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Postgrad Med J' 1996; 72: 105-108 C) The Fellowship of Postgraduate Medicine, 1996

Local anaesthesia for major general surgical Postgrad Med J: first published as 10.1136/pgmj.72.844.105 on 1 February 1996. Downloaded from procedures A review of 1 16 cases over 12 years

A Dennison, N Oakley, D Appleton, J Paraskevopoulos, D Kerrigan, J Cole, WEG Thomas

Summary ation was collated from medical notes, anaes- Between 1980 and 1992, 116 patients had thetic records and operation notes. Cases in either a simple mastectomy (32) or intra- which local anaesthesia was augmented by abdominal procedures (84) under local regional or intravenous techniques were exc- anaesthesia (0.5-1% lignocaine with luded from the study. Patients were not 1:200 000 ). A wide variety of included ifthey had neck/head or limb , general surgical procedures were feasible abdominal repair, simple drainage of using only supplementary intravenous intra-abdominal abscess or any minor proce- (54%). Complications were un- dures including peritoneo-venous shunts, common and related to surgical proce- laparoscopic or endoscopic procedures. dure (three incorrect diagnoses, three The 116 patients presented in the study are procedures impossible) rather than the those who had intra-abdominal surgery (84; 53 anaesthetic technique. There were no women, 31 men) or simple mastectomy (32). anaesthetic toxicity or postoperative pro- The median age was 74 years (range 27-92) blems. Local anaesthesia is extremely and all the patients were grade III or worse on safe and facilitates larger surgical proce- the American Society of Anaesthesiologists dures than is generally appreciated. (ASA) classification of illness (box 1). The decision that a procedure would be best Keywords: anaesthetic techniques, local anaesthesia, performed under local anaesthesia was always general surgery made jointly between the senior surgeon and anaesthetist based on individual clinical grounds. The absolute requirement was full Over recent decades there have been significant consent and co-operation ofthe patient and was advances in general anaesthesia but surgery in obtained after full discussion in all cases. The http://pmj.bmj.com/ the elderly and in patients with significant anaesthetist was always present in theatre to medical problems still has an attendant mor- monitor the patient and in case sedation or bidity and mortality. Local anaesthesia has general anaesthesia was required. The ASA been steadily refined since its' introduction by standards for basic intra-operative Koller in 1884' and is now widely used in a were observed in all cases with more intensive number of surgical specialities, particularly monitoring at the anaesthetist's discretion with ophthalmology. In general and orthopaedic regard to the procedure and the patients' pre- surgery, whilst a limited number of operations morbid condition. on September 26, 2021 by guest. Protected copyright. (such as hernia repair) are frequently per- formed under local anaesthesia, this procedure Local anaesthetic technique is not widespread. A number of authors have Royal Hallamshire described the use of local anaesthesia for more with 2 mg oforal lorazepam was Hospital, Sheffield S10 major procedures24 but in general these tech- used in many of the earlier patients but was 2JF, UK niques were employed of necessity rather than Department of choice. This is particularly so for Surgery intra- A Dennison abdominal procedures. This review presents N Oakley the operations that have been performed by J Paraskevopoulos four enthusiasts over a 12-year period. The aim ASA classification ofillness D Kerrigan is to highlight the potential of local anaesthesia WEG Thomas * Grade I: A fit and healthy patient by demonstrating the range of procedures that * Grade II: A patient Department of can be safely the with mild systemic Anaesthesia, undertaken, techniques illness D Appleton involved and the possible complications. * Grade III: A patient with severe systemic J Cole illness that is not incapacitating Patients and methods * Grade IV: A patient with an incapacitating illness that is a constant threat to life Correspondence to Neil * Grade Oakley, Lincoln County The study consists of a case review of all V: A moribund patient who is not Hospital, Greetwell Road, expected to live for more than 24 hours, with Lincoln, UK patients operated on under local anaesthesia or without surgery (not regional) by four surgeons (AD, JP, DK Accepted 5 September 1995 and WEGT) between 1980 and 1992. Inform- Box 1 106 Dennison, Oakley, Appleton, et al

abandoned because it was felt this disinhibited prevent direct intravenous or injec- elderly patients. Any supplementary sedation tion into inflamed tissue (box 2). was given the calculated by anaesthetist who The choice oflocal anaesthetic was left to the Postgrad Med J: first published as 10.1136/pgmj.72.844.105 on 1 February 1996. Downloaded from the maximal dose of local anaesthetic, usually surgeon performing the operation as there were lignocaine 0.5 or 1% with 1:200000 adren- differing indications for each agent (table 2). aline. Occasionally prilocaine (also with The addition ofadrenaline reduced the amount adrenaline) or bupivocaine were used when a of local anaesthetic reaching the circulation by larger volume than usual was needed or the decreasing the uptake from the injection site, prolonged action of bupivocaine was felt likely thereby giving the local anaesthetic a greater to be of benefit postoperatively. In all cases the effect and longer duration of action. Following surgeon's aim was to perform the procedure using the minimum amount oflocal anaesthetic required to give adequate anaesthesia. All planned incisions were marked with Bonneys blue and anaesthetic was infiltrated Local anaesthesia: dose calculation beneath the marked area, specifically and then diffusely into deeper fascial layers. Our Wt/volume measurements are given as g/dl (ie, previously described technique for mastec- 1% = 1 g/100 ml ofsolvent) tomy has not changed.4 Skin infiltration was Hence, occasionally supplemented by a little Volume allowable (ml) = infiltration into the pectoralis major fascia. In (safe dose [mg/kg]) x (patient's weight[kg]) abdominal cases the skin infiltration was 10 x (wt/vol percentage[g/dl]) augmented by infiltration ofthe extraperitoneal space when reached. As a general rule in NB Adrenaline maximum dose = 500 lg = intra-abdominal procedures, an attempt was 100 ml at 1:200 000 concentration made not to exceed 50% of available anaes- thetic into the peritoneal cavity. Box 2 As the only sensation appreciated by visceral peritoneum is stretch, both cutting and the use of diathermy are painless. Any remaining local Basic monitoring standards ofthe anaesthetic was saved for infiltration across the ASA mesentery of bowel to be resected but it was found that with gentle handling of the bowel * Standard 1: Qualified anaesthesia personnel and avoidance of stretch, the intraperitoneal shall be present in the room throughout the part of the procedure could be performed with conduct ofall general anaesthetics, regional no additional anaesthesia. anaesthetics and monitored anaesthesia care * Standard 2: During all anaesthetics, the patient's oxygenation, ventilation, circulation MAXIMUM DOSE CALCULATION and temperature shall be continually While recommended maximum doses of local evaluated. anaesthetics offer a useful guide (table 1), the

current manufacturer's recommendations are Box 3 http://pmj.bmj.com/ by necessity over cautious and not fully just- ified on a scientific basis.5 As the risk of toxic side effects on the and Basic monitoring required during cardiovascular system (box 2) is directly related local anaesthesia to blood concentrations, great care was taken to * oxygenation: , adequate illumination, observe/auscultate ventilation * circulation: ECG continuously displayed, on September 26, 2021 by guest. Protected copyright. Table 1 Toxicity data and potency of local anaesthetic agents and every 5 mins (adapted from Reynolds)6 * temperature: ready available means to continuously monitor temperature Bupivocaine Lignocaine Prilocaine Box 4 Max. safe dose, plain 2-3.5 3-4.5 6 (mg/kg) Max. safe dose (mg/kg), with 2-3.5 7 6-8* adrenaline 1:200 000 Local anaesthesia: toxic effects Relative potency 3-4 1 1 *Limited due to methaemoglobin formation * CNS: circumoral tingling + nervousness/ excitability + convulsions -> coma -> respiratory arrest * CVS: depressed myocardial excitability, Table 2 Indications for use of particular agent contractility and conductivity -* and decreased pulse Bupivocaine Lignocaine Prilocaine rate -* cardiac arrest * respiratory: due to Advantages longest action rapid onset low toxicity hypersensitivity reaction, most potent largest volume largest volume methaemoglobinaemia with prilocaine (with adrenaline) (without adrenaline) * local: ischaemic tissue necrosis due to for infiltration for infiltration adrenaline Disadvantages least volume for least potent least potent infiltration Box 5 Local anaesthesia for major surgery 107

inadvertent intravascular injection, the tachy- had an end-to-end anastomosis, the other two cardia from adrenaline also gives warning of had Paul-Mikulicz colostomies. The other pending complications, constant three large bowel resections were limited resec- monitoring Postgrad Med J: first published as 10.1136/pgmj.72.844.105 on 1 February 1996. Downloaded from being essential (boxes 3 and 4). tions ofcaecal carcinoma, ischaemic bowel, and Blood levels of local anaesthetic were not leaking anastomosis line. measured as toxicity from normal, slow absorp- tion of correctly placed local anaesthetics (box Discussion 5) in a submaximum dose has not been shown to be a problem.6 The operations described here indicate the type ofprocedure that, with the help ofthe anaesth- Results etist, can be performed under local anaesthesia and demonstrate the very low associated mor- Adequate anaesthesia was produced in all bidity and mortality. The choice ofpatients and patients and allowed the performance of the the indications for the use of local anaesthetic surgery without significant deviations from the tended to be relative rather than absolute and usual technique. No patient had to be con- decided in consultation with the anaesthetist. verted to a . There was no In younger patients problems were often more local anaesthetic toxicity encountered and no specific but in the elderly patients, familiarity patient had any immediate postoperative prob- with the effectiveness of this method gradually lems related to the technique. Surgical mor- altered our approach so that we used it out of bidity in terms of skin haematoma, skin nec- choice rather than due to lack of choice. rosis, discomfort, or an increase in the wound We have previously described the advantage infection rate was absent. of performing simple mastectomy under local Local anaesthetic dosage did not exceed 80% anaesthesia and we have continued to use this of the maximum recommended dose in any method. It is extremely valuable in elderly patient. However, 62 patients (54%) were patients whose tumours have escaped tamoxi- given additional intravenous sedation but then fen control (or who are unlikely to comply with only in small doses (2.5-5 mg diazepam), to treatment) or in those patients whose lesions prevent disinhibition that can oocur with larger are large or unpleasant at initial presentation. doses. A total of 84 patients had intra-abdominal Theoperationsperformed are shown in table 3. procedures for a wide range ofpathology and in No procedure was possible in three elderly none did the use oflocal anaesthesia prevent the patients with extensive mesenteric ischaemia correct operation being performed. A case in but this was anticipated and the laparotomy point was a patient with a perforated duodenal was essentially diagnostic, removing the need ulcer and a low-lying liver, displaced below the for a general anaesthetic in very ill, hypotensive incision by emphysema. More local anaesthetic patients. Incorrect pre-operative diagnoses was infused to extend the incision and gentle were made in three patients, however the use of retraction successfully employed. a local anaesthetic did not preclude the correct In our experience, there are few absolute operation (caecostomy for pseudo-obstruction, contraindication to local anaesthesia: patient enterostomy for widespread intraperitoneal refusal or non-compliance being the most sign- http://pmj.bmj.com/ malignancy, and reduction of lateral space ificant. requires more anaesthetic (but hernia). usually still less than 80% ofthe maximal dose) Of the six patients who had large bowel resections, five had supplemental infiltration of the mesentery. Sigmoid colectomy for volvulus was successfully performed in three patients, one who had already had a bowel preparation, Summary ofresults on September 26, 2021 by guest. Protected copyright. * conversion to general anaesthetic not required but approximately halfrequired supplemental Table 3 Procedures performed (n = 116) sedation * < 80% ofmaximum dose oflocal anaesthetic Agegroup used with no toxic side-effects Procedure Number (years) * local side-effects comparable to general * obesity no contraindication Mastectomy 32 49-89 Appendicectomy 11 34-89 Cholecystotomy 11 62-81 Box 6 Stoma formation 16 66-83 Perforated peptic ulcer 8 34-92 Closure ofstoma 12 62-85 Laparotomy dehiscence repair 4 59-77 Local anaesthesia: key points Gastroenterostomy 4 69-80 * Laparotomy for mesenteric 3 61-73 wide range ofmajor surgical procedures ischaemia feasible duodenalulcer 2 43-71 * requires close co-operation with and Large bowel resection 6 73-88 monitoring by anaesthetist Adhesionolysis 2 41-67 * patient compliance and understanding Enterostomy 1 27 essential Internal hernia and bowel 3 57-79 * awareness ofpotential of local anaesthesia resection widens treatment options Detorsion sigmoid 1 76 Box 7 108 Dennison, Oakley, Appleton, et al

and is technically more difficult but is still between anaesthetist, surgeon and patient in a feasible. The presence of an anaesthetist is careful standardised approach.

essential for assistance in monitoring the Much damage was done by WR Stone in Postgrad Med J: first published as 10.1136/pgmj.72.844.105 on 1 February 1996. Downloaded from patient and administering additional sedation. 19018 when he wrote "The presence of an This will obviously also allow the use ofgeneral anaesthetist and his expertise can be dispensed anaesthetic if the need arises. The usually with if cocaine be employed". We believe that quoted reasons for why local anaesthetic is surgeons and anaesthetists should adopt a more under used (Britain performs less procedures positive approach to local anaesthesia. Our under local anaesthetic than Scandinavia, the experience has demonstrated that many major USA or the Third World5'6) are fear of failure, operations are technically possible under local the time taken for induction, the fear of neuro- anaesthesia which facilitates a far wider range logical complications and the unpopularity of ofsurgical procedures than is generally apprec- having an awake patient.7 Clearly these object- iated. ions can all be overcome by co-operation

1 Koller C. On the use ofcocaine for producing anaesthesia on 5 Scott DB. Maximum recommended doses of local anaes- the eye. Lancet 1884; 2: 990-2. thetic drugs. Br J Anaesth 1989; 64: 373-4. 2 Caffee HH, Benfield JR. Data favouring biopsy ofthe breast 6 Reynolds F. Adverse effects of local anaesthetics. Br J under local anaesthesia. Surg Gynecol Obstet 1975; 140: Anaesth 1987; 59: 78-95. 88-90. 7 Atkinson RS, Rushman GB, Lee AJ. Regional anaesthesia 3 Howard CB, Mackie IG, Fairclough J, Austin TR. Femoral In: A synopsis ofanaesthesia, 10th edn. Bristol: Wright, 1987; neck surgery using a local anaesthetic technique. Anaesthesia pp 593-6. 1983; 38: 993-4. 8 Stone WR. Cocainization of the by means of 4 Dennison AR, Watkins RM, Ward ME, Lee ECG. Simple lumbar puncture during labor. Am J Obstet 1901; 63: mastectomy under local anaesthesia. Ann R Coll Surg Engl 145-55. 1985; 67: 243-4.

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