Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Jun 2002
ReviewMajor surgery in the ambulatory environment: continuous catheters and home infusions.
The ability to provide continuous peripheral nerve blocks to patients safely on an outpatient basis has been a major advance in ambulatory surgery over the past several years. The first reports of patients self-administering local anaesthetic via wound and perineural catheters were published in 1998. Such infusions have now become a necessary component for the success of various ambulatory procedures. ⋯ Many of the concepts used to provide safe ambulatory infusion have been drawn from studies of patients receiving these types of therapies in a hospital setting. Few studies have actually examined these techniques is an outpatient environment. However, the advantages of these analgesic techniques over traditional oral narcotics for patients undergoing major surgery in the ambulatory environment have led to their rapid acceptance as a standard of care at many institutions.
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Best Pract Res Clin Anaesthesiol · Jun 2002
ReviewContinuous interscalene block for ambulatory shoulder surgery.
Management of acute post-operative pain due to shoulder surgery may be successfully and consistently achieved in ambulatory patients by using continuous interscalene block. This chapter outlines the anterior and posterior approaches to the proximal brachial plexus and describes a method of precisely placing a catheter along the brachial plexus by stimulating the plexus through the needle used for placing the catheter as well as through the catheter itself. ⋯ Suggested drugs and dosages for initial boluses, continuous infusions and patient controlled interscalene analgesia are discussed. Sedation for block placement, and special precautions, are outlined.
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Best Pract Res Clin Anaesthesiol · Jun 2002
ReviewThe Holy Grail: long-acting local anaesthetics and liposomes.
The ability to provide an extended duration of analgesia of days following a single injection without the need for catheters, pumps and infusion systems would be a great benefit in acute and chronic pain. Exciting progress is being made in our ability to combine local anaesthetics with liposomes and polymer microspheres. These interesting formulations in animal models have allowed up to 4 days of analgesia. Their use clinically will be a great advance which could possibly occur in the near future.
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Best Pract Res Clin Anaesthesiol · Jun 2002
ReviewMaking an ambulatory surgery centre suitable for regional anaesthesia.
This chapter reviews a management strategy for transforming an outpatient surgery centre from that which exclusively uses general anaesthesia to one using regional anaesthesia with peripheral nerve blocks. Barriers presented by patients, nursing staff, surgeons and administrators can be notable; these might undermine the well-intended efforts of highly-skilled regionalists. ⋯ The centerpiece of the anaesthesia care process remains pre-emptive multimodal analgesia, routine multimodal antiemetic prophylaxis and avoidance of general anaesthesia (GA) with volatile agents. The remainder of the care process relies on teamwork among all healthcare providers and meaningful administrative support.
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The considerable development of ambulatory surgery has led to an increase in the number of lower extremity procedures performed in an outpatient setting. More recently, the availability of disposable pumps has allowed us to extend the indications of continuous nerve blocks for ambulatory post-operative pain management. Indications for lumbar plexus continuous blocks include anterior cruciate ligament (ACL) reconstruction and patella repairs as well as frozen knee, whereas continuous sciatic blocks are indicated for major foot and ankle surgery. ⋯ This latter technique seems to be the preferred mode because it offers the advantage of tailoring the amount of local anaesthetics, mostly 0.2% ropivacaine, to the individual need and also maximizes the duration of infusion for a given volume of local anaesthetic. Although the preliminary reports indicate that lower extremity continuous blocks provide effective post-operative ambulatory analgesia and are safe, especially as a part of a multimodal approach, appropriate training in these techniques represents one of the most important limiting factors of the placement of perineural catheters. Additional research is required to determine the optimal conditions in which these techniques are indicated.