Continuous peripheral nerve blocks in hospital wards after orthopedic surgery: a multicenter prospective analysis of the quality of postoperative analgesia and complications in 1,416 patients

Outpatient Management of Continuous Peripheral Nerve Catheters Placed Using Ultrasound Guidance: An Experience in 620 Patients

BACKGROUND

Continuous peripheral nerve block (CPNB) is an optimal choice for analgesia after orthopedic procedures, but is not commonly used in outpatients because of concern regarding the possibility of catheter-related complications. In addition, it may be difficult to provide adequate patient access to physicians in this setting. We present 620 outpatients who were treated with CPNB using an established protocol.

METHODS

All catheters were placed using direct ultrasound visualization. These patients received extensive oral and written preoperative instruction and were provided continuous telephone access to the anesthesiologist during the postoperative period. All patients were also contacted at home by telephone on the first postoperative day. In addition, each patient was seen and examined by the surgeon within 2 wk of hospital discharge.

RESULTS

Of the 620 patients, there were 190 interscalene (brachial plexus), 206 fascia iliaca (femoral nerve), and 224 popliteal fossa (sciatic nerve) catheters. Two patients (0.3%) had complications related to the nerve block. In both of these patients, the symptoms resolved within 6 wk of surgery. Twenty-six patients (4.2%) required postoperative interventions by the anesthesiologist. One patient returned to the hospital for catheter removal.

CONCLUSIONS

In this large series of outpatients treated with CPNB, there were surprisingly few interventions requiring an anesthesiologist. Likewise, patients were able to manage and remove their catheters at home without additional follow-up. This suggests that with adequate instruction and telephone access to health care providers, patients are comfortable with managing and removing CPNB catheters at home.

The Feasibility and Complications of the Continuous Popliteal Nerve Block: A 1001-Case Survey

Perineural catheters are increasingly used worldwide for the treatment of postoperative pain in orthopedics. Long-term complications associated with the placement of a perineural catheter remain largely unstudied. We investigated the efficacy and the acute and late complications associated with the continuous popliteal nerve block. One-thousand-one patients undergoing elective surgery of the ankle or foot and scheduled to have a continuous popliteal nerve block were prospectively evaluated. All patients received an initial bolus of 40 mL ropivacaine 0.5% through the catheter. A continuous infusion of ropivacaine 0.3% initiated 6 h after the initial bolus was administered for the first 24 h and then decreased to ropivacaine 0.2% until the end of the study period. The success rate and acute complications were recorded. The overall success rate was 97.5%. The highest success rate was associated with foot inversion. Acute complications consisted of paresthesias during nerve localization (0.5%), pain during local anesthetic application (0.8%), and blood aspiration (0.4%). No central nervous system toxicity or cardiotoxicity occurred. Late complications were checked at 10 days and 3 mo after surgery. These included two cases of inflammation at the puncture site. No infection or neuropathy was observed. The use of continuous popliteal nerve block for ankle or foot surgery is associated with frequent success and few acute and late complications.

Responding to Challenges in Modern Combat Casualty Care: Innovative Use of Advanced Regional Anesthesia

BACKGROUND

The war in Iraq has resulted in a high incidence of severe extremity injury requiring multiple surgical procedures and extensive rehabilitation. We describe the use of advanced regional anesthesia to meet this significant medical challenge.

METHODS

From March 2003 to December 2004, 4,100 casualties have been evacuated to Walter Reed Army Medical Center (WRAMC). Of 1,400 inpatients, 750 have been battle-injured with 500 having extremity injuries. Of these, 287 (57%) received surgical care incorporating regional anesthesia including single-injection peripheral nerve blocks and continuous peripheral and epidural infusion catheters. Wounding, surgical, anesthetic, and outcomes data have been prospectively collected.

RESULTS

Over 900 operations (mean 4+/-2/patient) were performed on 287 casualties prior to arrival at WRAMC, and 634 operations (mean 2+/-1/patient) were performed at WRAMC. Thirty-five percent of this cohort was amputees. In the study group, 646 advanced regional anesthesia procedures, including 361 continuous peripheral nerve blocks (CPNBs), were performed with a mean catheter infusion time of 9 days (1-34). Catheter-related complications occurred in 11.9% of casualties and were technical or minor in nature. Catheter-related infection rate was 1.9%. In 126 casualties with indwelling CPNB catheters, a significant decrease in pain score over 7 days was apparent (mean 3.7+/-0.2 to 2.2+/-0.2, P<0.001).

CONCLUSION

Advanced regional anesthetic techniques allowed for safe perioperative surgical anesthesia and analgesia in the management of the modern combat casualty.

Perioperative management of chronic pain patients with opioid dependency

PURPOSE OF REVIEW

In this article, we discuss the perioperative anesthesia and pain management of patients with chronic pain receiving chronic opioid administration. In our practice we may expect to be confronted with opioid-dependent patients in routine anesthesia practice and should acquire specific knowledge and skills to effectively manage the perioperative and acute pain management issues that arise.

RECENT FINDINGS

The number of patients treated chronically with opioids has increased steadily over the past decade; currently about 10% of all chronic-pain patients are treated with opioids. As these patients are no longer confined to terminally ill cancer patients, growing numbers of these patients are facing surgical interventions.

SUMMARY

In our clinical practice, we should employ multimodal pain management therapy by using an around-the-clock regimen of nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, acetaminophen, and regional blockade. Dosing regimens should be individualized to optimize efficacy while minimizing the risk of adverse events.

Cost drivers in anesthesia: manpower, technique and other factors

PURPOSE OF REVIEW

This article reviews the recent literature on cost drivers in anesthesia with respect to staff, techniques and drug costs, and with special focus on anesthesia workflow in the postanesthesia care unit. Moreover, the costs of post-operative pain management provided by an acute pain service are highlighted.

RECENT FINDINGS

Staff costs represent the main contributor to anesthesia costs in all studies. Therefore, many studies address the reduction of personnel costs, e.g. by using fast-tracking procedures which allow the patients to bypass the postanesthesia care unit. However, postanesthesia care unit bypassing and replacement of anesthesiologists by certified anesthesia nurses were not able to significantly decrease anesthesia costs. If anesthesiologists are reimbursed by surgically controlled time, this time is the main determinator for anesthesia costs and should be carefully monitored. Regional anesthesia techniques can help to reduce costs in the ambulatory setting because of reduced post-operative side-effects and earlier home readiness of the patients. Low gas flow and modern electroencephalographic monitoring can contribute to decreased drug-related costs. Acute pain services are mainly run by anesthesia staff thus increasing the costs in anesthesia departments. However, an acute pain service can reduce costs of surgical procedures significantly.

SUMMARY

Clear definition of the meaning of cost drivers and of criteria which allow assessment of patients' condition, and peri-operative standard operating procedures are warranted to ensure comparability of economic data in anesthesia.