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Practical Regional Anesthesia for OutpatientsMeg A. Rosenblatt, M.D. New York, New York

106Page 1

Introduction

The advantages that regional anesthesia (RA) confers over general anesthesia (GA), especially in the outpatientsetting, are numerous. Pavlin

et al.,

in a prospective study of 1,088 patients undergoing ambulatory surgery, foundthat the most important factor in determining discharge time from the post-anesthesia care unit (PACU) was theanesthetic technique (general anesthesia, local, peripheral nerve block, or spinal-epidural anesthesia).

This studyhighlights the anesthesia-related issues that prolong patient PACU stays, which include pain, nausea and vomiting(PONV), unresolved neuraxial blocks and urinary retention. Pain accounted for half of the unanticipated admissionsin one review of 1,996 patients undergoing outpatient orthopedic surgery,

while a second study found thatorthopedic patients are the group of ambulatory patients with the highest incidence (16.1%) of pain in the PACU.

iii

The treatment of pain can increase PONV and further delay discharge, while the cost of nursing care associated with prolonged PACU stays contribute significantly to overall cost. Peripheral nerve blocks (PNBs) offer predictableintraoperative anesthesia, while providing analgesia into the postoperative period, the opportunity to bypass Phase Irecovery and the avoidance of airway manipulations. Despite their obvious advantages, PNBs are frequentlyunderutilized, particularly in the ambulatory and office based settings. This review will discuss how to choose peripheral nerve blocks appropriate for a patient’s needs, how to modify the block for outpatient procedures andthen how to integrate PNBs into an ambulatory anesthetic practice.

Developing proficiency in PNS

Kopacz and Neal, in their review of residency training in the year 2000, found that 40% of residents were receivingan inadequate experience with PNBs.

Since January 2001 the Accreditation Council for Graduate MedicalEducation has required that residents perform a minimum of 40 peripheral blocks, but does not provide guidelinesfor the number of any specific block. Learning manual skills in anesthesia is characterized by rapid increase insuccess during the first 20 attempts. Kopacz described the experience of 7 residents during their first six months of training and demonstrated significant improvement over baseline after 20 spinal and 25 epidural anesthetics but that90% success rate was not consistently achieved until 45 spinal and 60 epidural attempts.

Konrad, too, reported arapid improvement in skill acquisition during the first 20 attempts at epidural and spinal anesthesia, arterial lineinsertion, endotracheal intubation and performance of axillary block. After 20 cases he found a 70% success rateachieved by the 11 CA-1 residents he followed.

With 7-9 previous blocks only 50% of residents were able to perform an interscalene block autonomously, whereas with > 15 blocks, 87.5% reported autonomous success.

vii

Duke University Health System recently instituted a teaching model for resident training in regional anesthesia thatinvolves having a CA-3 resident perform PNBs in a preoperative area, as well as assisting CA-1 or CA-2 residentswho were assigned to operating rooms during the performance of their blocks. They were able to increase the totalnumber of experiences with PNBs from 80 (58-105 per resident) to 350 (237-407).

viii

Unfortunately mostresidencies cannot offer this number of blocks to their trainees, and thus, many residents finish training either without being exposed to certain blocks, or without the opportunity to develop proficiency.

Choosing Intelligently

Since the mastery of PNBs frequently does not occur during residency, the successful incorporation of blocks into practice requires that an anesthesiologist continues to acquire skills while often having to work in a rapid turnover environment and meet high surgeon and patient expectations. It is imperative that he or she critically evaluates the practice, looking for blocks that fill specific needs, and choosing techniques that offer a high likelihood of success.Enlisting the surgeon to introduce the concept of PNB while they offer patients’ preoperative instructions willimprove patient acceptance. Local anesthetics should be chosen to minimize onset times and general anesthesia usedto prevent operating room delays. Meticulous follow-up until resolution of all blocks and communication with thesurgeons can add to overall satisfaction.

Local Anesthetics and Adjuvants

Local anesthetic agents should be chosen according to the desired duration of action and the degree of motor blockade required. An insensate extremity in a patient whose procedure may not produce much post-operativediscomfort may be at risk for injury secondary to the loss of protective reflex of pain, or place the patient at risk secondary to a loss of proprioception—blocks of the longest possible duration are not always the wisest choice.Whereas some practitioners combine local anesthetics to decrease onset time while providing long duration,combining chloroprocaine 2% and bupivacaine 0.5% causes pH changes that create a block that resembles one

106Page 2 produced by bupivacaine alone. Galindo concluded that mixing local anesthetics leads to unpredictable blockadecharacteristics.

Local anesthetic diffuses into the nerve and the rate of diffusion is determined by theconcentration, therefore higher concentrations of local anesthetic result in more rapid onset of blockade.Ropivacaine 0.75% has been shown to have similar or shorter onset times for femoral, sciatic and interscalene blocks, while providing significantly longer postoperative analgesia.

x,xi

The effect of alkalinization of agents on the speed of onset of the block is unclear. It has been shown to offer noadvantage in perivascular blocks with 0.5% bupivacaine,

xii

but improvement in onset and quality of analgesia inaxillary blocks with 1.25% mepivacaine,

xiii

and in femoral and sciatic blocks with 2% mepivacaine.

xiv

Addingsodium bicarbonate to lidocaine has been shown to have no effect on the onset of axillary block,

and in rats it has been shown to decrease the intensity and duration of the block.

xvi

In one study fentanyl improved the sensory blockade achieved with an axillary block of 1.5% lidocaine, but the pH changes it conferred delayed the onset of analgesia.

xvii

Other studies have not shown efficacy of either fentanyl or morphine in the improvement of onset or quality of axillary blocks.

xviii,xix

Clonidine, an

-agonist, is known to prolong the duration of sensory and motor blockade, particularly when added to local anesthetics of intermediate duration. One study of 56 patients undergoingcarpal tunnel release under axillary block with 1% lidocaine and varying amounts of clonidine, showed a reductionin block onset time, but even with doses as small as 30

g patients experienced sedation. More than 50% of patientswere reported as dozing intermittently at 140 minutes after the block.

PNBs and When to Use Them

The following is a discussion of some useful blocks and their specific applications for outpatients.

Mid-Tarsal Ankle Block

First described in 1986 by Sharrock

et al.

xxi

this technique blocks the five nerves to the forefoot where they are mostsuperficial, thus requiring a small total volume of local anesthetic (10-15 cc) and offering a high degree of success.It is particularly useful for podiatric procedures and has the advantage over a traditional ankle block in that the posterior tibial nerve is anesthetized with the patient in a supine position, using minimal external rotation, and usingthe posterior tibial artery as a landmark. The deep peroneal nerve is blocked on either side of the dorsalis pedisartery, and a superficial ring from the medial malleolus to the base of the fifth metatarsal completes the block byanesthetizing the saphenous, superficial peroneal and sural nerves. The use of a 27-gauge needle minimizes trauma.

Popliteal Block

The block of the sciatic nerve in the popliteal fossa provides excellent anesthesia for foot and ankle surgeries,including repair of a ruptured Achilles tendon. The saphenous nerve must be blocked in order to provide completeanesthesia below the knee. The intertendinous approach described by Hadzic

et al,

uses the midpoint between thetendons of the biceps femoris and semitendinosus muscles 7 cm above the popliteal cease as the needle insertion point.

xxii

Using a nerve stimulator, one elicits a dorsiflexion, plantarflexion, inversion or eversion response at acurrent <0.4 mA. Forty cc of local anesthetic is then injected in increments. The block requires approximately 30minutes to achieve surgical anesthesia.Collins

et al

., described the impact of a regional anesthesia analgesia (RAA) program for outpatient foot surgery.They retrospectively reviewed 50 charts from patients who had undergone outpatient foot surgery before and after the implementation of the RAA program that resulted in an increase in the use of ankle or lateral popliteal blocksfrom 2% to 82%. All patients in the study had GA combined with their block secondary to the use of a thightourniquet. The mean anesthesia time only increased from 12 + 8.6 min to 13 + 7.3 min (mean + sd)with theaddition of the block, but both PACU and discharge lounge patient stays were significantly decreased. There was adecrease in the number of patients who required greater than one but fewer than four nursing interventions for analgesic administration. This finding may not have achieved statistical significance, secondary to lack of change innursing protocols regarding post operative management, which included the routine administration of oral analgesics prior to discharge from the hospital.

xxiii

In an earlier study at the same institution comparing lateral popliteal block to subcutaneous infiltration in patients undergoing osteotomies of the foot, the use of bupivacaine 0.5% plain, 20 ccwas associated with 1082 min (range 375-1930 min) of postoperative analgesia in the popliteal group.

xxiv

Poplitealfossa neural blockade with saphenous nerve infiltration has been described as the sole anesthetic technique for outpatient foot and ankle surgery. In a study of 48 patients who received this anesthetic for bunionectomy, openreduction and internal fixation of fractures, ankle ligament repair, Achilles tendon repair, hardware removal or ankle

106Page 3arthroscopy (all with proximal calf pneumatic tourniquets), analgesia continued for an average of 10 hours postoperatively. No patients required postoperative intravenous analgesics and all reported a high level of satisfaction.

xxv

This technique preserves contralateral leg strength and ipsilateral hamstring function, and allowsimmediate post-surgical ambulation with crutches, therefore facilitating early discharge.

Infragluteal Sciatic Block

Whereas the posterior approach to the popliteal block is straightforward, many have found the lateral poplitealapproach a bit more difficult. An alternative to this, especially useful for patients who cannot turn prone, is theinfragluteal sciatic block. The patient is placed in the lateral decubitus position with the leg to be blocked, up, rolledforward, and flexed at 90

at the knee. The gluteal crease and lateral border of the biceps femoris muscle areidentified, and 1 cm distal to the intersection, a needle is inserted at a 70-80

angle with a cephalad and anterior orientation.

xxvi

Thirty cc of local anesthetic is injected when plantar or dorsiflexion of the foot is achieved withstimulation < 0.4 mamps.

Femoral/(3-in-1) Block

The lumbar plexus gives rise to the femoral, lateral femoral cutaneous (LFC) and obturator nerves, which providesensory and motor innervation to the leg above the knee. When comparing four needle insertion sites for accuracyin locating the femoral nerve, Vloka found that using the inguinal crease, immediately adjacent to the femoral artery,yielded a higher success rate (as the femoral nerve was significantly wider and closer to the fascia lata), than at thelevel of the inguinal ligament.

xxvii

Using a nerve stimulating technique, the “patella snap” is sought at a current of <0.4 mA. Frequently, a contraction across the thigh is elicited, which represents stimulation of the sartorius muscle.The branches to this muscle may be outside the femoral sheath, and redirection of the needle laterally and deeper should yield the desired response. A femoral block with 20-25 cc of a long acting local anesthetic has been shownconsistently to provide superior postoperative analgesia for anterior cruciate ligament repair, than when compared tothe use of intra-articular local anesthetics.

xxviii,xxix

The femoral nerve block can also be used, in combination with agenitofemoral nerve block, to provide anesthesia for long saphenous vein stripping.

xxx

In 1973 Winnie described a technique of blocking all three nerves of the lumbar plexus using one injection of localanesthetic into the fibrous sheath surrounding the femoral nerve

xxxi

Since that time the efficacy of the block has beendisputed. Ritter studied six cadavers and injected 20cc and 40 cc aliquots of methylene blue dye. He foundconsistent staining of the femoral nerve, occasional staining of the LFC nerves with the larger volumes of dye, andno staining of the obturator nerves.

xxxii

Madej, too, found an 87.5% success rate in blocking the femoral nerve and67.5% for the lateral femoral cutaneous nerve, without evidence of obturator block in his study of 40 patientsundergoing vastus medialis biopsies for malignant hyperthermia.

xxxiii

Magnetic resonance imaging has been used todescribe the spread of the anesthestic during this block. It reveals a lateral, medial and caudal local anestheticspread, which correlates to blockade of the femoral, LFC and anterior branch of the obturator nerves when 30 cc of local anesthetic are used.

xxxiv

Fascia Iliaca Block

The fascia iliaca block provides more consistent block of the LFC nerve than the 3-in 1 block , as there is a reportedincrease in the successful blocking of the LFC from 62%to LFC to 90%.

xxxv

[It, too, can solely provide analgesia for patients with hip, femur and patella fractures or for post-surgical pain, including ACL repair.] It is performed bydrawing the inguinal ligament and then trisecting it. One cm caudal to the junction between the lateral and middlethirds is the location of the needle insertion site. A blunt needle is inserted at a 75

angle to the skin and advanced.The first “pop” is the needle passing through the fascia lata; the second, as it passes through the fascia iliaca. Theneedle angle to the skin is decreased to 30

, the needle advanced 1 cm, and 30 cc of local anesthetic injected. Thelocal anesthetic tracks adequately under the fascia between the psoas and iliacus muscles to block both the femoraland LFC nerves, but does not reliably block the obturator nerve. This block neither requires nerve stimulation nor elicitation of a paresthesia, and therefore can be performed in the PACU in a patient whose surgical site is encasedin a bulky dressing or knee immobilizer.

Axillary Block

The distribution of local anesthetic in the axillary brachial plexus is inconsistent. Whereas Partridge, in his study of 18 cadavers, found incomplete septa dividing the axillary sheath, single injections of dye resulted in staining of themedian, radial and ulnar nerves. He concluded that there was no support for the need for multiple injections when performing an axillary block.

xxxvi

Klaastad, in a study of 13 patients, concludes that there may be little correlation

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