful physical therapy, and complex regional pain syndrome. Continuous peripheral nerve blocks are usually performed under general anaesthesia or sedation, and require appropriate equipment in order to decrease the risk of nerve injury. New techniques, such as transcutaneous stimulation or ultrasound guidance, appear to facilitate nerve and plexus identification in paediatric patients. Nevertheless, continuous peripheral nerve block may mask compartment syndrome in certain surgical procedure or trauma. Finally, ropivacaine appears to be the best local anaesthetic for continuous peripheral nerve blocks in children, requiring low flow rate with low concentration of the local anaesthetic.     

Addition of dexmedetomidine to lidocaine for intravenous regional anaesthesia

BACKGROUND AND OBJECTIVE: The aim of this study was to determine the duration of onset and regression time of sensory and motor blocks, the quality of anaesthesia and postoperative analgesia by the addition of dexmedetomidine to local anaesthetic solution in intravenous regional anaesthesia (IVRA). METHODS: Forty patients scheduled for elective hand surgery participated in this prospective randomized double-blind study. The IVRA was achieved using 3 mg kg(-1) lidocaine diluted with saline to a total volume of 40 mL in the control group or 1 microg kg(-1) of dexmedetomidine + 3 mg kg(-1) lidocaine diluted with saline to a total volume of 40 mL in the dexmedetomidine group. The onset and regression times for sensory and motor blocks were recorded. Qualities of anaesthesia, intraoperative and postoperative analgesic requirements were noted. RESULTS: There was no difference between the groups with respect to sensory and motor blocks onset and regression time. The quality of anaesthesia was better in the dexmedetomidine group than the control group and the difference was statistically significant. Intraoperative and postoperative analgesic requirements were greater in the control group than in the dexmedetomidine group. CONCLUSIONS: Addition of dexmedetomidine to local anaesthetic solution in IVRA improved the quality of anaesthesia and decreased analgesic requirements, but had no effect on the sensory and motor blocks onset and regression times.     

Continuous peripheral regional analgesia in children

Continuous peripheral nerve blocks (CPNB) have important role in the therapeutic arsenal, anaesthetic or analgesic in children. Indications for CPNB depend on benefits/risks analysis for each patient. The indications include surgery associated with intense postoperative pain, surgery requiring painful physical therapy, and complex regional pain syndrome. CPNB are usually performed under sedation or general anaesthesia, and require appropriate equipment in order to decrease the risk of nerve injury. Nevertheless, CPNB may mask compartment syndrome in trauma or certain surgical procedure. Finally, ropivacaine, and perhaps levobupivacaine, appears to be the best local anaesthetic for continuous peripheral nerve blocks in children, requiring low flow rate with low concentration.     

Perioperative analgesia with continuous peripheral nerve blocks in children

Recently, regional anaesthesia in children has generated increasing interest. But single injection techniques have a limited duration of postoperative analgesia. Then, continuous peripheral nerve blocks have taken an important position in the anaesthetic arsenal, allowing an effective, safe and prolonged postoperative pain management. As adults, indications for continuous peripheral nerve blocks depend on the analysis of individual benefits/risks ratio. Main indications are intense postoperative pain surgical procedures, with or without postoperative rehabilitation, and complex regional pain syndrome. Contraindications to these procedures are rather similar to those in adults, plus parental and/or children refusal. Continuous peripheral nerve blocks are usually performed under general anaesthesia or sedation in children, and require appropriate equipment in order to decrease the risk of nerve injury. New techniques, such as transcutaneous nerve stimulation or ultrasound guidance, appeared to facilitate nerve and plexus approach identification in paediatric patients. Nevertheless, continuous peripheral nerve block may theoretically mask a compartment syndrome after trauma surgical procedures. Finally, ropivacaine appears to be the most appropriate drug for continuous peripheral nerve blocks in children, requiring low flow rates and concentrations of local anaesthetic. These techniques may facilitate early ambulation by an improved pain management or even postoperative analgesia at home with disposable pumps. One might infer from the current review that excellent pain relief coupled with a reduction of side effects would contribute to improve the quality of life and to decrease the frequency of disabling behavioural modifications in children, sometimes psychologically injured by hospital stay and postoperative pain.     

Regional blocks in orthopaedics

Acute postoperative pain management has played a significant role in decreased hospital stay and has been recognized to have a positive effect on functional recovery and patient satisfaction. Orthopaedic surgery is an expanding surgical specialty with a potentially difficult patient population. Regional anaesthesia is becoming increasingly popular as it offers several advantages over general anaesthesia. The aim of analgesic protocols is not only to reduce pain intensity but also to decrease the incidence of side-effects from analgesic agents and to improve patient comfort. Moreover, adequate pain control is a prerequisite for the use of rehabilitation programmes to accelerate functional recovery from orthopaedic surgery. Recently there has been resurgence in the use of regional anaesthesia as anaesthetists are better equipped with advanced techniques for nerve localization and visualization of needle and local anaesthetic spread hence can prevent side effects secondary to needle misplacement with ultrasound guidance. The use of peripheral nerve blocks has been associated with earlier discharge in ambulatory orthopaedic surgery when compared to general anaesthesia and neuraxial blockade. This article discusses the advantages and limitations of regional anaesthesia for perioperative pain management and various peripheral nerve blocks and catheter techniques used for commonly performed orthopaedic procedures. It also briefly mentions the recent advances in nerve localization techniques. Increased knowledge, training and practice in regional techniques has the benefit of improving analgesia and mobilization, shortened hospital stay and improving overall quality of care. Moreover, increased efficiency and decreased length of hospital stay have positive cost implications.     

Lower limb nerve blocks

Peripheral nerve blocks are increasingly used for a wide range of surgical procedures involving the lower limb. A number of techniques can be used to provide anaesthesia and highly effective postoperative analgesia, offering an alternative to general anaesthesia in some cases, minimizing the requirement for strong opiates and improving the quality of recovery following surgery. Ultrasound-guided nerve localization offers several potential advantages when performing femoral, sciatic and ankle blocks; however, neurostimulation remains a useful and widely used aid to lower limb regional anaesthesia practice.     

Regional blocks in orthopaedics

Effective postoperative pain management plays a significant role in decreasing hospital stay and has a positive effect on functional recovery and patient satisfaction. Orthopaedic surgery is an expanding surgical specialty with a potentially difficult patient population. Regional anaesthesia is becoming increasingly popular as it offers several advantages over general anaesthesia. The aim of analgesic protocols is not only to reduce pain intensity but also to decrease the incidence of side effects from analgesic agents and to improve patient comfort. Moreover, adequate pain control is a prerequisite for rehabilitation programmes to accelerate functional recovery and may have economic benefits. Recently there has been resurgence in the use of regional anaesthesia with advanced techniques for nerve localization and visualization of needle and local anaesthetic spread. The use of peripheral nerve blocks has been associated with earlier discharge in ambulatory orthopaedic surgery when compared to general anaesthesia and neuraxial blockade.     

Anesthésie locorégionale pour la chirurgie esthétique de la face et du cou

Plastic surgery is more and more developing. Facial blocks are adapted to surgical procedures performed in this setting. They are easy to perform and may prolong postoperative analgesia. Facial blocks may be used in ambulatory surgery as a single technique or combined with general anaesthesia or intravenous sedation. After a reminding of facial nerve anatomy, facial and cervical blocks are described with their indications. Guidelines for performance and monitoring are also indicated.     

Bloc ≪ 3 en 1 ≫ ou bloc femoral. Que faut-il faire et comment le faire ?

The “3 in 1” block and the femoral nerve block are widely used for lower limb surgery and postoperative analgesia. Whether these blocks are in fact a same regional block with two different names or represent definitively two different blocks remains controversial. A large number of anatomical as well as functional variations of the lumbar plexus have been described and complicate a rational analysis of the spread of local anaesthetics following these blocks. Anatomical, radiological and especially clinical data seem to confirm that these blocks are to be distinguished from one another. Femoral nerve block requires the use of a nerve stimulator and has a high success rate in the territory of the femoral nerve; a spread towards other lumbar nerves, especially the lateral femoral cutaneous nerve, is sometimes observed. The “3 in 1” block is supported by the idea of diffusion within a space that is located after going through two fascial layers. Even in experienced hands, the success predictive value is not high. However, once the “3 in 1” block is well performed, a complete anaesthesia covering the territories of the femoral nerve, the lateral femoral cutaneous nerve, and the obturator nerve occurs. Specific indications of each technique are different: major knee surgery and postoperative analgesia for the “3-in-1” block and leg surgery for femoral nerve block. The best approach for knee arthroscopy remains open for discussion.     

Postoperative analgesia for shoulder surgery: a critical appraisal and review of current techniques

Shoulder surgery is well recognised as having the potential to cause severe postoperative pain. The aim of this review is to assess critically the evidence relating to the effectiveness of regional anaesthesia techniques commonly used for postoperative analgesia following shoulder surgery. Subacromial/intra‐articular local anaesthetic infiltration appears to perform only marginally better than placebo, and because the technique has been associated with catastrophic chondrolysis, it can no longer be recommended. All single injection nerve blocks are limited by a short effective duration. Suprascapular nerve block reduces postoperative pain and opioid consumption following arthroscopic surgery, but provides inferior analgesia compared with single injection interscalene block. Continuous interscalene block incorporating a basal local anaesthetic infusion and patient controlled boluses is the most effective analgesic technique following both major and minor shoulder surgery. However, interscalene nerve block is an invasive procedure with potentially serious complications and should therefore only be performed by practitioners with appropriate experience.     

Lower limb blocks

Anaesthetists are very properly concerned about postoperative pain relief. Nerve blocks provide excellent analgesia after lower limb surgery. In recent years several aspects have become clearer. First, the 3 in 1 block frequently misses the obturator nerve; second, the separate figure-of-four obturator nerve block is very effective and easily mastered; and third, the Raj (lithotomy) approach to the sciatic nerve is superior to the Labat technique of the 1930s. Lower limb nerve blocks are simpler to perform and more reliable than many textbooks suggest. If the anaesthetist is familiar with femoral, obturator, sciatic, saphenous and ankle blocks then prolonged analgesia can be provided for any lower limb surgery. The introduction of ropivacaine and chirocaine has removed concerns about drug toxicity when large volumes of local anaesthetic are required. In the very high-risk patient it is usually possible to avoid general or neuraxial anaesthesia for lower limb surgery. Lower limb blocks are becoming more widely practised and should be part of every anaesthetist's repertoire.     

Ultrasonographic guidance for sciatic and femoral nerve blocks in children

Background: Recent studies have shown that ultrasound guidance for paediatricregional anaesthesia can improve the quality of upper extremityand neuraxial blocks. We therefore investigated whether ultrasoundguidance for sciatic and femoral nerve blocks prolongs sensoryblockade in comparison with nerve stimulator guidance in children. Methods: Forty-six children scheduled for surgery of one lower extremitywere randomized to receive a sciatic and femoral nerve blockunder either ultrasound or nerve stimulator guidance. Afterinduction of general anaesthesia, the blocks were performedusing an ultrasound-guided multiple injection technique untilthe nerves were surrounded by levobupivacaine, or by nerve stimulatorguidance using a predefined dose of 0.3 ml kg^–1 of levobupivacaine.An increase in heart rate of more than 15% of baseline duringsurgery defined a failed block. The duration of the block wasdetermined from the injection of local anaesthetic to the timewhen the patient received the first postoperative analgesic. Results: Two blocks in the nerve stimulator group failed. There wereno failures in the ultrasound group. The duration of analgesiawas longer in the ultrasound group mean (SD) 508 (178) vs 335(169) min (P < 0.05). The volume of local anaesthetic insciatic and femoral nerve blocks was reduced with ultrasoundcompared with nerve stimulator guidance [0.2 (0.06) vs 0.3 mlkg^–1 (P < 0.001) and 0.15 (0.04) vs 0.3 ml kg^–1(P < 0.001), respectively]. Conclusions: Ultrasound guidance for sciatic and femoral nerve blocks inchildren increased the duration of sensory blockade in comparisonwith nerve stimulator guidance. Prolonged sensory blockade wasachieved with smaller volumes of local anaesthetic when usingultrasound guidance.     

Techniques of epidural block

Epidural blocks can be performed at any level from the high cervical spine down to the sacral hiatus. A lumbar epidural can provide surgical anaesthesia and postoperative analgesia for sub-umbilical surgery, whereas a thoracic epidural will provide effective analgesia but not anaesthesia for thoracic and upper abdominal surgery. A single-shot bolus has a duration of 2-4 hours, using a long-acting local anaesthetic, but in the majority of cases prolonged postoperative analgesia is achieved by inserting an epidural catheter and infusing a dilute local anaesthetic and opioid drug combination. Although a useful regional anaesthetic technique with significant patient benefits, an epidural is an invasive procedure, can be technically difficult, and has the potential to cause serious adverse events (direct needle trauma to the spinal cord or the spinal nerve roots, vertebral canal haematoma and meningitis or epidural abscess) if not done to a high standard and managed appropriately. Epidural and caudal blockade have a number of synonyms, which can be confusing. The terms ‘epidural’ (extradural, peridural) and ‘caudal’ (sacral epidural) are used throughout this article.     

Regional anaesthesia for orthopaedic procedures

Regional anaesthesia is apposite for orthopaedic surgery for anatomical reasons and to reduce complications from general anaesthesia. A reduction in pain scores, drowsiness and nausea can improve postoperative mobility and facilitate earlier hospital discharge. Disadvantages include block failure, nerve injury, possible loss of motor function and proprioception and local anaesthetic toxicity. Complications are rare but may be reduced by the use of ultrasound and nerve stimulation, performing the block on a conscious patient and stopping injection if there is pain or high resistance. Patients should be assessed preoperatively to rule out contraindications such as local infection or coagulopathy, and clear explanations of the procedure and any possible complications should be given. Patients should also be assessed postoperatively and any suspicious findings investigated promptly and followed up until there is complete resolution.     

Peripheral nerve block at the elbow and wrist

Wrist and elbow blocks are used to provide anaesthesia and analgesiafor hand and forearm surgery. They may be used to supplementa brachial plexus block or to provide perioperative analgesiaafter a regional or a general anaesthetic. Wrist or elbow blocksalone may be used to provide anaesthesia for minor hand procedures;thus, sparing the patient the complications of general anaesthesiaand providing excellent postoperative analgesia with a reducedrequirement for opioid analgesics.¹ Proximal brachial plexusblock is associated with more motor block, but will providepartial or complete tourniquet anaesthesia. Therefore, solereliance on peripheral arm blocks can only be advocated in proceduresthat do not require a tourniquet or last approximately <20min.²