Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Jun 2002
ReviewContinuous interscalene block for ambulatory shoulder surgery.
Management of acute post-operative pain due to shoulder surgery may be successfully and consistently achieved in ambulatory patients by using continuous interscalene block. This chapter outlines the anterior and posterior approaches to the proximal brachial plexus and describes a method of precisely placing a catheter along the brachial plexus by stimulating the plexus through the needle used for placing the catheter as well as through the catheter itself. ⋯ Suggested drugs and dosages for initial boluses, continuous infusions and patient controlled interscalene analgesia are discussed. Sedation for block placement, and special precautions, are outlined.
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Best Pract Res Clin Anaesthesiol · Jun 2002
ReviewMaking an ambulatory surgery centre suitable for regional anaesthesia.
This chapter reviews a management strategy for transforming an outpatient surgery centre from that which exclusively uses general anaesthesia to one using regional anaesthesia with peripheral nerve blocks. Barriers presented by patients, nursing staff, surgeons and administrators can be notable; these might undermine the well-intended efforts of highly-skilled regionalists. ⋯ The centerpiece of the anaesthesia care process remains pre-emptive multimodal analgesia, routine multimodal antiemetic prophylaxis and avoidance of general anaesthesia (GA) with volatile agents. The remainder of the care process relies on teamwork among all healthcare providers and meaningful administrative support.
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Early and efficient rehabilitation is necessary for improving outcome after shoulder surgery. Pain, which is severe to very severe in this condition, is the major factor which compromises early physical therapy. Interscalene block is a well recognized and efficient technique for controlling pain after major open shoulder surgery. ⋯ However, the application of a continuous infusion of local anaesthetics through an interscalene catheter is actually the best technique available to achieve pain relief at rest and on movement after this type of surgery. This chapter emphasizes the advantages of the modified lateral approach, the use of patient-controlled interscalene analgesia and the traps and tricks of the interscalene block. Thus, this chapter demonstrates why interscalene anaesthesia and analgesia are the most appropriate techniques for shoulder surgery.
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Best Pract Res Clin Anaesthesiol · Jun 2002
ReviewMajor surgery in the ambulatory environment: continuous catheters and home infusions.
The ability to provide continuous peripheral nerve blocks to patients safely on an outpatient basis has been a major advance in ambulatory surgery over the past several years. The first reports of patients self-administering local anaesthetic via wound and perineural catheters were published in 1998. Such infusions have now become a necessary component for the success of various ambulatory procedures. ⋯ Many of the concepts used to provide safe ambulatory infusion have been drawn from studies of patients receiving these types of therapies in a hospital setting. Few studies have actually examined these techniques is an outpatient environment. However, the advantages of these analgesic techniques over traditional oral narcotics for patients undergoing major surgery in the ambulatory environment have led to their rapid acceptance as a standard of care at many institutions.
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Incisional and intra-articular local anaesthetic techniques are simple, safe and inexpensive analgesic methods for the management of post-operative pain following a variety of surgical procedures. These techniques are capable of providing effective analgesia over a limited field and with minimal systemic effects. ⋯ The incisional and intra-articular use of opioids and several non-opioids, either alone or in combination with local anaesthetics, has also been evaluated. This chapter reviews the current status of single dose and infusions of local anaesthetics and adjuvants for incisional and intra-articular analgesic techniques and also looks at future perspectives.