Combined popliteal and posterior cutaneous nerve of the thigh blocks for short saphenous vein stripping in outpatients: an alternative to spinal anesthesia

Ultrasound-Guided Posterior Femoral Cutaneous Nerve Block: A Cadaveric Study

OBJECTIVES

To identify any anatomic barriers to local anesthetic spread between the sciatic nerve (SN) and the posterior femoral cutaneous nerve (PFCN) at the level of the infragluteal crease and to describe a potential technique for an ultrasound (US)-guided subgluteal PFCN block in a cadaveric model.

METHODS

Bilateral US-guided subgluteal injections of a colored latex solution were performed around the SN (15 mL) and PFCN (10 mL) in 4 unembalmed cadavers, for a total of 8 cadaver thighs. The specimens were dissected after latex polymerization to observe the spread of the latex solutions.

RESULTS

With US guidance, the PFCN was visualized deep to the gluteus maximus and slightly superficial or lateral to the SN at the level of the infragluteal crease. The SN and PFCN were found on dissection to be coated with their respective colored latex in all 8 thighs. The SN and PFCN were consistently separated by the deep investing muscular fascia of the thigh, with only 2 thighs showing substantial mixing of latex injectates.

CONCLUSIONS

The deep investing muscular fascia of the thigh appears to impede the spread of injectate between the SN and PFCN in a most unembalmed cadaver specimens. A US-guided subgluteal PFCN blockade may be a feasible technique to complement an SN block when complete anesthesia of the posterior thigh is required.

Monitored anesthesia care for great saphenous vein stripping surgery with target controlled infusion of propofol and remifentanil: a prospective study

Background

The aim of this study was to determine the appropriate target concentrations at the effect site of propofol and remifentanil when deep sedation was achieved by monitored anesthesia care (MAC) anesthesia and related respiratory depression during vein stripping surgery for varicose veins.

Methods

In total, 51 adult patients who were scheduled for varicose vein stripping surgery were sedated with propofol and remifentanil during the surgery, after administration of midazolam. Target concentrations at the effect site of the two drugs were changed based on the patient's status. Respiratory support was applied in the order of oxygen supply, chin lift, and assisted mask ventilation. Target concentrations at the effect site of propofol and remifentanil, the need for respiratory support, and a six-point rating scale satisfaction score were the outcome measurements.

Results

Only one patient did not require oxygen, eight patients needed oxygen alone, 22 patients required use of the chin lift technique, and 20 patients were assisted with mask ventilation. There was no significant difference in the target concentration of propofol or remifentanil between the patients who required mask ventilation and those who did not. Fifty of the 51 patients reported a satisfaction score of 6.

Conclusions

Although MAC using low target concentrations of propofol and remifentanil during vein stripping surgery was satisfactory to patients, close observation regarding the need for respiratory assistance was necessary.

Anesthesia for the elderly outpatient

PURPOSE OF REVIEW

As the number of ambulatory surgery procedures continues to grow in an aging global society, the implementation of evidence-based perioperative care programs for the elderly patients will assume increased importance.

RECENT FINDINGS

Increasing evidence supports the expanded use of ambulatory surgery for managing elderly patients undergoing elective surgery procedures.

SUMMARY

This review article describes the demographics of ambulatory surgery in the elderly population. This review article describes the effects of aging on the responses of geriatric patients to anesthetic and analgesic drugs used during ambulatory surgery. Important considerations in the preoperative evaluation of elderly outpatients with co-existing diseases, as well as the advantages and disadvantages of different anesthetic techniques on a procedural-specific basis, and recommendations regarding the management of common postoperative side-effects (including delirium and cognitive dysfunction, fatigue, dizziness, pain, and gastrointestinal dysfunction) after ambulatory surgery. Finally, we discuss the future challenges related to the continued expansion of ambulatory surgery practice in this growing segment of our surgical population. The role of anesthesiologists as perioperative physicians is of critical importance for optimizing surgical outcomes for elderly patients undergoing ambulatory surgery. Providing high-quality, evidence-based anesthetic and analgesic care for elderly patients undergoing elective operations on an ambulatory basis will assume greater importance in the future.

Implementation of a fast-track-pathway including analgo-sedation with local anaesthesia for outpatient varicose vein surgery: a cohort study

Objective

To evaluate the clinical and economical impact of a fast-track anaesthesia protocol in the management of primary varicose vein (VV) surgery.

Methods

Over a 10-month period (from 1 December 2009 to 30 September 2011), all patients eligible for open VV surgery ( N = 176) were enrolled in a fast-track clinical pathway including titrated analgo-sedation combined with local anaesthesia. This fast-track cohort was compared with a historical cohort undergoing similar procedures and receiving general anaesthesia (GA) or spinal anaesthesia (SA) (between 1 December 2009 to 30 September 2011, N = 200). The length of stay in the operating facilities and postoperative recovery areas were reported and hospital costs were estimated. In addition, the occurrence of adverse events and unplanned hospital admission were compared between the two consecutive periods.

Results

Patients characteristics and surgical procedure were not different in the two cohorts. After implementation of the fast-track pathway, the incidence of postoperative adverse events decreased from 41% to 2.3%, with no need for overnight hospital stay (0% versus 7%). The reduction in anaesthesia-controlled time (-47%) and in postoperative recovery time (-61%) were associated with an increased operating capacity (1 extra case per day) and with substantial cost-savings (mean reduction of €312 per case, P < 0.001).

Conclusions

Implementation of a fast-track pathway for outpatient VV surgery was successful, safe and efficient. Analgo-sedation combined with infiltrative anaesthesia (instead of GA or SA) contributed to increase the operating capacity and to reduce the workload of nursing personnel.

Perioperative care for the older outpatient undergoing ambulatory surgery

As the number of ambulatory surgery procedures continues to grow in an aging global society, the implementation of evidence-based perioperative care programs for the elderly will assume increased importance. Given the recent advances in anesthesia, surgery, and monitoring technology, the ambulatory setting offers potential advantages for elderly patients undergoing elective surgery. In this review article we summarize the physiologic and pharmacologic effects of aging and their influence on anesthetic drugs, the important considerations in the preoperative evaluation of elderly outpatients with coexisting diseases, the advantages and disadvantages of different anesthetic techniques on a procedural-specific basis, and offer recommendations regarding the management of common postoperative side effects (including delirium and cognitive dysfunction, fatigue, dizziness, pain, and gastrointestinal dysfunction) after ambulatory surgery. We conclude with a discussion of future challenges related to the growth of ambulatory surgery practice in this segment of our surgical population. When information specifically for the elderly population was not available in the peer-reviewed literature, we drew from relevant information in other ambulatory surgery populations.

Combined femoral and popliteal sciatic nerve blocks versus epidural anesthesia in great saphenous veins stripping surgery with multiple stab avulsion

BACKGROUND

This study was designed to test the hypothesis that a combined femoral and politeal sciatic nerve blocks (FPSNB) would have excellent clinical properties and better patient satisfaction than epidural anesthesia for the great saphenous veins stripping (GSVS) surgery with multiple stab avulsion (MSA).

METHODS

Sixty patients were allocated into two groups. The epidural group received epidural anesthesia with 15 ml of 0.75% ropivacaine (n = 30), and the FPSNB group received a combined FPSNB with 25 ml of 1.5% mepivacaine with a nerve stimulator (n = 30). We assessed the anesthetic and postoperative records. A questionnaire-based study including patient satisfaction for anesthetic techniques (100 point scale) was conducted 3 days postoperatively by a blinded observer.

RESULTS

The time from initial injection to the start of surgery and the duration of sensory blockade were not different between groups (P > 0.05). The percentage of patients with anesthesia-related complications in epidural anesthesia was 33.3%, 46.6%, 23.3% and 20% for shivering, hypotension, bradycardia and postoperative voiding difficulty, respectively. FPSNB did not produce these complications. Additional analgesia with 50-100 microgram of fentanyl was more frequently used in FPSNB (60% vs 6.7%, FPSNB vs Epidural group, P < 0.01), but patient satisfaction of FPSNB was higher than epidural anesthesia (88.1 +/- 13.2 vs 76.5 +/- 15.8, FPSNB vs Epidural group, P < 0.01).

CONCLUSIONS

A combined FPSNB with a small amount of narcotics is an adequate anesthetic technique for unilateral GSVS surgery with MSA.

Peripheral Nerve Block Techniques for Ambulatory Surgery

Peripheral nerve blocks (PNBs) have an increasingly important role in ambulatory anesthesia and have many characteristics of the ideal outpatient anesthetic: surgical anesthesia, prolonged postoperative analgesia, and facilitated discharge. Critically evaluating the potential benefits and supporting evidence is essential to appropriate technique selection. When PNBs are used for upper extremity procedures, there is consistent opioid sparing and fewer treatment-related side effects when compared with general anesthesia. This has been demonstrated in the immediate perioperative period but has not been extensively investigated after discharge. Lower extremity PNBs are particularly useful for procedures resulting in greater tissue trauma when the benefits of dense analgesia appear to be magnified, as evidenced by less hospital readmission. The majority of current studies do not support the concept that a patient will have difficulty coping with pain when their block resolves at home. Initial investigations of outpatient continuous peripheral nerve blocks demonstrate analgesic potential beyond that obtained with single-injection blocks and offer promise for extending the duration of postoperative analgesia. The encouraging results of these studies will have to be balanced with the resources needed to safely manage catheters at home. Despite supportive data for ambulatory PNBs, most studies have been either case series or relatively small prospective trials, with a narrow focus on analgesia, opioids, and immediate side effects. Ultimately, having larger prospective data with a broader focus on outcome benefits would be more persuasive for anesthesiologists to perform procedures that are still viewed by many as technically challenging.

Peripheral Nerve Blocks and Continuous Catheter Techniques

Peripheral nerve blocks provide intense, site-specific analgesia and are associated with a lower incidence of side effects when compared with many other modalities of postoperative analgesia. Continuous catheter techniques further prolong these benefits. These advantages can facilitate a prompt recovery and discharge and achieve significant perioperative cost savings. This is of tremendous value in a modern health care system that stresses cost-effective use of resources and a continued shift toward shorter hospital stay as well as outpatient surgery.

A comparison of intertendinous and classical approaches to popliteal nerve block using magnetic resonance imaging simulation

The classical approach to sciatic nerve block in the popliteal fossa (popliteal block) often requires multiple attempts to localize the sciatic nerve. Recently, it has been suggested that an intertendinous approach to popliteal block may result in a more consistent localization of the sciatic nerve. In the current study, we compared anatomical landmarks for the intertendinous and classical approaches to popliteal block with respect to the accuracy in localizing the sciatic nerve using magnetic resonance imaging simulation. Two anesthesiologists experienced in popliteal block drew landmarks for the intertendinous and classical approaches on 10 volunteers; a 1.5 Tesla superconducting magnet was used to obtain simultaneous, 10-mm thick, fast-spin echo proton density transverse axial sequences of the lower extremities. Using these acquired images, the two approaches were simulated off-line using previously identified landmarks. The spatial relationships of the simulated needle paths to the nerves and vessels in the popliteal fossa, as well as other relevant structures, were measured and compared. Simulation of the intertendinous approach to popliteal block resulted in needle-to-sciatic nerve contact in 14 legs (70%) versus 5 legs (25%) when the classical approach was used (P < 0.05). We conclude that the intertendinous approach might result in a more consistent localization of the sciatic nerve and may decrease the risk of sciatic vessel puncture.

IMPLICATIONS

A simulation of popliteal block using magnetic resonance imaging in volunteers suggests that using tendons of the hamstring muscles as the anatomical landmarks yields a more consistent localization of the sciatic nerve.

Popliteal fossa neural blockade as the sole anesthetic technique for outpatient foot and ankle surgery

Foot and ankle operations are being performed with greater frequency as outpatient procedures. Although the surgical procedure remains the same whether the operation is done in an inpatient or an outpatient setting, the anesthesia and postoperative analgesia are greatly affected when patients must be discharged soon after their operation. We have evaluated a regional anesthetic technique which blocks the sciatic nerve in the popliteal fossa and the saphenous nerve block at the knee. This was the sole anesthetic technique for both the operation and the immediate postoperative period. This technique appears to have several advantages: 1) Excellent anesthesia during the operation and for about ten hours postoperatively; 2) Use of a proximal calf tourniquet, and 3) Absence of systemic or local complications as might be seen with general, spinal or epidural anesthesia.

Local and regional block in postoperative pain control

Local and regional block provides an effective means for the control of postoperative pain. In surgery involving the trunk, it serves as a useful alternative to epidural analgesia. With the increasing use of low molecular weight heparin, the use of peripheral nerve block is increasingly popular for patients undergoing lower limb surgery.