Anaesthesia
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The advances in regional techniques for blocks of the lower limb have been driven primarily by the need to produce effective analgesia in the postoperative period and beyond. These techniques are commonly performed before or after central neuraxial blockade when this technique is used to provide anaesthesia and analgesia for the surgical procedure. Increasingly, modern practice demands a shorter hospital stay, improved patient expectations and early mobilisation. This article describes the current methods and reasons for performing specific blocks to the lower limb and the management of these blocks particularly in the postoperative period.
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The goals for ambulatory surgery are rapid recovery with minimal side effects, adequate postoperative pain control, rapid patient discharge and overall cost containment. The addition of regional anaesthetic techniques has been shown to decrease nausea, postoperative pain scores and the need for post-anaesthesia care unit monitoring. The use of regional anaesthesia is increasing as studies confirm the goals for ambulatory anaesthesia can be met with a combination of regional anaesthesia and a multimodal pain management regimen.
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This article discusses recent innovations and changes in practice in upper limb regional anaesthesia, dividing the blocks into those performed above the clavicle, those performed in the area of the clavicle and those performed below it. It offers a critical appraisal of the current status with regard to the use of ultrasound nerve location for upper limb regional anaesthesia and, while accepting that the use of ultrasound in this way has many theoretical advantages and will therefore continue to grow, concludes that there is currently insufficient published evidence to determine conclusively that the use of this technique is associated with nerve blocks that are more successful or safer.
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Regional anaesthesia is undergoing a renaissance, perhaps assisted by the introduction of (and enthusiasm for) ultrasound-guided regional anaesthesia into clinical practice. This article summarises the technology and principles of ultrasound imaging in anaesthesia and describes the development of three-dimensional ultrasound imaging, considering whether this new technology has an application in regional anaesthesia.
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Despite recent advances in analgesia delivery techniques and the availability of new analgesic agents with favourable pharmacokinetic profiles, current evidence suggests that postoperative pain continues to be inadequately managed, with the proportion of patients reporting severe or extreme postoperative pain having changed little over the past decade. Regional techniques are superior to systemic opioid agents with regards to analgesia profile and adverse effects in the context of general, thoracic, gynaecological, orthopaedic and laparoscopic surgery. Outcome studies demonstrate that regional analgesic techniques also reduce multisystem co-morbidity and mortality following major surgery in high risk patients. This review will discuss the efficacy of regional anaesthetic techniques for acute postoperative analgesia, the impact of regional block techniques on physiological outcomes, and the implications of acute peri-operative regional anaesthesia on chronic (persistent) postoperative pain.