586. Regional Anesthesia Outside the Operating Room: Indications And

REVIEW CURRENT OPINION Regional anesthesia outside the operating room: indications and techniques Frederik De Buck, Sarah Devroe, Carlo Missant, and Marc Van de Velde Purpose of review Regional anesthesia is not only performed in the operating room. There are indications for the use of these techniques for pain relief in the emergency department and for anesthesia support of procedures outside the operating room. In this review, we will provide an overview of the indications for the regional techniques performed in the out-of-operating room environment. Recent findings In the emergency department, patients may experience significant pain, and adequate analgesia is not always provided. Regional analgesia is effective and indicated for many trauma situations including hip fracture, reduction of shoulder dislocation, treatment of upper limb fractures and multiple rib fractures. Ultrasound guidance makes the performance of regional blocks more accessible and safer for use in the emergency department setting. For therapeutic procedures outside the operating room, regional anesthesia is possible for uterine artery embolization and for postoperative analgesia after implantation of cervical brachytherapy needles. Summary Regional anesthesia is a valuable option for analgesia in trauma patients, enabling improved pain control in the emergency department and has benefits in the anesthetic management of therapeutic procedures outside the operating room. For many blocks, ultrasound guidance is useful. Keywords cervical brachytherapy, hip fracture, multiple fractured ribs, regional anesthesia, shoulder dislocation, uterine artery embolization INTRODUCTION room and in locations outside the operating room Regional anesthetic techniques have well known in which patients undergo diverse procedures, for benefits for the surgical patient and are well estab- which anesthesia is sometimes needed. lished in the operating theatre for perioperative and postoperative care. REGIONAL ANESTHESIA IN THE Their use during surgery and in the post- EMERGENCY ROOM operative period offers excellent pain control, and decreases the need for systemic analgesics Trauma patients presenting in the emergency room [1&]. Outcome studies demonstrate benefits of generally experience significant levels of pain and regional anesthetic techniques with faster recovery, stress. Analgesia is therefore an important part of decreased length of hospital stay [2] and improved the care of these patients, even before the definitive cardiac and pulmonary function postoperatively treatment, operative or otherwise, of their injuries [1&]. The use of regional anesthesia is associated [4]. with decreased neuroendocrine stress responses in & the perioperative period [3 ]. University Hospitals Leuven, Department of anesthesiology, Leuven, Although the same benefits and favorable out- Belgium comes of regional anesthesia are also valid outside Correspondence to Frederik De Buck, MD, University Hospitals Leuven, the operating theatre, the use of these techniques is Department of anesthesiology, Herestraat 49, B-3000 Leuven, Belgium. less common. Tel: +32 16 343825; e-mail: [email protected] In this review, we will focus both on the use of Curr Opin Anesthesiol 2012, 25:501–507 regional anesthetic techniques in the emergency DOI:10.1097/ACO.0b013e3283556f58 0952-7907 ß 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins www.co-anesthesiology.com Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Anesthesia outside the operating room however their use is limited due to difficulties in KEY POINTS positioning of the patient and the hemodynamic Regional anesthesia is beneficial for patients with a side-effects of a more extended block. Also an wide variety of trauma, including hip fracture, shoulder increased risk of serious neurologic side-effects has dislocation and multiple fractured ribs. recently been reported, especially in the elderly [10]. Peripheral nerve blocks lack these disadvan- With the use of ultrasound guidance, many blocks can tages; useful techniques include the femoral nerve be safely performed in the emergency department. block and the fascia iliacae compartment nerve In patients with multiple rib fractures, regional block (FICB). Both can be administered in a supine analgesia techniques allow for a significant reduction patient and only block the affected limb, limiting in the duration of mechanical ventilation when the possibility for hemodynamic disturbances. They compared with systemic opioid analgesia. can be placed with or without ultrasound. Local anesthetic systemic toxicity is a risk with certain regional techniques, and resuscitation equipment including lipid emulsion should always be readily Femoral nerve block available in areas where these procedures The femoral nerve block is well established in the are performed. perioperative pain control of hip fracture repair. Regional anesthesia has a role for therapeutic Theaimofthethree-in-onefemoralnerveblock procedures outside the operating room. is to anesthetize the lateral cutaneous, obturator and femoral nerves using a single injection [11]. It can be performed using a landmark-based technique. In patients with a fractured femoral neck, Recent surveys have demonstrated great vari- the femoral nerve may be easier to approach at the ation in the use of analgesics and analgesic strategies mid-inguinal crease [12]. When only landmarks are in different emergency rooms, with the majority of used there is a risk of injecting local anesthetic into trauma patients receiving inadequate pain relief [5]. the femoral artery or vein, resulting in local anes- Terms such as ‘hypoanalgesia’ are used in describing thetic systemic toxicity (LAST) [13&]. Nerve stimu- the status of pain control in the emergency rooms lation to localize the nerve reduces the risk for [6&&]. intravascular injections, but can be painful in the Systemic analgesia may be avoided in trauma traumatized patient, due to induced muscle move- patients because of concerns about hemodynamic ments. Ultrasound guidance for femoral nerve and respiratory function. Furthermore, an adequate block is feasible in the emergency room and helps assessment of mental status can be hindered by the minimize the pain associated with this procedure. use of systemic sedative analgesics such as opioids. [14]. This technique is also useful for pediatric Regional anesthetic techniques can prove patients [15&]. beneficial for trauma patients, even before they Care has to be taken, especially in high-impact arrive in the operating theatre. Early, effective anal- injuries, that compartment syndrome of the thigh is gesia can provide better conditions and reduce the not masked or overlooked when using a femoral stress response during transport and the initial nerve block [16&&]. examination of trauma patients [7&&]. Theoretically, better pain control achieved with the use of regional techniques can have a positive Fascia iliaca compartment block impact on the eventual outcome of the patient, The fascia iliaca compartment block is an alternative reducing the chance of developing chronic pain to the femoral nerve block for analgesia after a and post-traumatic stress disorders. fracture of the femoral neck. It appears to be equally effective, and easy to learn for emergency room physicians, without a background in anesthesiology Lower extremity trauma [17&]. The fascia iliaca compartment block is a land- Fractures of the hip are associated with severe pain, mark-based technique with identification of the and often occur in the elderly patient population fascia iliaca compartment by a ‘double-plop’ tech- making the use of systemic opioids challenging [8]. nique. There is no need for identification of the In this population, the use of regional analgesia has nerve, because the local anesthetic spreads in been shown to improve analgesia with fewer side- the fascia iliaca compartment where the femoral effects than systemic analgesia [9&]. nerve also passes [17&]. Cephalad spread of the local Neuraxial techniques such as epidural block anesthetic is enhanced by manual compression on can provide excellent analgesia for hip fractures, the thigh distal to the injection site. 502 www.co-anesthesiology.com Volume 25 Number 4 August 2012 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Regional anesthesia outside the operating room De Buck et al. The fascia iliaca compartment block is also evacuation of abscesses of the upper extremities effective for analgesia in pediatric patients, using [27]. Ultrasound guided supraclavicular nerve block a similar technique [18]. is an alternative to the interscalene brachial plexus Ultrasound guidance is possible when the block and can be performed without nerve stimu- ‘double-plop’ technique is difficult to perform, lation. The supraclavicular nerve block has a lower especially in children [19] and increases the efficacy incidence of recurrent laryngeal nerve and phrenic and success rate of the block [20]. The use of ultra- nerve paralysis compared with the interscalene sound also allows placement of a catheter in the fascia approach, making this technique preferable in iliaca compartment, for long-lasting pain relief [21&]. selected patients. The use of ultrasound guidance also reduces the risks of pleural or vascular punctu- res. Other peripheral nerve blocks for the lower The suprascapular nerve block can be used as an limb alternative

Load more