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12 Practical Regional Anesthes
12 Practical Regional Anesthes
V O L U M E T H I R T Y - F O U R
PRACTICAL REGIONAL
ANESTHESIA FOR
OUTPATIENTS
The advantages that regional anesthesia (RA) confers over general anesthesia (GA),
especially in the outpatient setting, are numerous. Pavlin et al., in a prospective study
of 1,088 patients undergoing ambulatory surgery, found that the most important factor
in determining discharge time from the postanesthesia care unit (PACU) was the anes-
thetic technique (general anesthesia, local, peripheral nerve block, or spinal–epidural
anesthesia).1 This study highlights 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 admissions
in one review of 1,996 patients undergoing outpatient orthopedic surgery,2 whereas a
second study found that orthopedic patients are the group of ambulatory patients with
the greatest incidence (16.1%) of pain in the PACU.3 The treatment of pain can increase
PONV and further delay discharge, whereas the nursing care associated with prolonged
PACU stays contributes significantly to overall cost. Peripheral nerve blocks (PNBs)
offer predictable intraoperative anesthesia, analgesia that continues in the postopera-
tive period, the opportunity to bypass phase I recovery, and the avoidance of airway
manipulations. Despite their obvious advantages, PNBs are frequently underused, par-
ticularly in the ambulatory and office-based settings. This Refresher Course discusses
how to choose PNBs appropriate for a patient’s needs, how to modify the block for out-
patient procedures, and how to integrate PNBs into an ambulatory anesthetic practice.
Choosing Intelligently
Because the mastery of PNBs frequently does not occur during residency, the suc-
cessful incorporation of blocks into practice requires that an anesthesiologist contin-
ues 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 tech-
niques that offer a high likelihood of success. Enlisting the surgeon to introduce the
concept of PNB while they offer patients preoperative instructions will improve
patient acceptance. Local anesthetics should be chosen to minimize onset times and
general anesthesia used to prevent operating room delays. Meticulous follow up until
resolution of all blocks and communication with the surgeons can add to overall sat-
isfaction.
Equipment
Making sure that one is familiar with equipment may sound obvious, but equipment
designed for peripheral nerve stimulation has lately undergone many improvements
and changes. Peripheral nerve stimulators should have the following characteristics:
Newer models may offer several options for pulse width and stimulating frequen-
cies. Inappropriate choices may lead to patient discomfort or even difficulties in nerve
location.
Ultrasound is becoming a popular modality for the identification of nerves and
nerve plexuses, but because it is a relatively new and somewhat expensive modality
that may not be available for every practitioner. The rest of this discussion is confined
to the use of surface anatomy and peripheral nerve stimulation.
FIG. 1. Insertion site of needle to block the posterior tibial nerve, posterior to the medial
malleolus and adjacent to the pulsations of the posterior tibial artery.
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 to provide complete anesthesia below the knee. The inter-
tendinous approach described by Hadzic et al. uses the midpoint between the tendons
of the biceps femoris and semitendinosus muscles 7 cm above the popliteal stop as the
needle insertion point (Fig. 3).20 Using a nerve stimulator, one elicits a dorsiflexion,
plantarflexion, inversion, or eversion response at a current <0.4 mA. A dosage of 40 cc
of local anesthetic is then injected in increments. The block requires approximately
30 minutes 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 blocks from
2% to 82%. All patients in the study had GA combined with their block secondary to the
use of a thigh tourniquet. The mean anesthesia time only increased from 12 ± 8.6 min-
utes to 13 ± 7.3 minutes (mean ± standard deviation) with the addition of the block, but
both PACU and discharge lounge patient stays were significantly decreased. There was
a decrease in the number of patients who required greater than one but fewer than four
PRACTICAL REGIONAL ANESTHESIA FOR OUTPATIENTS 129
FIG. 2. Insertion site of the needle to block the deep peroneal nerve adjacent to the dorsalis
pedis artery and the superficial ring that will block the saphenous, superficial peroneal, and sural
nerves.
nursing interventions for analgesic administration. This finding may not have achieved
statistical significance secondary to lack of change in nursing protocols regarding post-
operative management, which included the routine administration of oral analgesics
before discharge from the hospital.21 In an earlier study at the same institution com-
paring lateral popliteal block with subcutaneous infiltration in patients undergoing
osteotomies of the foot, the use of 20 mL bupivacaine 0.5% plain was associated with
1,082 minutes (range, 375–1,930 minutes) of postoperative analgesia in the popliteal
group.22 Popliteal fossa 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, open reduction
and internal fixation of fractures, ankle ligament repair, Achilles tendon repair, hard-
ware removal, or ankle arthroscopy (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.23 This
technique preserves contralateral leg strength and ipsilateral hamstring function, and
allows immediate postsurgical ambulation with crutches, therefore facilitating early dis-
charge.
Pearls
• Ensure the foot is perpendicular to the long axis of the leg when determining
landmarks
• Use at least 40 mL of local anesthetic to ensure that both the tibial and common
peroneal components are blocked
130 ROSENBLATT
FIG. 3. Landmarks for the intertendinous approach to the popliteal nerve block.
Remember that to ensure complete anesthesia below the knee, the saphenous nerve
must be blocked:
• At the knee
• In the inguinal crease
• Confirm that the surgeon is not planning to use a tourniquet at the level of the
thigh
In 1973, Winnie described a technique of blocking all three nerves of the lumbar
plexus using one injection of local anesthetic into the fibrous sheath surrounding the
femoral nerve,28 Since that time, the efficacy of the block has been disputed. Ritter
studied six cadavers and injected 20-mL and 40-mL aliquots of methylene blue dye. He
found consistent staining of the femoral nerve, occasional staining of the LFC nerves
with the larger volumes of dye, and no staining of the obturator nerves.29 Madej, too,
found an 87.5% success rate in blocking the femoral nerve and 67.5% for the lateral
femoral cutaneous nerve without evidence of obturator block in his study of 40
patients undergoing vastus medialis biopsies for malignant hyperthermia.30 Magnetic
resonance imaging has been used to describe the spread of the anesthetic during this
block. It reveals a lateral, medial, and caudal local anesthetic spread, which correlates
to blockade of the femoral, LFC, and anterior branch of the obturator nerves when
30 mL of local anesthetic is used.31
Pearls
• Performing the block at the level of the inguinal crease allows easy palpation of
the femoral nerve
• If a sartorius twitch is elicited, walk the stimulating needle laterally to elicit one
from the patella tendon
FIG. 4. Insertion site of the needle for the fascia iliaca block.
132 ROSENBLATT
centimeters caudal to the junction between the lateral and middle thirds is the loca-
tion of the needle insertion site (Fig. 4). 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. The needle angle to the skin is decreased
to 30°, the needle advanced 1 cm, and 30 mL of local anesthetic injected. The local
anesthetic tracks adequately under the fascia between the psoas and iliacus muscles
to block both the femoral and 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 encased
in a bulky dressing or knee immobilizer.
Pearls
• Use blunt needles (i.e., at least a 22-gauge pencil-point or short-bevel needle)
• Ensure that your initial puncture has not pierced the fascia lata
Axillary Block
The distribution of local anesthetic in the axillary brachial plexus sheath is incon-
sistent. Whereas Partridge, in his study of 18 cadavers, found incomplete septa divid-
ing the axillary sheath, single injections of dye resulted in staining of the median, radial,
and ulnar nerves. He concluded that there was no support for the need for multiple
injections when performing an axillary block.33 Klaastad, in a study of 13 patients, con-
cluded that there may be little correlation between the spread of methylene blue in
cadavers and what occurs with local anesthetics in humans. He used a catheter tech-
nique and, after stimulating the median nerve, showed irregular areas of local anes-
thetic spread in the cross-section views of his magnetic resonance imaging studies.
Patients with complete filling of the circle also demonstrated incomplete blocks.34
Studies of arm position affecting spread have yielded conflicting results. Yamamoto
found, in a study of 80 patients, that central spread of local anesthetic was facilitated
by injection without abduction of the arm,35 whereas Koscielniak-Nielsen found no
effect of arm position on the circumferential or proximal spread of local anesthesia
after axillary block in 90 patients.36 Proximal spread was not found to be as important
as circumferential spread in providing complete plexus anesthesia.37
A transarterial approach to axillary blockade is technically simple, usually quick to
perform, and associated with a high success rate when large volumes (50–60 mL) of
anesthetic are used.38 The axillary nerve regularly and the musculocutaneous nerve in
more than half of cases exit the neurovascular bundle proximally and should be
blocked individually if a tourniquet will be used or if the procedure is in the sensory
distribution of the musculocutaneous nerve. Multiple injection techniques are suc-
cessful, using smaller amounts of local anesthetic, but require familiarization with the
equipment, longer times to perform, and a high rate of discomfort during block place-
ment (18.3%).39 When using a multiple stimulation technique, the rate of blocking the
musculocutaneous nerve after stimulating the median and radial nerves is only 80%,
so the use of a third stimulation (of the musculocutaneous nerve) may be required.40
Supplemental blocks at the elbow or wrist can convert a partial block into a success-
ful one.
Pearls
• Blockade of the musculocutaneous nerve—5–7 mL within the coracobrachialis
muscle
• Blockade of the intercostobrachial nerve—subcutaneous band of local anesthetic
from site of previous needle insertion posteriorly toward the operating room table
PRACTICAL REGIONAL ANESTHESIA FOR OUTPATIENTS 133
Infraclavicular Block
Infraclavicular block of the brachial plexus provides anesthesia for surgery of the
forearm, wrist, hand, and elbow. One advantage of this block is that it can usually be
performed with the arm in any position, rather than requiring abduction (and it offers
the ability to affix an indwelling catheter on the chest—a more stable and easier loca-
tion to maintain sterility than in the axilla). One approach to this block uses the cora-
coid process as a landmark, and the needle is inserted 2 cm medial and 2 cm caudad
to the tip of the coracoid process (Fig. 5). The distance from the skin to the anterior
wall of the neurovascular bundle has been shown to be 4.24 ± 1.49 cm (2.25–7.75 cm)
in men and 4.01 ± 1.29 cm (2.25 ± 6.5 cm) in women,41 and a motor response of the
wrist or hand at a current of <0.5 mA has been associated with reliable anesthesia and
minimal complications and side effects.42 Borgeat et al. describe a modified approach
of the Raj technique. They abduct the arm and increase it approximately 30° and then
use the surface landmarks of the anterior acromial process, jugular notch, and emer-
gence of the axillary artery. A skin wheal is raised 1 cm caudad below the inferior bor-
der of the clavicle at its midpoint, and the needle is directed laterally toward the emer-
gence of the axillary artery at a 45° to 60° angle to the skin. When they accepted
flexion/extension of the wrist or fingers at currents <0.5 mA, a success rate >97% was
reported.43 Stimulating the individual cord(s) that coincide with the specific region of
the surgery will increase block success. Borene has recently described how following
the direction of the movement of the fifth finger in response to stimulation identifies the
cord that is being stimulated.44
FIG. 5. Insertion site of the needle to perform the coracoid approach to the infraclavicular
block.
134 ROSENBLATT
Pearls
• Do not accept biceps stimulation
• Move the needle caudad and laterally
• Never go medially (toward the lung!)
• Keep the arm adducted
Interscalene Block
Surgery of the shoulder is easily performed with interscalene block anesthesia. Mul-
tiple studies have reported that interscalene anesthesia provides excellent surgical
conditions (analgesia and muscle relaxation), and patients experience less PONV, have
fewer unplanned hospital admissions, and shorter nonsurgical intraoperative and
PACU times than those who have general anesthetics.45,46 In a study of 25 patients who
had previous shoulder surgery with general anesthesia and who chose interscalene
block for a second operation, 24 reported that they would prefer the regional tech-
nique if they required any subsequent procedures.47 This block is associated with 100%
incidence of ipsilateral hemidiaphragmatic paresis,48 which may not make it ideal for
patients with respiratory compromise, and a 17% to 24% incidence of activation of the
Bezold-Jarisch reflex (hypotension and bradycardia), possibly induced by increased cir-
culating epinephrine in the sitting position.49 The overall rate of neurologic compli-
cations associated with interscalene block for shoulder surgery has been reported to
be as high as 14% 10 days postoperatively. Symptoms include paresthesia, dysesthe-
sia, and pain not related to surgery. The majority of these symptoms resolve sponta-
neously, with only 0.2% (one of 520) of patients reporting persistent dysesthesia at
9 months postoperatively.50 It is imperative to accept stimulation of the biceps, triceps,
or deltoid muscles at <0.4 mA, and not to allow a trapezius stimulation with its con-
current upper extremity movement to be an acceptable end point. Interscalene anes-
thesia with 30 mL of 0.5% bupivacaine, 0.5% ropivacaine, and 0.75% ropivacaine were
all associated with mean onset of sensory and motor blocks <6 minutes and similar
recovery characteristics.51
Pearls
• Every attempt should tell you something
• If you elicit phrenic nerve stimulation (diaphragm) you are in the anterior sca-
lene—reinsert needle posteriorly
• If you elicit trapezius muscle stimulation—look for another groove anteriorly
• The surgeon must inject for posterior portals
after 60 minutes of observation.53 A cost analysis study of anesthetic techniques for out-
patient hand surgery found that IVRA conferred an approximately 30% cost savings over
general anesthesia and brachial plexus blocks, which was secondary to shorter induc-
tion times and lower anesthetic drug and equipment costs.54
Conclusions
The use of PNBs is associated with shortened postprocedure operating room, PACU
and discharge times, the provision of postoperative analgesia, and a high level of
patient satisfaction. Epidural anesthesia with short-acting agents may offer advantages
over spinal anesthesia in the ambulatory setting. Regional anesthetic techniques
should be both encouraged and used for extremity procedures in outpatients.
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PRACTICAL REGIONAL ANESTHESIA FOR OUTPATIENTS 137
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