Textbook of Regional Anesthesia

Textbook of Regional Anesthesia 2003 EDITION P. PRITHVI RAJ MD Professor of Anesthesiology Co-Director of Pain Services International Pain Institute Texas Tech University Health Sciences Center School of Medicine Lubbock, Texas

CHURCHILL LIVINGSTONE An imprint of Elsevier Science New York•Edinburgh•London•Melbourne•Tokyo

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CHURCHILL LIVINGSTONE An imprint of Elsevier Science The Curtis Center Independence Square West Philadelphia, Pennsylvania 19106

NOTICE Anesthesiology is an ever-changing field. Standard safety precautions must be followed, but as new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current product information provided by the manufacturer of each drug to be administered to verify the recommended dose, the method and duration of administration, and contraindications. It is the responsibility of the treating physician, relying on experience and knowledge of the patient, to determine dosages and the best treatment for each individual patient. Neither the Publisher nor the editor assumes any liability for any injury and/or damage to persons or property arising from this publication. THE PUBLISHER

Library of Congress Cataloging-in-Publication Data Raj, P. Prithvi. Textbook of regional anesthesia/P. Prithvi Raj. p. ; cm. ISBN 0–443–06569–1 1. Conduction anesthesia. I. Title. [DNLM: 1. Anesthesia, Conduction—methods. WO 300 R161t 2002] RD84 .R35 2002 617.9′64—dc21 2001037149 Acquisitions Editor: Allan Ross Project Manager: Robin E. Davis Senior Editorial Assistant: Josh Hawkins TEXTBOOK OF REGIONAL ANESTHESIA ISBN 0–443–06569–1 Copyright © 2002 Elsevier Science (USA). All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher. CHURCHILL LIVINGSTONE and the Sail Boat Design are registered trademarks. Printed in the United States of America. Last digit is the print number: 9 8 7 6 5 4 3 2 1 II

Contributors ELI ALON MD Professor of Anesthesiology, University of Zurich, Zurich, Switzerland; Chairman, Department of Anesthesiology, Ospedale Civico and Ospedale Italiano, Lugano, Switzerland Efficacy Outcome of Regional Anesthesia Techniques in Obstetrics SUSAN R. ANDERSON MD Assistant Professor, Director of Education, Advanced Pain Centers of Alaska, Anchorage, Alaska Drugs Used in Regional Anesthesia: Chemical Neurolytic Agents; Continuous Regional Analgesia; Epiduroscopy; Discography and Intradiscal Electrothermal Annuloplasty; Vertebroplasty JOSE DE ANDRÉS MD Associate Professor of Anesthesia, Valencia University Medical School; Director, Pain Management Center, Department of Anesthesiology and Critical Care, Valencia University General Hospital, Valencia, Spain Aids to Localization of Peripheral Nerves; Common Techniques for Regional Anesthesia: Subarachnoid and Epidural Anesthesia DOUGLAS R. BACON MD Associate Professor of Anesthesiology, Mayo Medical School; Senior Associate Consultant, Mayo Clinic Rochester Minnesota Beyond Blocks: The History of the Development of Techniques in Regional Anesthesia

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RONALD BANISTER MD Resident, Department of Anesthesiology, Texas Tech University Health Sciences Center School of Medicine, Lubbock, Texas Aids to Localization of Peripheral Nerves ALDO BARBATI MD Staff Anesthesiologist, Department of Anesthesia and Intensive Care, Cardarelli Hospital, Naples, Italy Equipment and Techniques SHAUNA BAUGHCUM CPC Business Manager, International Pain Institute, Texas Tech University Health Sciences, Center School of Medicine Lubbock Texas Appendix A: Selected Pain Management Billing Codes; Appendix B: Selected Diagnoses for Pain Management DIEGO BELTRUTTI MD Head, Department of Anesthesia and Resuscitation, Pain Control Center, Santo Spirito Hospital, Bra, Italy Organization of Chronic Pain Services; Organization of Palliative Care Services JAY B. BENDER MD Pain Fellow, Department of Anesthesiology, University of Texas M.D. Anderson Cancer Center, Houston, Texas Chronic Pain: Outcomes Using Procedures for Nociceptive Pain HONORIO T. BENZON MD Professor of Anesthesiology, Northwestern University Medical School; Chief Division of Pain Medicine, Northwestern Memorial Hospital Chicago, Illinois Acute Situations: Trauma

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HEMMO A. BOSSCHER MD Assistant Professor of Anesthesiology, Texas Tech University Health Sciences Center School of Medicine, Lubbock, Texas Epidural Steroids CHRISTOPHER M. BURKLE MD Instructor in Anesthesiology, Mayo Medical School; Senior Associate Consultant in Anesthesiology, Mayo Clinic, Rochester, Minnesota Beyond Blocks: The History of the Development of Techniques in Regional Anesthesia ALLEN W. BURTON MD Associate Professor of Anesthesiology, Section Chief of Cancer Pain Management, University of Texas M.D. Anderson Cancer Center, Houston, Texas Chronic Pain: Outcomes Using Procedures for Nociceptive Pain JEFFREY CARRUTH MD Chief Resident, Department of Anesthesiology, Texas Tech University Health Sciences Center, Lubbock, Texas Radiographic Imaging in Regional Anesthesia VINCENT W. S. CHAN MD Associate Professor of Anesthesia, University of Toronto; Director Regional Anesthesia Acute Pain Service, Department of Anesthesia University Health Network, Toronto Western Hospital Toronto, Ontario, Canada Training Education of a Physician for Regional Anesthesia MILES DAY MD, DAPBM Assistant Professor of Pain Management/Anesthesiology, International Pain Institute, Texas Tech University Health Sciences Center School of Medicine; Staff Physician, University Medical Center, Lubbock, Texas V

Nerve Root Neurolysis; Sphenopalatine Analgesia FRANCESCO DONATELLI MD Resident, School of Specialization in Anesthesiology, L’Aquila, Italy Economic Impact of Regional Anesthesia; Organization of an Acute Pain Service and Pain Management CLAUDE ECOFFEY MD Professor of Anesthesiology, Centre Hospitalier Universitaire de Rennes, Rennes, France Common Techniques for Regional Anesthesia: Regional Anesthesia in Children SERDAR ERDINE MD Professor, Medical Faculty of Istanbul University; Chairman, Department of Algology, Capa Klinikleri, Istanbul, Turkey Trigeminal Ganglion Procedures P. M. FINCH MD Perth Pain Management Centre, South Perth, Western Australia Sympathetic Neurolysis BRIAN FLANAGAN MD Progressive Pain Management Dallas, Texas Discography Intradiscal Electrothermal Annuloplasty KAREN GALLOWAY MD Instructor, Division of Pediatric Anesthesiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Anesthesiologist, Shriners Hospital for Children, Honolulu, Hawaii Chronic Pediatric Pain MELVIN G. GITLIN MD VI

Professor and Interim Chairman, Department of Anesthesiology, Tulane School of Medicine; Director, Pain Management Care, Tulane University Hospital and Clinic, New Orleans, Louisiana Epidural Steroids STEWART GRANT MD Associate Professor of Anesthesiology, Duke University Medical Center Durham, North Carolina Common Techniques for Regional Anesthesia: Peripheral Nerve Blocks ROY GREENGRASS MD Associate Professor of Anesthesiology; Co-Director, Division of Ambulatory Anesthesiology, Duke University Medical Center, Durham, North Carolina Common Techniques for Regional Anesthesia: Peripheral Nerve Blocks PAOLO GROSSI Director, Department of Regional Anesthesia and Pain Treatment, Instituto Policlinico, San Donato Milano, Milano, Italy Aids to Localization of Peripheral Nerves MARC B. HAHN DO Dean, Texas College of Osteopathic Medicine, University of North Texas Health Science Center at Fort Worth Fort Worth, Texas Peripheral Nerve Blockade RICHARD A. HARDART MD Instructor, Department of Anesthesiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland Pediatric Pain Management CRAIG T. HARTRICK MD

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Director, Anesthesia Research, William Beaumont Hospital, Royal Oak, Michigan Regional Anesthesia for Chronic Situations: Nonmalignant Pain; Trauma SAMUEL J. HASSENBUSCH MD Professor of Neurosurgery, University of Texas, M.D. Anderson Cancer Center, Houston, Texas Neuroaugmentative Procedures for Pain JAMES E. HEAVNER DVM, PhD Professor of Anesthesiology and Physiology, Director of Anesthesia Research, Texas Tech University Health Sciences Center School of Medicine, Lubbock, Texas Pain Mechanisms and Local Anesthetics: Scientific Foundations for Clinical Practice CHRISTOPHER J. JANKOWSKI MD Assistant Professor of Anesthesiology, Mayo Medical School; Consultant, Department of Anesthesiology, Mayo Clinic and Foundation, Rochester, Minnesota Neuraxial Anesthetic Techniques MOLLY JOHNSTON RN Texas Wesleyan University, Fort Worth, Texas Organization Function of the Nerve Block Facility ALAN D. KAYE MD, PhD Professor and Chairman, Department of Anesthesiology, Professor of Pharmacology, Texas Tech University Health Sciences Center School of Medicine, Lubbock, Texas Drugs Used in Regional Anesthesia: Local Anesthetics; Epidural Steroids

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HENRIK KEHLET MD, PhD Professor of Anesthesiology, Copenhagen University, Hvidovre Hospital, Hvidovre, Denmark Endocrine-Metabolic Effects STEVEN KLEIN MD Assistant Professor of Anesthesiology, Division of Ambulatory Regional Anesthesia, Duke University Medical Center Durham, North Carolina Common Techniques for Regional Anesthesia: Peripheral Nerve Blocks ADRIENNE E. KNIGHT MD Assistant Professor of Anesthesiology, University of Colorado, Denver, Colorado Acute Situations: Trauma MARK KRAFT MD Private Practice, Las Vegas, Nevada Discography and Intradiscal Electrothermal Annuloplasty ELLIOT S. KRAMES MD Medical Director, Pacific Pain Treatment Centers, San Francisco, California Untreated Pain and Its Cost to Society: What Are Our Options?; Intrathecal Therapies for the Treatment of Chronic Pain DONALD H. LAMBERT MD, PhD Anesthesiologist, Anesthesia Associates of Massachusetts; Boston University Medical Center, Boston, Massachusetts Efficacy of Regional versus General Anesthesia TIM J. LAMER MD Assistant Professor of Anesthesiology, Mayo Medical School, Rochester, Minnesota; Consultant, Department of Anesthesiology, IX

Mayo Clinic Jacksonville, Jacksonville, Florida Cancer Pain ERIC LANG MD Pharmaceutical Licensing Group, Johnson and Johnson, Titusville, New Jersey Clinical Research ALBERT Y. LEUNG MD Assistant Clinical Professor of Anesthesiology, University of California, San Diego, School of Medicine; Faculty, Center for Pain and Palliative Medicine, University of California, San Diego, Medical Center, La Jolla, California Regional Anesthesia for Chronic Situations: Malignant Pain ANDRES LÓPEZ MD Chairman, Department of Anesthesiology and Critical Care, Móstoles Hospital, Madrid Montepríncipe Hospital, Madrid, Spain Common Techniques for Regional Anesthesia: Subarachnoid and Epidural Anesthesia EDWARD A. R. LORD MD Pain Fellow, Department of Anesthesiology, University of Texas, M.D. Anderson Cancer Center Houston, Texas Chronic Pain: Outcomes Using Procedures for Nociceptive Pain LELAND LOU MD, MPH, DABPM Assistant Professor of Pain Management, Anesthesiology, International Pain Institute, Texas Tech University Health Sciences Center School of Medicine, Lubbock, Texas Drugs Used in Regional Anesthesia: Local Anesthetics; Radiographic Imaging in Regional Anesthesia; Spinal Decompressive Neuroplasty via the Caudal and Cervical Approaches

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DAVID C. MACKEY MD Assistant Professor of Anesthesiology, Mayo Medical School, Rochester, Minnesota; Consultant, Department of Anesthesiology, Mayo Clinic Jacksonville, Jacksonville, Florida Cancer Pain CARLOS B. MANTILLA MD Assistant Professor of Anesthesiology, Mayo Medical School; Senior Associate Consultant, Mayo Clinic, Rochester, Minnesota Cancer Pain FRANCO MARINANGELI MD Researcher, School of Specialization in Anesthesiology, L’Aquila, Italy Economic Impact of Regional Anesthesia; Organization of an Acute Pain Service and Pain Management MICHAEL D. McBETH MD Clinical Instructor (Voluntary), Department of Anesthesiology, Center for Pain and Palliative Medicine, University of California, San Diego, School of Medicine, La Jolla, California; Director, Pain Management Group, Assistant Chief, Department of Anesthesiology, Kaiser Permanente, San Diego, California Regional Anesthesia for Chronic Situations: Malignant Pain COLIN J. L. McCARTNEY MD Assistant Professor, University of Toronto; Staff Anesthesiologist, Toronto Western Hospital, Toronto, Ontario, Canada Training Education of a Physician for Regional Anesthesia XI

ROBERT S. F. McKAY MD Associate Professor of Anesthesiology and Obstetrics/Gynecology, University of Kansas School of Medicine; Medical Director and Chairman, Department of Anesthesiology, Wesley Medical Center, Wichita, Kansas Efficacy and Outcome of Regional Anesthesia Techniques in Obstetrics SEBASTIANO MERCADANTE MD Director, Anesthesia and Intensive Care Unit, Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy Equipment and Techniques GENE MORETTI MD Assistant Professor of Anesthesiology, Duke University Medical Center Durham, North Carolina Common Techniques for Regional Anesthesia: Peripheral Nerve Blocks MAURO S. NICOSCIA MD Servizio di Anestesia e Rianimazione, Ospedale S. Carlo, Genova Voltri, Italy Organization of Palliative Care Services KAREN NIELSEN MD Assistant Professor of Anesthesiology, Division of Ambulatory Anesthesiology, Duke University Medical Center, Durham, North Carolina Common Techniques for Regional Anesthesia: Peripheral Nerve Blocks DAVID NIV MD Professor Sackler Faculty of Medicine, Tel-Aviv University; Director Center for Pain Medicine, Tel-Aviv Sourasky Medical Center Tel-Aviv, Israel Clinical Research

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MARK C. NORRIS MD Staff Anesthesiologist, Henry Medical Center, Stockbridge, Georgia Acute Situations: Obstetrics MAURICIO ORBEGOZO MD Comprehensive Pain Care, Calumet City, Illinois Facet Block and Denervation ANTONELLA PALADINI MD Regional Hospital “S. Salvatore” L’Aquila, Italy Economic Impact of Regional Anesthesia; Organization of an Acute Pain Service Pain Management LOUIS M. PANLILIO MD Assistant Professor of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine; Director of Acute Pain Medicine, The Johns Hopkins University Hospital, Baltimore, Maryland Chronic Pain: Neuropathic Pain: Outcome Studies on the Role of Nerve Blocks FRANCIS S. PECORARO MD Medical Director, Integrated Pain Rehabilitation, Integrated Pain Management, Concord, California Untreated Pain and Its Cost to Society: What Are Our Options?; Intrathecal Therapies for the Treatment of Chronic Pain RICARDO S. PLANCARTE MD Professor of Postgraduate Medical Especiality in Anesthesia, Intensive Care and Pain Clinic, Universidad Nacional Autónoma de México; Chairman, Pain Clinic and Palliative Care Department, Instituto Nacional de Cancerologia, México D.F. México Monitoring in Regional Anesthesia

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GABOR B. RACZ MD Grober and Murray Professor, Director, Pain Services, Chairman Emeritus, Department of Anesthesiology, Texas Tech University Health Sciences Center School of Medicine, Lubbock, Texas Spinal Decompressive Neuroplasty via the Caudal and Cervical Approaches; Trigeminal Ganglion Procedures P. PRITHVI RAJ MD, DABPM Professor of Anesthesiology, Co-Director of Pain Services, International Pain Institute, Texas Tech University Health Sciences Center School of Medicine, Lubbock, Texas Historical Aspects of Regional Anesthesia; Organization and Function of the Nerve Block Facility; Aids to Localization of Peripheral Nerves; Common Techniques for Regional Anesthesia: Conduction Blocks; Efficacy of Regional versus General Anesthesia; Endocrine-Metabolic Effects; Regional Anesthesia Options in Surgical Specialties SRINIVASA N. RAJA MD Professor of Anesthesiology, Critical Care Medicine, The Johns Hopkins University School of Medicine; Director of Pain Research, Division of Pain Medicine, The Johns Hopkins University Hospital, Baltimore, Maryland Chronic Pain: Neuropathic Pain: Outcome Studies on the Role of Nerve Blocks NARINDER RAWAL MD Professor, University Hospital, Örebro, Sweden Organization of an Acute Pain Service and Pain Management MIGUEL ANGEL REINA MD Department of Anesthesiology and Critical Care, Móstoles Hospital, Madrid Montepríncipe Hospital, Madrid, Spain Common Techniques for Regional Anesthesia: Subarachnoid and Epidural Anesthesia XIV

FRANCISCO JAVIER MAYER RIVERA MD Assistant Professor of Postgraduate Medical Course in Pain Clinic, Universidad Nacional Autónoma de México; Coordinator of Palliative Care Service Pain Clinic and Palliative Care, Instituto Nacional de Cancerologia México D.F. México Monitoring in Regional Anesthesia RICARDO RUIZ-LÓPEZ MD Clinica del Dolor de Barcelona, Barcelona, Spain Organization of Chronic Pain Services; Organization of Palliative Care Services; Radiofrequency for the Treatment of Chronic Pain RAJ SABAR MD Resident Physician, Department of Anesthesiology, Texas Tech University Health Sciences Center, Lubbock, Texas Drugs Used in Regional Anesthesia: Local Anesthetics XAVIER SALA-BLANCH MD Staff Anesthesiolgist, Servicio de Anestesiologia y Reanimacion, Hospital Clinic de Barcelona, Universidad de Barcelona Barcelona, Spain Aids to Localization of Peripheral Nerves ROBERT P. SANDS JR. MD Clinical Assistant Professor of Anesthesiology, State University of New York at Buffalo; Director, Resident Education, Roswell Park Cancer Institute, Buffalo, New York Beyond Blocks: The History of the Development of Techniques in Regional Anesthesia PHILLIP S. SIZER JR. MEd, PT, MOMT, PhD(c) Texas Tech University Health Sciences Center, Lubbock, Texas Facet Block and Denervation

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SUSAN STEELE MD Associate Professor of Anesthesiology, Director, Division of Ambulatory Anesthesiology, Medical Director, Ambulatory Surgery Center, Duke University Medical Center Durham, North Carolina Common Techniques for Regional Anesthesia: Peripheral Nerve Blocks CARL A. TANDATNICK MD Attending Physician, Diagnostic Clinic, Largo, Florida Peripheral Nerve Blockade PRABHAV TELLA MPH Research Program Coordinator, The Johns Hopkins University School of Medicine, Baltimore, Maryland Chronic Pain: Neuropathic Pain: Outcome Studies on the Role of Nerve Blocks ATHINA N. VADALOUCA MD Assistant Professor of Anesthesia, Pain Management, University of Athens; Aretaeon Hospital Athens, Greece Organization of Palliative Care Services; Drugs Used in Regional Anesthesia: Adjuvant Drugs GIUSTINO VARRASSI MD Professor of Anesthesiology, University of L’Aquila Medical School, L’Aquila, Italy Economic Impact of Regional Anesthesia; Organization of an Acute Pain Service and Pain Management RAMANI VIJAYAN MD Professor of Anaesthesiology, University of Malaya; Consultant Anaesthesiologist, University of Malaya Medical Centre, Kuala Lumpur, Malaysia The Practice of Regional Anesthesia in Developing Countries

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MARK S. WALLACE MD Associate Professor of Clinical Anesthesiology, Fellowship Program Director, University of California, San Diego, School of Medicine; Program Director, Center for Pain and Palliative Medicine, University of California, San Diego, Medical Center, La Jolla, California Regional Anesthesia for Chronic Situations: Malignant Pain MICHAEL A. WEAVER MD Assistant Professor of Anesthesiology, Pennsylvania State University College of Medicine; Milton S. Hershey Medical Center, Hershey, Pennsylvania Peripheral Nerve Blockade BRANKO M. WEISS MD Consultant, Department of Anesthesiology, University Hospital, Zurich, Switzerland Efficacy and Outcome of Regional Anesthesia Techniques in Obstetrics JACK L. WILSON MD Assistant Professor of Anesthesiology, Mayo Medical School; Consultant, Department of Anesthesiology, Mayo Clinic Rochester, Minnesota Cancer Pain CYNTHIA A. WONG MD Assistant Professor, Northwestern University Medical School; Chief, Section of Obstetric Anesthesiology, Division of Pain Medicine, Northwestern Memorial Hospital, Chicago, Illinois Acute Situations: Obstetrics GILBERT Y. WONG MD Assistant Professor of Anesthesiology, Mayo Medical School; XVII

Consultant, Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Rochester, Minnesota Cancer Pain CHRISTOPHER L. WU MD Associate Professor of Anesthesiology, Critical Care Medicine, The Johns Hopkins University School of Medicine; Director, Acute Pain Service, Director, Regional Anesthesia, The Johns Hopkins University Hospital, Baltimore, Maryland Efficacy of Neuraxial and Peripheral Nerve Blocks in Acute Pain Management MYRON YASTER MD Professor of Anesthesiology, Critical Care Medicine, and Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland Pediatric Pain Management

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Foreword Dr. Raj painstakingly has assembled a stellar roster of internationally recognized experts to put the stamp of credibility and currency on Textbook of Regional Anesthesia . Sweeping changes have modernized the practice of regional anesthesia since Dr. Raj first published Handbook of Regional Anesthesia in 1985: unheard-of imaging techniques, safer local anesthetics, cuttingedge laboratory experiments, innovative clinical studies, streamlined practice methods, and (at least in the United States) increasingly restrictive regulation of medical practice that rewards haste, hustle, and false economy over individualized patient care. All these happenings—the good, the bad, the new, the challenging, and the basics—have been addressed in this fully current comprehensive text, a work with a sweeping mandate that promises to set the global gold standard of regional anesthesia for the present and years to come. Textbook of Regional Anesthesia is a seminally mature work of awesome breadth and depth— truly the capstone of a lifetime of research, graduate teaching, clinical experience, and worldwide travel. The contributors, likewise, are established scholars in their own right whose global representation makes this not just another North American text, but a learning and teaching resource of international proportions. Dr. Raj has the uncanny knack of picking rising young talent and for offering them the opportunity to prove their worth. Some of the old war horses return to contribute the seasoned traditional expertise that lends structure and backbone to any comprehensive text. But the input from younger, less-established voices is refreshing; their chapters contribute the new blood that gives regional anesthesia currency and nurtures its growth, and they pass on the hard-gained nuggets of clinical science to the next generation of physicians now in training, but soon to be in independent practice. Ten section editors groomed the eight discrete sections to include not just the traditional how, what, when, and why of regional anesthesia but also the newly emerging trends, such as the hard data from clinical outcome studies and the ongoing shift toward evidence-based medical practice. The detailed sections on procedural fundamentals and advanced interventional techniques will prove of particular interest to busy clinicians. The resulting 54 chapters, contributed by the editors with the assistance of many international collaborators, span the field of regional anesthesia from past history, through current practice, to future directions to form a monumentally defining work. With its handsome modern design and contemporary ambience, Dr. Raj’s Textbook of Regional Anesthesia once more demonstrates that the art of regional anesthesia—crafted and refined over the decades by grand masters such as Labat, Bier, Bonica, Macintosh, and so many others—lives on to flourish and grow. As one of Dr. Raj’s contemporaries and former pupils, I am honored to recommend this fine textbook to my colleagues, and I am proud yet humbled to have been asked to introduce this, the crown jewel of his collective works. RUDOLPH H. DE JONG, MD Professor (Hon), University of South Carolina, Columbia, South Carolina

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Preface Textbook of Regional Anesthesia is a further progression of regional anesthesia books I have published along with the publisher, Churchill Livingstone. This book presents a fresh look at the dynamic field of regional anesthesia. The format and content of the textbook are innovative. The book has new authors and contains new material, new sections, and updated chapters from the last book I published on this subject, Clinical Practice of Regional Anesthesia . The idea of writing this book arose because apart from Neural Blockade in Clinical Anesthesia and Management of Pain , edited by Cousins and Bridenbaugh, there wasn’t another regional anesthesia textbook available to clinicians. Rapid advances are occurring in regional anesthesia and pain management. The aim of Textbook of Regional Anesthesia is to provide updated content in this field to all clinicians. This book presents a new organizational structure. Even though I have remained as the chief editor, well-recognized international authorities in regional anesthesia were asked to be section editors and provide advice on the topics included. Section editors Christopher Wells, Diego Beltrutti, James E. Heavner, David Niv, Richard L. Rauck, Honorio T. Benzon, Gabor B. Racz, Carol Warfield, Peter S. Staats, and Serdar Erdine were chosen for their expertise and international reputations. Great care has been taken to see that all aspects of regional anesthesia are included in this edition. Advanced regional anesthesia techniques and outcome sections are the special features of the book. Many thanks are to be offered for the completion of this book. The publisher comes to mind first. Everyone at Churchill Livingstone has been very understanding of my needs and, despite changes in ownership, support from them has remained solid. The section editors are especially to be thanked for their foresight, perseverance, and expertise in getting this edition completed. Illustrators and copy and manuscript editors have been working extremely hard for a prolonged period, when the demands for completing their tasks were numerous and incessant. I am indebted especially to Susan Raj for her coordinating efforts and to Marla Hall for her assistance in getting the manuscripts ready. I congratulate the authors for completing their chapters and maintaining a high quality of scientific content. I hope readers will find this book current and useful in their practice. P. PRITHVI RAJ, MD

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Section I - Development of Regional Anesthesia

Chapter 1 - Historical Aspects of Regional Anesthesia

Section I - Development of Regional Anesthesia Christopher Wells

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Section I - Development of Regional Anesthesia

Chapter 1 - Historical Aspects of Regional Anesthesia

Chapter 1 - Historical Aspects of Regional Anesthesia P. PRITHVI RAJ

Regional nerve blocks are based on the concept that pain is conveyed by nerve fibers, which are amenable to interruption anywhere along their pathway. The idea that pain is conducted in the nervous system originated with the specific theory of Johannes P. Müller, described in 1826. This was followed by the alternate intensity theory of Erb in 1874 (Dallenbach, 1939), an idea that later culminated in the gate theory of pain by Melzack and Wall in 1965. [1]

[2] [3]

Regional anesthesia was not available when general anesthesia was first successfully administered in 1846. It had to wait until 1855, when Rynd described the idea of introducing a solution of morphine hypodermically around a peripheral nerve. Because he did not have a needle or a syringe, he improvised by introducing a trocar and cannula into the region and then allowing the solution to reach the nerves by gravity. Wood, in 1855, was the first person to perform a subcutaneous injection with a graduated glass syringe and a hollow needle, a device developed initially by ( Fig. 1-1 ). Pravaz for injection of ferric chloride into an aneurysm to produce a coagulation [4]

[5] [6]

Efforts to Produce Analgesia Before the Discovery of Regional Anesthesia Primitive man, seeing in illness and pain the work of evil spirits that had taken possession of the body, tried to get rid of such invaders by methods based on effects on the patient’s imagination. Incantations, charms, amulets, special ceremonies, and faith in the power of medicine men and sorcerers made more or less deep impressions on the subject. In many cases, these methods probably contributed to the alleviation, or even abolition, of pain. A kind of local anesthesia was, therefore, able to be established, which was found valuable in connection with surgical interference, especially in minor operations. From early times, mankind has very often used analogous methods, although the procedures have changed with our supposedly—or perhaps actually— increased understanding of nature and of man himself. Thus, religion has played a role in this connection and still does to some extent, as well as the personal influence of prominent men (e.g., laying on of hands by kings and prophets). Physicians and charlatans have both found similar methods useful in numerous cases, and it has often been difficult to differentiate between the two types of practitioners. The main difference between them seems to be that the physician, with his better knowledge of the nature of illnesses and resources to combat them, has a clearer understanding of the limitations of the psychic methods. A classic example of the influence of psychic factors in alleviating pain is the well-known story of J. Mesmer (1734–1815) and his pretended use of “animal magnetism,” which was an effort to apply to living matter proof of the great progress that had just recently been made in those days with regard to electrical and similar phenomena. Mesmer’s methods were soon severely criticized, and an official commission, with Lavoisier as one of its members, concluded, “Imagination does everything, magnetism nothing.” There was certainly, however, a kernel of truth in Mesmer’s work, insofar as the practical results were remarkable. The mystery may have increased the effects. In 1843, Elliotson, the first holder of a medical professorship at the University College in London and “one of the eminent Victorians,” described the successful use of “the mesmeric state” to abolish pain in clinical operations ( Fig. 1-2 ). His results were interesting and indicated a close connection between bodily functions and the mental state. Unfortunately, he supported Mesmer’s idea of some “fluid” (in modern language, radiation) as the link between the doctor and the patient. After meeting with strong opposition, he resigned his professorship and continued to work on the problem, without convincing even his surgical colleagues of the usefulness of “mesmerism” in reducing or preventing the pain of operations. [7]

Three years later, Esdaile, who had been inspired

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Section I - Development of Regional Anesthesia

Chapter 1 - Historical Aspects of Regional Anesthesia

Figure 1-1 Syringe and needle as used in 1855.[6]

by Elliotson’s work, published a paper on his experience with “mesmerization” in India. He had obtained “complete suspension of sensibility to external impressions of a most painful kind.” Among his successful cases were the amputation of an arm and the removal of an 80-pound tumor. He had a total record of 261 painless operations (with 5.5% mortality) under mesmerization. After returning to Scotland, however, Esdaile found it impossible to repeat his excellent results of India, thus demonstrating the varying susceptibility to the treatment as well as the role played by racial characteristics in this field. [8]

In his comprehensive work on hypnosis, Braid also dwelled on its power to alleviate or prevent pain in surgery. He mentioned that he himself had painlessly extracted teeth from six patients, and that, in other cases, patients experienced only a little pain under the influence of hypnosis. There were others whose experiences accorded with those of Braid, as described in the following quotation (translated from the original) from a book by the well-known Swiss psychiatrist Forel: [9]

I have arranged extraction of teeth during hypnosis. I have removed a corn and made deep stabs without the hypnotized having felt anything. It was sufficient to assure that the pertinent part of the body was dead, insensible. Surgical operations and even parturitions are possible, though less often, under hypnosis. … If one succeeds in suggesting a thorough anesthesia, painless surgical operations are always possible, if they are not too protracted. But the anxiety before the operation, especially if the patient sees the extensive preparations, usually destroys the suggestibility. There lies the greatest difficulty. [10]

The limitations of the method and the great individual variations mentioned are clearly illustrated in the passage in the preceding paragraph. On the other hand, psychological considerations in connection with other factors will always be important. This may be seen in a report by McGlinn, who says: It was for the reasons of unpleasant reaction from drugs and the fear of complete loss of consciousness when using spinal anesthesia that led me to look for some method that would obviate these objections and allay the fears of the conscious patient. Anything which would appeal to the senses sufficiently to keep the minds of the patients occupied would divert from them the thought of operation. Music best fulfilled the requirements. … Music has been used for untold ages during operations and childbirth … to divert the mind of the sufferer. … We have been using music for a year and have been well satisfied with the results and feel that it is a valuable addition to the operating room. [11]

Mention should also be made of acupuncture, which has been used in China since approximately 2700 B.C. and which was introduced somewhat later in Japan (Fig. 1-3 (Figure Not Available) ). This method consists of inserting It has been used against numerous diseases (e.g., metal needles at certain points of the skin to varying depths. sciatica, other kinds of neuritis), with the aim of counteracting pain and other symptoms. According to Hume, Hun T’O, “the most famous surgeon in Chinese medical history,” who was born about A.D. 190, “used few drugs and needles, and he used cautery in only a few places. If the disease proved resistant to acupuncture and if drugs proved unavailing, he then first caused the patient to swallow wine containing an anesthetic effervescent powder, which produced intoxication and complete insensibility.” He could then perform [12] [13]

[14]

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Section I - Development of Regional Anesthesia

Chapter 1 - Historical Aspects of Regional Anesthesia

Figure 1-3 (Figure Not Available) Ming Dynasty acupuncture chart showing puncture points along meridians of the body, which apply to treatment for various organs, often quite distant from the point. This important Chinese medical technique has been in continual use for thousands of years. (From Lyons AS, Petrucelli JR: Medicine: An Illustrated History. New York, Albans, 1978.)

the desired operation. This shows that although acupuncture was also used as a local anesthetic, it was not always reliable. It has been noted that the method of acupuncture is used today in places where there is a shortage of modern chemical anesthetics. Acupuncture has gained a certain level of acceptance in Europe, but it seems to have been insufficiently studied by modern methods. Its efficacy has been partly explained as a kind of “referred pain,” but probably there is also some psychological factor contributing to the effect. [15]

NERVE COMPRESSION Pressure on nerves to produce local anesthesia may well be of ancient origin, especially in limb amputations. If the pressure is sufficiently strong, the innervated area becomes anesthetized. In such cases today, we speak of conduction, or regional anesthesia. Corradi considered it probable that compressions were used by ancient healers to stop bleeding, but whether this also led to abolition of pain, as he assumed, is doubtful. However, the famous military surgeon A. Paré (1510–1590) gave a good description of the use of compression for amputation, mentioning three advantages derived from firm ligation above the seat of operation. First, because the muscles were simultaneously pushed proximately, the bone could be better covered after the amputation and recovery was more rapid; second, bleeding was prevented; and, third, pain was greatly diminished. [16]

In 1784, a young English surgeon, J. Moore, tried to improve the compression method ( Fig. 1-4 ). In experiments on himself, he found that complete insensibility of the whole leg and loss of power to move it could be obtained in about half an hour after he had applied compression to the sciatic as well as the crural and obturator nerves. He constructed a special apparatus that facilitated compression of two opposite areas while still permitting a certain flow of blood. In this case, complete insensibility extended only to below the knee. The method was tried in combination with the tourniquet, which had produced insensibility in a patient whose leg was amputated below the knee by no less a person than J. Hunter. The operation seems to have been successful, but Moore clearly saw the necessity for further trials. His work, however, demonstrated the relative difficulties in obtaining the desired result, which could hardly have had a stimulating influence. Furthermore, discussions arose as to whether the anesthesia after compression was due to ischemia or to direct action on the nerve. Such a discussion was published after a communication by Le Fort. The introduction by Esmarch, another prominent military surgeon, of his “bandage”—a rubber tube that was greatly stretched and then wound four or five times around the limb above the place of operation—was a revival [17]

[18]

[19]

Figure 1-4 Apparatus designed by J. Moore for compression of nerves (1784).

of Paré’s method. When cocaine was introduced as a local anesthetic, it seemed desirable to use the Esmarch bandage in conjunction with it in order to lower the rate of absorption of the cocaine and thus to prolong its effect. The method of arresting the local blood flow before the injection of a relatively weak solution of cocaine close to the regional nerves (e.g., those of the fingers and toes), was adopted by several workers, among them M. Oberst at the surgical clinic in Halle, as described by Pernice. The question again raised was whether the complete stoppage of blood flow to the limb itself contributed to the change in sensibility. [20]

Valuable insight has been obtained on compression and other kinds of anesthesia by studies of the order in which different nerve fibers are affected. As early as 1881, Lüderitz observed that in animal experiments the motor fibers [21]

4

Section I - Development of Regional Anesthesia

Chapter 1 - Historical Aspects of Regional Anesthesia

were less resistant to pressure than the sensitive fibers, and he therefore assumed that some physiologic difference existed between the fibers. Boeri and di Silvestro studied the corresponding situation in humans with respect to the sensitive fibers, using the ulnar and sciatic nerves. During pressure, tactile sensations were blocked first, whereas thermal stimuli were less influenced and pain impressions were the least affected. The same order was found after application of the Esmarch bandage. Refrigeration, however, first affected pain and then thermal sensations, and finally tactile stimuli became inefficient. The order was thus the reverse of that observed under constriction. [22]

REFRIGERATION Hunter, who as a military surgeon took a great interest in the prevention of pain, performed experiments on animals and men to study the effect of refrigeration. Here is a typical example of his observations: I have taken a bucket of cold spring water with me when I made an attempt on a wasp’s nest, and put my hand into it after having been stung; and while my hand was in the water I felt no pain, but when I took it out again the pain was greater than when I put it in. [23]

Furnas mentions that D. J. Larrey (1766–1842), the famous surgeon-in-chief to the Grande Armée, “recounted the anesthetic effects of exposure to freezing battlefield conditions in his memoirs; the −19°C temperature allowed him to perform painless amputations on the half-frozen soldier-patients.” The only references given are the four volumes of Larrey’s great work from the battles (Larrey, 1812). Braun and Killian, in their respective handbooks, reported that Larrey, in February 1807, at the battlefield of Prussian-Eylau painlessly amputated numerous wounded soldiers with good results. The battle itself (1812) was characterized by Larrey as the most terrible that had ever occurred, and he complained several times about the cold, which once went down to a low of −19°C and became so intense that the instruments often fell from the hands of the pupils who were to serve him during the operations. He does not mention, however, that insensibility had occurred in the patients, although this is very probable. [24]

[25]

The most obvious effects of a cold environment on sensibility to pain appear more or less locally in peripheral parts of the body such as the limbs, ears, and nose, where circulation may be impaired at the same time. There is probably also some influence on the central nervous system, as is apparent from Larrey’s reports. This may indirectly be of importance, because it may diminish shock symptoms. The introduction of general anesthesia through inhalation of ether or chloroform was hailed as one of the greatest advances in the history of medicine. Early experience of death under the influence of the anesthetics, however, gave renewed urgency to the question of substituting local anesthetic agents for those of general action. In an article from 1848, Simpson, famous for the introduction of chloroform, emphasized that “if we could by any means induce a local anesthesia, without the temporary absence of consciousness which is found in the state of general anesthesia, many would regard it as a still greater improvement in this branch of practice.” He had tried localized effects of vapors from chloroform, ether, carbon disulfide, and even hydrocyanic acid. Although a reversible local action could be obtained, especially in lower animals, the results in mammals were less convincing. In the human subject, the local effect of chloroform vapors was not sufficiently deep to allow the part to be cut or operated on without pain, and it would probably have been dangerous. [26]

Simpson’s article led Arnott to call attention to the benumbing effect of cold, which he had described before. A bladder, taken from a small pig, containing tepid water was placed so as to cover the skin to be rendered insensible; ice and salt were then gradually “dropped in” to bring the temperature considerably below the freezing point. After 15 to 20 minutes, all sensations generally having disappeared, the operation could begin. Arnott added the following remark: “Perhaps … so low a degree of cold as I have mentioned is not required to produce the requisite degree of insensibility, and if pressure is conjoined with cold, so as to squeeze blood from the part, and check the circulation, the effect would certainly be more rapid, complete and extensive.” [27]

Richardson found that a frozen nerve showed a considerably lessened conductivity of electric current, and the same was observed when mechanical pressure was applied. The nerve was thus temporarily disorganized, but if it was frozen until all the water had been converted to ice, transmission of the current was stopped completely and permanently. This is, of course, in agreement with the fact that the metabolic processes in the cells are highly dependent on the temperature. At a few degrees above zero, the metabolism of a warm-blooded animal is only a few percentage points less than its value at normal body temperature. [28]

5

Section I - Development of Regional Anesthesia

Chapter 1 - Historical Aspects of Regional Anesthesia

In conformity with these results are those obtained by Trendelenburg. In 1914, his interest was aroused by a very unusual case of an 8-year-old boy suffering from tetanus infection. When the boy was brought to the hospital, he was seized within a short time by three heavy attacks of convulsions, with fixation of the thoracic cage, increasing cyanosis, and, in one of the attacks, unconsciousness. Both phrenic nerves were divided, so that artificial respiration with oxygen could be applied when needed. This, together with careful supervision and the use of chloral hydrate, made it possible to save the boy’s life, but owing to the operation he did not regain his diaphragmatic respiration. This case inspired Trendelenburg to investigate whether it would not be possible to break the transmission in motor fibers in such a way that regeneration could take place after a period of time. He froze nerves in cats and dogs by sucking ethyl chloride through a tube positioned around the nerves and thus succeeded in breaking the conductivity of the motor fibers; after several months, regeneration started and became complete after about a year. Further demonstrated that sensory fibers of mixed nerves (e.g., sciatic nerve) were put out of action at a experiments much lower degree of freezing than the motor fibers; hence, graded freezing could be used in cases of gunshot wound neuritis and for relieving patients from intolerable pain (the work was performed during World War I) and some other conditions. Perthes confirmed the beneficial effects of this treatment in humans. [29]

[30] [31]

[32]

Development of Regional Anesthesia The idea that drugs might diminish local pain not only by their action on the central nervous system but also by their direct effect on the nerve endings or on the nerves themselves was put to trial after syringes for injection were made available in the middle of the 19th century. Thus, ethyl alcohol, in relatively high concentrations (>50%), was used to treat patients with neuritis. The injection of alcohol into the affected nerve killed it, resulting in alleviation of the patient’s pain. The method is still recommended today in certain cases. Injections of opium suspensions and, later, of solutions of morphium chloride into the vicinity of the nerves were also tried, but results were poor. As was demonstrated by Macht and his collaborators, the peripheral action of opium alkaloids is—in contrast to the central effect—not prominent, and it was also shown that morphine had a lesser effect in this respect than papaverine and narcotine. [15]

[33] [34]

Cocaine

Long before the conquest of Peru by Francesco Pizarro in 1532, the Incas knew that the leaves of the coca bush could be used to stimulate a general feeling of well-being and prevent hunger. A small quantity of an amorphous mixture of coca leaves was prepared by Gaedcke, which on somewhat uncertain grounds, he believed to be an alkaloid that he called erythroxyline. He thought erythroxyline might be related to caffeine, but he was unable to prove it. A few years later, Niemann obtained from coca leaves a crystalline alkaloid to which he gave the name cocaine. He found that on degradation the substance gave rise to a weak base, ecgonine, and also to benzoic acid. After Niemann’s death, the work was continued by Lossen, who also split off methyl alcohol. [35]

[36] [36A]

[37]

It has been suggested that the Incas knew about the anesthetic properties of coca leaves, which they used to diminish local pain during certain surgical procedures. Thus, Singer and Underwood stated, “From early times, the natives of Peru knew about the anesthetic qualities of the coca plant, and they used to chew leaves and allow the saliva to run over the part of the body which had to be cut.” Killian goes further and says, “It seems that the juice of the leaves of the coca plant was dropped into painful wounds in order to decrease pain when trephining the skull.” Some time earlier, Leake, in a historical review, made the following statement: [38]

[25]

[39]

Local anesthesia was established upon a firm basis with the demonstration of the local anesthetic properties of cocaine. The aboriginal inhabitants of the highland of South America were acquainted with these properties. Roy L. Moodie has reconstructed an early surgical operation among the Incas, showing a blanket-clad shaman using a cautery to make a cruciform incision in the scalp of a woman suffering from melancholia. The operator chewed a cud of coca leaves, the juice from which he could drop upon the wound if the pain became severe. To this might be added that another picture of trephining in ancient Peru, as imagined by R. A. Thom, depicts the corresponding situation without the use of the coca leaves, nor is it mentioned in the accompanying text (written by Bender and checked by the historian E. H. Ackerknecht). No reference to early observations of the actual use of coca leaves for the purpose mentioned has been given by any of the authors quoted. Nor was Dr. S. H. Wassén of the Ethnographical Museum of Gothenburg, who kindly consulted the ethnographic literature to ascertain whether any mention was made of this point, able to find any indication that such was the case. It seems that the whole story is only the result of imagination rather than definite knowledge. [40]

Even if the aborigines of Peru had applied coca leaves in any form to wounds for the purpose of allaying pain, such a practice would undoubtedly have been completely forgotten shortly after the conquest of Peru by the Spaniards. It is, of course, possible that loss of this knowledge could have been a consequence of the intense efforts by the

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Section I - Development of Regional Anesthesia

Chapter 1 - Historical Aspects of Regional Anesthesia

representatives of the Church to eradicate what they considered to be superstitious behavior. As is well known, the Church’s disapproval resulted for some time in the prohibition of chewing of coca leaves as a stimulating agent. Later, it was demonstrated that chewing coca had a considerable stimulating effect on the working capacity of Indian laborers, and the ban on chewing coca leaves was lifted, but there may not have been any understanding of the value of the juice in lessening sensibility. [41]

Niemann described that cocaine on the tongue caused a kind of anesthesia, so that it became temporarily insensible to touch. He tried it on his own eye and observed no effects from it. Eight years later, Moréno y Maiz, who later became the physician-in-chief of the Peruvian army, wrote a fairly extensive paper on cocaine. Using frogs and guinea pigs, he confirmed an increased irritability of the brain manifested by convulsions. Moreover he also observed in experiments on himself the effects of cocaine on his general feeling of well-being, leading him to conclude that “these were the most blessed moments of my life.” He also observed a peripheral effect leading to insensibility after local injection of the alkaloid into the calf muscle. Although he did not closely follow up on this finding, he understood its possibilities, because he remarked in a footnote, “Could we use it as a local anesthetic? It is not possible to give an answer after such a small number of experiments; the future will have to decide this.” [42]

Bennett carried out a comparative study of caffeine (and the identical substance, theine), guaranine, theobromine, and cocaine and found that they were to all appearances identical in pharmacologic action. In small doses, they produced cerebral excitement and partial loss of sensibility; in large doses, complete paralysis. Nothing is mentioned about local effects. With this background, it is perhaps not so remarkable that a British medical commission in 1881 reported on cocaine as merely being a poor substitute for caffeine. [43]

[44]

In the same year, a detailed report by von Anrep was published in which he described a number of experiments with the new substance on mammals, birds, and even himself. He confirmed earlier findings on the general stimulating effects on animals. About the studies on himself he said: [45]

Local Action. (a) On cutaneous nerves, I have injected a weak solution (0.003–0.5 percent) under the skin of my arm, and at first experienced a feeling of heat; then insensibility to rather strong pinpricks at the place of injection; after about 15 minutes, the skin became quite red; and after about 25 to 30 minutes, all these manifestations disappeared again. (b) On the nerves of the tongue: Painting the tongue with a somewhat stronger solution (0.005–0.5 percent) acts anesthetizing on the taste nerves; after 15 minutes, I was unable to differentiate between sugar, salt, and acids. Pinpricks gave not rise to pain, whereas the other, not painted side of the tongue reacted normally.… (c) On the pupil: With local use on the pupil in mammals, there always sets in mydriasis. In frogs not constantly.… von Anrep concluded his report on the experiments in the following terms: I have had the intention after the study of the physiological effects of cocaine on animals also to make experiments on man. Other engagements until now have prevented me from doing so, and the animal experiments do not permit practical conclusions. In spite of this, I would like to recommend cocaine as a local anesthetic and in melancholiacs. Thus, von Anrep has pointed very definitely to the possibility of using cocaine for local anesthesia as well as for its psychological effects. When one remembers that the disappearance of hunger after chewing coca was considered to be the result of a local anesthetic effect on the mucous membrane of the stomach, it seems very remarkable that von Anrep’s advice did not lead to anything for several years, especially because some valuable results in the treatment of pain had been obtained with cocaine even before von Anrep’s paper. Thus, Collin reported on experiments by Ch. Fauvel on the anesthetic action of coca on the mucous membrane of the mouth and also by him and others on the useful application of preparations containing cocaine, especially in cases of granulatomatous pharyngitis and tonsillar angina. The preparations used were made by A. Mariani, who had erected a plantation of coca bushes close to Paris and who made the Mariani brand wine as well as paste and lozenges. The wine was Bordeaux and was thought to be especially valuable. Einhorn mentioned—without any reference to Mariani—that Bordeaux wine often causes local anesthesia of short duration on the tongue; he supposed that this was owing to the presence of esters of aromatic acids, although he did not think their existence had been proved. One is tempted to question the remark made by Clark when he discussed the history of general anesthesia: “Indeed, an enemy of our profession might claim that it showed extreme slowness and conservatism in accepting the gift offered by science.” [46]

[47]

[48]

7

Section I - Development of Regional Anesthesia The Birth of Regional Anesthesia

Chapter 1 - Historical Aspects of Regional Anesthesia

The decisive step in the development of regional anesthesia was taken by C. Koller (1858–1944), a young Viennese physician who had been working for some time in S. Stricker’s experimental pathology laboratory, and who also devoted himself to the study of ophthalmology ( Fig. 1-5 ). Both these circumstances were of importance, because Koller became familiar with experimental methods and also had personal experience with the need for using local anesthesia when operating on the eyes. He had observed the unsuitability of general narcosis for eye operations, because not only is the cooperation of the patient greatly desirable in such operations but the sequelae of general narcosis— vomiting, retching, and general restlessness—are frequently so severe that they could constitute a grave danger to the operated eye. This was especially true at a time when narcosis was not skillfully administered by trained experts, as it is now. During Koller’s time, eye operations were performed without the use of any anesthesia whatsoever. The information is from Koller’s retrospective survey written many years later. He, therefore, experimented with chloral hydrate, bromide, morphine, and other substances, but without success. For a while, he gave up his experiments. [49]

In the summer of 1884, Sigmund Freud (later to achieve fame as a psychiatrist) was attached to the general hospital in Vienna as a “Sekundararzt.” He had been treating a colleague who was a morphine addict by substituting cocaine, and he asked Koller to cooperate in some studies evaluating the effect of cocaine on muscular strength and degree of fatigue as measured by a dynamometer. Koller thus became familiar with cocaine and decided to try it on the eye. Some interesting details have been told by Koller’s daughter, who quotes an untitled paper from 1919 written by her father. Koller noted that the numbing effect of cocaine on the tongue suddenly made him realize that he was carrying in his pocket the local anesthetic he had searched for years earlier. He immediately went to Stricker’s laboratory with the well-known result. This story is supported by the only witness to the discovery, the assistant of the laboratory, J. Gaertner. [50]

[51]

Freud was planning a vacation, and before he left, he asked his friend L. Königstein, an assistant professor of ophthalmology, to try cocaine in patients with eye diseases. When Freud returned from his vacation, the preliminary communication by Koller had already been made. Thus, in 1884, Koller’s famous communication about cocaine as a local anesthetic took place. He was naturally very anxious to report his findings as soon as possible, and because he was unable to go in person to the German Ophthalmological Society’s meeting in Heidelberg on September 15 and 16, he invited Dr. Brettauer from Trieste to read the communication at the session. This brief classical report is quoted in full from the translation published in Archives of Ophthalmology: [52]

It is a well-known fact that the alkaloid cocaine, which is obtained from coca leaves (Erythroxylon coca) makes the mucous membrane of the throat and mouth anesthetic when brought in contact with it, and this led me to investigate the action of this agent on the eye. I have reached the following conclusions: After a few drops of cocaine hydrochloride (I used a 2% watery solution of cocaine in my experiments) are applied to the cornea of a rabbit or a dog, or after the solution is instilled into the conjunctival sac in the usual manner, a stage of irritation develops which generally lasts from 1/2 to 1 minute, as shown by the contraction of the eyelids, and the cornea and the conjunctiva of the eyeball become insensitive to contact. All reflexes, which usually develop on touching the cornea, such as closure of the lid, eversion of the eyeball, and drawing back of the head, are eliminated. Insensitiveness is complete and lasts 10 minutes. During this time the cornea can be scratched with a needle, punctured, or cauterized with silver nitrate until it becomes white, or deep incisions can be made without the animal reacting in any way. Not until the aqueous escapes or the iris is touched is there a sensation of pain. Whether additional drops of cocaine hydrochloride applied after a corneal section, or cocaine administered by some other procedure, will also produce anesthesia of the iris has not been investigated on account of the difficulties of examining sensation in animals. In my experiments with animals, I found that when anesthesia ceases there exists a moderate and not always well-pronounced dilatation of the pupil. As these experiments on animals succeeded, I tried the action of cocaine on myself and on a colleague, with the following results: The immediate effect of the instillation of 1 or 2 drops of a 2% solution of cocaine was a moderate burning, which lasted for 1/2 minute and was succeeded by a feeling of dryness. The palpebral fissure appeared wider than that of the untreated eye. If the cornea or the conjunctiva of the eyeball was touched with the head of a pin 1 or 2 minutes after beginning the experiment, this contact was appreciated only to the slightest degree. When the sensation and the reflexes were not completely exhausted, this effect could be obtained by the instillation of additional drops of cocaine hydrochloride. A depression could be produced in the cornea by pressure on the conjunctiva, or the eyeball could be grasped with the forceps without producing any sensation whatever. The state of anesthesia lasted 10 minutes. This was followed by a weakened sensitivity, which was lost after several hours. During the period of anesthesia, the function of the eye was in no way disturbed. After 20 or 30 minutes

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Chapter 1 - Historical Aspects of Regional Anesthesia

following the instillation, the pupil began to dilate. The dilatation increased during the course of an hour to a moderate grade; in the second hour, it gradually disappeared, and after several more hours (up to 12 hours) was entirely overcome. During this entire period, the pupil reacted promptly to light and to convergence. The weakness of accommodation disappeared earlier than the difference in the size of the pupil. I have not had any opportunity to perform experiments on diseased eyes, though I could convince myself that the anesthetic action of cocaine also took place in animals in which I had produced keratitis by the introduction of a foreign body. Perhaps it is not too bold to hope that cocaine can be used with success as an anesthetic in the removal of foreign bodies from the cornea as well as in more extensive operations, or as a narcotic in diseases of the cornea and conjunctiva. As I performed these experiments only during the past 2 weeks, I shall have to take up in a later publication the work which has previously been done on this subject. [53]

Mrs. Koller-Becker placed a facsimile of the original German text at the disposal of Dr. Brettauer. This communication, a model of scientific accuracy, cautious conclusions, and hopeful optimism, was obviously very well received by the meeting, especially after demonstrations by Brettauer of the remarkable anesthetic effect of a 2% solution of cocaine hydrochloride on the cornea and conjunctiva of one of the patients at the Heidelberg Eye Clinic. The detailed publication mentioned by Koller took the form of a lecture before the Viennese Medical Association on October 17, 1884. He could then report that his results had already been confirmed in various places in Germany, and he pointed out that “for us Viennese, cocaine has become a favorite topic because of the thorough review and interesting therapeutic work of my colleague at the general hospital, Dr. Sigmund Freud.” He could also add several important observations, such as the fact that ischemia occurred in the normal conjunctiva after cocaine administration. He saw that the widening of the palpebral fissure preceded the actions on the muscles in the iris and the ciliary body, and, therefore, should be attributed to removal of stimuli, which determine the width of the fissure by acting on the cornea and the conjunctiva. He also concluded from the late effects on the pupil and on accommodation that a slow absorption had taken place. He never saw any signs of stimulation after the administration of cocaine to the eye. [54]

In Vienna, Koller’s findings were confirmed immediately after his lecture by Königstein, and Koller persuaded Jellinek to try cocaine in the field of laryngology, so that he could publish a report on its useful application in the extirpation of polypous and papillomatous growth. Fränkel soon afterwards found that cocaine was well suited for anesthetizing the genital mucosa, even if it was inflamed. However, this was only the beginning. Before the end of the year, numerous “letters from the readers” appeared about the subject in England in Lancet; in other countries as well, interest was obviously very great. [55]

[56]

Perhaps this is best illustrated by the response in the United States. As early as on October 11, 1884, a report about the Heidelberg meeting, written by H. D. Noyes, a professor of ophthalmology in New York, was published in a well-known medical journal. He expressed enthusiasm about Koller’s discovery, and a stream of communications on the subject soon poured forth. As shown in the careful retrospect by Matas, the first use in the United States of cocaine as an anesthetic for the eye had already taken place on October 8, as a consequence of a letter from Noyes (the case had not yet been published). Knapp, also a professor of ophthalmology in New York and editor of the Archives of Ophthalmology, published at the end of the year an article starting with the following words: [57]

[58]

“No modern remedy has been received with such general enthusiasm, none has been so rapidly popular, and scarcely any one has shown so extensive a field of useful application as cocaine, the local anesthetic introduced by Dr. C. Koller of Vienna.” Knapp then gave the translation mentioned earlier, “not only as an acknowledgment of a debt of gratitude we all owe to him, but also as an appropriate introduction.” In conclusion, he said that cocaine had been found useful in ophthalmology, otology, rhinolaryngology, pharyngology, urology, gynecology, and also in general surgery. It was, of course, to be expected, especially after von Anrep’s experiments, that the subcutaneous application of cocaine would also be of value. This was definitely shown by Halsted, who in the year 1884 also successfully established the efficacy of regional anesthesia by blocking the corresponding nerve, as evident from a letter to the New York Medical Journal by his collaborator. In the autumn of 1885, Halsted, during a visit to Vienna, demonstrated how to use cocaine, with the result that A. Wölffler, assistant at Billroth’s clinic, who had at first declared cocaine to be without value in surgery, now wrote an enthusiastic article about it in a daily paper. Regional anesthesia with cocaine was also demonstrated in Vienna by Halsted. Because of his unfortunate ignorance of the dangers associated with cocaine, Halsted later became an addict as a result of numerous experiments on himself. In 1885, he published the first part of an article on the use and abuse of cocaine, but the last part of it never appeared. He had become a victim of his scientific enthusiasm, and only after great difficulties did he succeed in recovering from the addiction. In 1885, Corning called attention to the considerable prolongation [59]

[60]

[61]

[62]

[63]

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Chapter 1 - Historical Aspects of Regional Anesthesia

of the effect of cocaine injections in the arm brought about by the application of a tourniquet shortly after the injection. [64]

It is of interest to discuss the criticism of Koller by Jones in his chapter, “The Cocaine Episode.” His opening remark was: “When publishing the paper he had read in Vienna in October 1884, he quoted Freud’s monograph as dating from August instead of July, giving thus the impression that his work was simultaneous with Freud’s and not after it.” This can be countered with the fact that Koller in his article mentions Freud’s review, pointing out that it and the therapeutic papers had brought cocaine to the notice of Viennese physicians. The careful reader must understand that he had no intention of giving the impression insinuated by Jones. It was easy for Koller to make such a slip. Königstein, in his article of October 19, 1884, made the same mistake. Furthermore, Koller stated in the Heidelberg report that he had performed his experiments “during the past 2 weeks,” thus mainly in September. Jones continued his criticism with the following statement: “As time went on, Koller presented the discrepancy in still grosser terms, even asserting that Freud’s monograph appeared a whole year after his own discovery, which was, therefore, made quite independently of anything that Freud had ever done.” This is completely wrong. The paper referred to by Jones was presumably the letter written in 1941 to M.D. Seelig, in which Koller says: “The facts are that Freud did not have anything whatever to do with cocaine anesthesia, nor did he write a single word about cocaine in 1885 (whereas my work dates from 1884) that had not been done better and more scientifically by Anrep in 1878.” Obviously, Koller was not concerned with Freud’s “monograph” at all, the indirect influence of which he but with the reports of 1885 on Freud’s own somewhat illhad already mentioned on various earlier occasions, Jones erroneously assumed that Koller must have meant the literary review of fated experimental work. 1884. A psychoanalyst might find it interesting to analyze the several mistakes made by Jones. [49]

[49] [52] [53]

[65] [65A] [65B] [65C]

Although there can be no doubt about the importance of Koller’s work, it is often stated, even in modern literature, that Koller started his work at the suggestion of Freud. This is quite erroneous as is evident already from the wellestablished fact that Freud had turned to Königstein, the elder of the two ophthalmologists and the one with better opportunities for working on patients, and it would have been very remarkable if Freud had asked both to do the same job. Moreover, we have Freud’s own words that Koller made his discovery on his own initiative and without any suggestion from Freud. On the other hand, Koller, as we have seen, emphasized that Freud’s work on cocaine and his review had influenced interest in cocaine in Vienna.

[15]

[66]

[65]

It is not surprising that Freud personally regretted that he had missed the opportunity of making the great discovery that fell on Koller. However, it is probably true, as pointed out by Jones, that “it is not altogether likely that Freud, even with more time at his disposal, would have thought of the surgical application, one foreign to his interests.” The similarity between the two great discoveries discussed here was also reflected in the unusually rapid acceptance of new possibilities and in the early observation of danger, which led to new progress on the foundation that had been laid. However, it also happened that the men who had fought for the new methods were fated personally to suffer disagreeable hardships. As was common with the pioneers of general anesthesia, Morton died in poverty, exhausted from his efforts to get the appreciation he had hoped for, Wells committed suicide, and Jackson’s life ended in an asylum. Only Long had a peaceful life, but he never fought for the new discovery, preferring to keep it for himself. The fate of Koller was certainly influenced by the work he had performed. The difficulties he encountered in Vienna, which he refers to as “distress and continuous humiliating enmities,” were added to the fact that he did not even get the position of assistant at the eye clinic as he—with good reason one might say—had hoped. He finally emigrated to the United States, where he at last found a refuge. [67]

DEVELOPMENT OF COCAINE ANESTHESIA Cocaine came into general use in 1884, not only for application to mucous membranes but also for subcutaneous injections, and because of its suitability for blocking nerves, it found use in regional anesthesia. New methods for cocaine administration were soon added to those mentioned. Thus, in 1885, Corning published a paper in which he described experiments he had conducted on dogs, injecting 1.18 mL of a 2% solution of cocaine hydrochloride into the space “situated between the spinous processes of two inferior dorsal vertebrae,” with the result that the animal did not react for several hours, even if a stimulus was applied from a powerful faradic battery or if the hind limbs were pinched or pricked ( Fig. 1-6 ). One human experiment produced a similar local effect, and the author concluded: “Whether the method will ever find an application as a substitute for etherization in genitourinary or other branches of surgery, further experiments alone can show.” Corning came back to the problem 3 years later. His main interest was, however, the alleviation of pain in certain nervous diseases, and from the last of the papers mentioned, it is obvious that he succeeded with this in four cases. The reservations that were entertained about his first publication—it seemed uncertain whether he had really been in the subarachnoidal space—were removed, and there can be little doubt that Corning was the first to apply cocaine (and some other substances) to the nerves at their origin in the spinal cord. However, the pioneer in introducing the method for surgical purposes was Bier, who was [64]

[68]

[69]

10

Section I - Development of Regional Anesthesia

Chapter 1 - Historical Aspects of Regional Anesthesia

of the opinion that this kind of “spinal anesthesia” was in response to an action on the unmyelinated fibers and perhaps also on the ganglion cells ( Fig. 1-7 ). He carefully described six patients on whom he had operated for osteomyelitis, resections, and so forth, with success under spinal anesthesia, obtained with 0.005–0.015 g cocaine injections. However, because several of the patients had suffered from considerable postoperative effects (e.g., headache, vomiting), he decided to do some experiments on himself. Because much of Bier’s cerebrospinal fluid had escaped during administration of the solution, and because part of this had also been lost, the experiment was continued on his assistant, Dr. Hildebrandt. The two subjects confirmed that injection of as little as 5 mg of cocaine into the lumbar theca reduced the sensibility in approximately two thirds of the body to such an extent that major operations without the patient feeling any pain would have been feasible. It was also found, however, that some very unpleasant after-effects occurred. The work of Bier stimulated the interest of many surgeons, and soon spinal anesthesia was tried by others as well. The after-effects were sometimes mild or absent, but the fact that sometimes they were severe, or even fatal, caused hesitation in its use. Presumably, the effects were due to attack on the medulla oblongata by the cocaine that had diffused into the liquor as well as the slow normal circulation of the liquor, which after being “secreted” in the choroid plexus slowly passed via the ventricles into the epidural space and back through the subarachnoid space, ending in the pacchionian bodies, where it was partly transferred into the blood. This circulation takes several hours and is greatly influenced by the body position. In sitting or standing positions, the pressure of the cerebrospinal fluid increases greatly, and the circulation time consequently increases. This may partly explain the fact that in the cases of Bier and Hildebrandt it took a longer time for the after-effects to appear and disappear than in patients who were lying in bed. In order to counteract such effects, Pitkin added to the solution of the anesthetic—procaine—a mucilaginous substance and ethyl alcohol in such proportions that the specific gravity and viscosity of the “spinacene” could be held above those in the cerebrospinal fluid. Solutions of high specific gravity were used when the upper part of the body was elevated and those with low specific gravity when the operation took place with the pelvis in a high position. Special measures were also taken to prevent excessive decreases in blood pressure. [70]

A different method was indicated for other cases. Sicard, having used the method of Bier, tried a less dangerous technique. After trials on dogs, he found it possible to reach the nerve trunks at their exit from the medulla by injecting into the extradural space (i.e., between the dura and the bone). He injected cocaine in this way into 9 patients suffering from pains of various kinds (lumbar, sciatic, and even tabetic), who obtained relief of varying duration. Sicard pointed out that it was the surgeon’s prerogative to ascertain whether the method (“sacral anesthesia”) could be improved sufficiently to evoke analgesia of the lower limbs. Shortly thereafter, Cathelin reported similar animal experiments. He also claimed that he had tried the method in four patients with inguinal hernia, but the resulting reduction in sensibility was not sufficient for serious operations. This, he pointed out, was probably due to the fact that the nerves passing through the extradural space were still surrounded by a cover of dura. Because complete analgesia had occurred in the dog, the same result would be expected in the human if the dose were increased or if the solution were diluted. [71]

[72]

Several workers tried sacral anesthesia in human subjects without any evident success, until, in 1910, Läwen solved the problem. He used a 2% solution of procaine-bicarbonate, varying the amount of the injected fluid according to the desired degree of anesthesia. Gros had demonstrated that the effect of some local anesthetics (e.g., cocaine, procaine) is highly dependent on the pH; therefore, the effect would decrease if the acidity rose, a fact observed by Königstein in 1884. Owing to its greater lipid solubility, the free base probably penetrates much more easily into the nerve than salts such as hydrochloride. By injecting in this way, he obtained better penetration into the nerve. Together with von Gaza he proved that procaine applied intradurally in rabbits was considerably more toxic than when introduced extradurally; therefore, the prospects for useful application of sacral block were greatly improved. That variations in the amount of fluid injected determine the area affected is illustrated by the fact that 10 mL provided saddle block, whereas 50 mL caused the anesthesia to reach as far as the nipple. [73]

[74]

[75]

[15]

Other new and modified methods of application of anesthetics are available, such as paravertebral, parasacral, venous, and arterial injections, but they need not be discussed here. The heavy toll exacted by cocainization for surgical purposes (grave intoxications and even several deaths) during the early years of its general use caused great distrust of the new methods, especially when the substance was injected or applied to certain mucous membranes where it was easily absorbed. However, these unfortunate occurrences led to important investigations that aimed to reduce the amount of cocaine applied without unduly decreasing the anesthetic effect. Careful studies in this area were made by Reclus, who was able to show that the concentration of the solutions could be considerably lowered ( Fig. 1-8 ). Whereas in the early days cocaine solutions of 2% to 5% were used in general surgery and on certain mucous membranes even as high as 20%, Reclus found 1% to 2% to be enough. In fact, he communicated that he had performed about 3200 operations using these [76]

11

Section I - Development of Regional Anesthesia

Chapter 1 - Historical Aspects of Regional Anesthesia

dosages, without a single death, and even without disturbing the physical equilibrium of his patients. Some technical changes were necessary with use of the lower concentrations, such as anesthetizing successive layers as the operation proceeded and waiting longer for the anesthetic effect to become strong enough. Even concentrations as low as 0.5% were sometimes sufficient. The idea of using still more dilute solutions was further developed by Schleich[ ] [ ] with the introduction of “infiltration anesthesia.” He used three solutions, one[ ] for general purposes and two for special occasions. 77

77A

2

Solution 1

Solution 2

Solution 3

Cocaine hydrochloride

0.2

0.1

0.01

Morphine hydrochloride

0.02

0.02

0.005

Sodium chloride 0.2

0.2

0.2

100.0

100.0

Distilled water to 100.0

Schleich had observed the well-known phenomenon that the injection of water first caused heavy pain followed by local anesthesia. Because physiologic saline (0.9%) has no pain-inducing action, he tried to find an intermediate concentration that would cause no pain but that would still produce some swelling in the surrounding cells, with consequent disturbance in the functional activity of the nerve endings and decreasing sensibility. The effect was intended to be a summation of the actions of hypotonicity and cocaine; morphine has so small a peripheral effect that it seems impossible to prove that it has any effect in this instance. Schleich tried the method of infiltrating tissues with these solutions and found a good level of anesthesia, permitting performance of many operations without pain. Schleich’s work was at first met with the greatest distrust, but Braun (1897) showed convincingly that the method had great potential for use, even in fairly large operations. He denied the results obtained with 0.2% saline, and he preferred eukaine B to cocaine, but there was no doubt that the principle of infiltration with low concentrations was correct.

DEVELOPMENT OF OTHER LOCAL ANESTHETICS It was only natural that discoveries in organic chemistry, both analytic and synthetic, should have led to efforts to find preparations with good anesthetic properties and without the drawbacks of cocaine. Besides its highly acute toxicity and the risk of addiction (which came to play a greater role as time went by), cocaine is easily decomposed when the solution is sterilized. It is also expensive. As emphasized by Willstätter, the vegetable bases, such as cocaine, are often so complex that the imagination of the chemist is not equal to the task of shaping them without the natural model, “at least in our time.” The constitutional formula of cocaine and its synthesis were not completed before 1934, 60 years after the isolation of the alkaloid by Niemann. For a long time, the ideas about the structure of the base ecgonine were erroneous, but this did not prevent great progress from being made in the field of new local anesthetics. The points of departure were the discoveries of the products split from cocaine, namely, benzoic acid and methyl alcohol. As early as 1887, Filehne called attention to a certain analogy between cocaine and atropine—an ester between tropic acid and the complex organic base tropine or tropanol. According to Filehne, a weak local anesthetizing effect is exercised by atropine, and this was increased if mandelic acid was substituted for tropic acid (homatropine). If the still simpler benzoic acid is introduced into the molecule instead of tropic acid, the compound obtained (benzoyltropine) becomes a strong local anesthetic. With ecgonine—obtained from Lossen himself—no anesthetic action at all was observed. Benzoyl derivatives of several alkaloids, such as quinine and morphine, on the other hand, were highly active. Benzoic acid must, therefore, play a fundamental role in the anesthetic effect of cocaine. Soon after, Poulsson found that the local anesthetic effect of cocaine disappeared if the esterifying alcohol group was removed; the general effects then changed, and the toxicity decreased considerably, especially for mammals. If an ethyl or propyl group was introduced instead of the methyl group, the usual cocaine activity remained, on the whole, unchanged; therefore, esterification of the acidic group was of great importance for the anesthetic action. A second methyl group, attached to a nitrogen atom, can be removed without any loss of activity; indeed, its removal increases cocaine’s activity. Ehrlich confirmed that mice fed on cakes containing varying amounts of cocaine developed pathologic liver changes (substantial enlargement and vacuolization) and that this effect was much influenced by changing special groups in the molecule. The intermediate compounds leading from ecgonine to cocaine were only about frac120; as toxic as cocaine itself. Soon after, Ehrlich and Einhorn observed that the esterifying methyl group in cocaine was not the only group that could be substituted by other alcoholic radicals; the benzoyl group could also be replaced by other acidic groups belonging to the aliphatic or the aromatic series, without the loss of anesthetic action. These [78]

[79]

[80]

[81]

[82]

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Section I - Development of Regional Anesthesia

Chapter 1 - Historical Aspects of Regional Anesthesia

observations combined with the imperfect knowledge of the structure of ecgonine led to the development of hundreds of new synthetic anesthetics, many of them less toxic than cocaine relative to their anesthetic action. It is, of course, impossible to go into the details here, and the reader is referred to the works of Poulsson, Laubender, Drill, Braun and Läwen, and Killian for more specific information. Only a few typical examples illustrating the trend of the evolution are given here. [80]

[13]

[84]

[83]

[25]

Einhorn and Heinz found that even relatively simple derivatives of amino esters were anesthetic, but although their salts could not be used owing to their acidity and consequent irritating effects, the free amino esters produced excellent local anesthesia on wounds. Because the preparations were made soluble in water only with difficulty, the effect lasted for a long time, which was highly desirable for the type of treatment needed. Many of the new substances, in contrast to cocaine, caused no contraction of the blood vessels, which led to fairly rapid absorption. Thanks to the important discovery by Braun that the addition of small amounts of adrenaline to these solutions could often act as a “chemical tourniquet,” an increase in anesthetic action could be obtained. [85]

[86]

As another example, it should be mentioned that Einhorn and Uhlfelder described a new product, p-aminobenzoic acid diethylaminoethylester, or Novocaine (procaine), which was carefully tried on humans by Braun, who produced wheals on the skin of the forearm by injection and could state that the new compound exhibited potent local anesthetic action with practically no irritation. The general toxicity was relatively lower than that of cocaine, its solution could be boiled without decomposition, and the effect was potentiated with adrenaline. Numerous modifications of procaine have since been developed, but it is still a valuable anesthetic in many cases. [87]

[88]

When the final steps in the synthesis of cocaine had been taken by Willstätter and his collaborators, the former also succeeded in synthesizing a number of its numerous optical isomers. These were studied pharmacologically by who found the dextrorotatory cocaine (with cis-transisometry) to be somewhat less toxic than the Gottlieb, natural product, probably because the “unnatural” isomers are often metabolized more rapidly than those occurring in nature. At the same time, dextrorotatory cocaine is about twice as active as cocaine on the sciatic nerve of the frog, which is explained by its greater lipid solubility; it also has the advantage that the solution can stand sterilization well. In contrast to cocaine, however, it caused no contraction of the blood vessels, but this could be changed by Brown’s method. Psicaine, as the product was named, seemed to be suitable, at least for use on mucous membranes. On the whole, however, the intimate knowledge of the structure of cocaine did not yield the harvest one had hoped for with regard to new and better local anesthetics. [78]

[89] [90]

A valuable impetus in the search for new local anesthetics came from an unexpected quarter. In 1935, von Euler and Erdtman in a study on the structure of the alkaloid gramine, observed that although this substance had no anesthetic effect, its isomer, isogramine, or 2-(dimethylaminomethyl)-indole at first tasted bittersweet and then caused anesthesia on the tongue. This discovery was duly appreciated, and a series of investigations were started, beginning with Erdtman and Löfgren. Numerous compounds with local anesthetic action were synthesized, but often they also caused irritation or had other effects that precluded practical use. Löfgren and associates (Löfgren, 1946 and 1948) continued the work with great energy, and after more than 100 compounds had been investigated, they found 2-diethylamine-2′,6′-acetoxylidide (lidocaine [Xylocaine]), a preparation which marked a considerable It had great stability, no irritating action, and good anesthetic effects. These findings were confirmed by advance. extensive pharmacologic studies, especially by Goldberg and also by Björn, who evolved an elegant method for estimating the effect of local anesthetics in dentistry. In collaboration with Huldt, Björn demonstrated the value of lidocaine in dentistry, whereas Gordh and others made corresponding communications from surgical quarters. At present, lidocaine is used extensively throughout the world. [91]

[92]

[66] [93]

[94]

[95]

[96]

[97]

Development of the Technique of Regional Anesthesia In 1908, August Bier devised a very effective method of bringing about complete anesthesia and motor paralysis of a limb. He injected a solution of procaine into one of the subcutaneous veins that was exposed between two constricting bands in a space that had previously been rendered bloodless by an elastic rubber bandage extending from fingers or toes. The injected solution permeated the entire section of the limb very quickly, producing what Bier called direct vein anesthesia in 5 to l5 minutes. The anesthesia lasted as long as the upper constricting band was kept in place. After it was removed, sensation returned in a few minutes. [98]

Interestingly, the first spinal anesthesia occurred 5 years before the first lumbar puncture. The term spinal anesthesia was introduced by Corning in his famous second paper of 1885. Unfortunately, what he had in mind was neither spinal nor epidural anesthesia as presently understood. Corning was under the mistaken impression that the interspinal blood vessels communicated with those of the spinal cord, and his intention was to inject cocaine into the minute interspinal vessels and have it carried by communicating vessels into the spinal cord. He made no mention of cerebrospinal fluid, nor of how far he introduced the needle into the spinal space.

13

Section I - Development of Regional Anesthesia

Chapter 1 - Historical Aspects of Regional Anesthesia

It fell to Heinrich Quincke to perform the first lumbar puncture. He based his approach on the anatomic principle that the subarachnoid spaces of the brain and spinal cord were continuous and ended in the adult at the level of S2, whereas the spinal cord extended only to L2. Thus, a puncture effected in the third or fourth lumbar intervertebral space would not damage the spinal cord. Lumbar puncture was invented as a treatment for hydrocephalus. Quincke acknowledged in his communication that he followed Essex Wynter, who 6 months earlier had described the use of a Southey’s tube and trocar for a similar purpose. This device was originally designed to drain fluid in cases of dropsy. Wynter introduced the tube between the lumbar vertebrae after making a small incision in the skin for the purpose of instituting drainage of the fluid in two patients with tuberculous meningitis. Quincke prescribed bedrest for the 24 hours after the puncture. It is noteworthy that he entered the skin 5 mm to 10 mm from the midline. Thus, the paramedian and not the median approach is the classic one, contrary to what is sometimes taught. [99]

August Bier published his celebrated paper on spinal anesthesia in 1899, under the title “Versuche uber Cocainisirung des Ruckenmarkes” (“Research on Cocainization of the Spinal Cord”). Bier assumed that intrathecal injection of cocaine produced anesthesia by a direct action on the spinal cord. He wanted to apply cocaine anesthesia for major operations and regarded spinal anesthesia as a means of safely producing a maximal area of anesthesia using a minimal amount of drug. It was his opinion that the anesthesia evoked by small amounts of cocaine injected into the dural sac resulted from its spread in the cerebrospinal fluid and that it acted not only on the surface of the spinal cord but especially on the unsheathed nerves that traverse the intramembranous space. The extent of the anesthesia produced was somewhat unpredictable, so Bier decided to try the experiment on himself. His assistant, Hildebrandt, performed a lumbar puncture on Bier, but when the time came to attach the syringe to the needle, a crisis developed; the needle did not fit. A considerable amount of cerebrospinal fluid and most of the cocaine dripped onto the floor. To salvage the experiment, Hildebrandt volunteered his own body. This time there was a good fit and complete success. However, the incident did not end there. Both of them celebrated the success with wine and cigars, but on the next day Bier had an oppressive headache that lasted for 9 days. Hildebrandt’s “hangover” developed even before the night ended. News of Bier’s work spread quickly, and, although he abandoned it himself, his method of subarachnoid spinal anesthesia was soon brought into prominence by Tuffier. In 1900, in a report of 63 operations, Tuffier promulgated the rule, “Never inject the cocaine solution until the cerebrospinal fluid is distinctly recognized.” The sensation caused by Tuffier’s demonstrations is well conveyed by Hopkins, who wrote, “To be able to converse with a patient during the performance of a hysterectomy, the patient all the while evincing not the slightest indication of pain (and even being unable to tell where the knife was being applied) was certainly a marvel, and was well worth crossing the Atlantic to see.” Rudolph Matas, in his description of spinal anesthesia, used cocaine hydrochloride, 10 to 20 mg, dissolved in distilled water. The solution instilled was, therefore, clearly hypotonic. Fowler preferred to have his patients in the sitting position for the injection and, not surprisingly, was often astonished by the rapidity and completeness of the anesthesia. Gravity methods were not yet understood. [100]

[101]

[102]

[58]

[103]

Aseptic precautions were strictly observed, and Lee mentions that the injection he used consisted of 12 to 20 minims of a 2% sterilized solution prepared in hermetically sealed tubes by Truax, Green, and Company of Chicago. This appears to be the earliest published reference to this method of packaging, which represented an important advance, because previously it was necessary for the surgeon to prepare his own solution from tablets and sterilize it. [104]

In 1912, Gray and Parsons of Birmingham, England, undertook an extensive study of variations in blood pressure associated with the induction of spinal anesthesia. They concluded that the bulk of the fall in arterial blood pressure during high spinal anesthesia is attributable to diminished negative intrathoracic pressure during inspiration, which is dependent on abdominal and lower thoracic paralysis. They noted that when the negative pressure in the thorax was increased, the arterial blood pressure also increased. [105]

It was by then quite clear that one of the principal dangers of spinal anesthesia is the lowering of the blood pressure. Smith and Porter found that the quantity of anesthetic solution was more important for diffusion than its concentration; dilute solutions usually spread farther than concentrated ones. The introduction of procaine beneath the dura in the region in which the splanchnic nerves arise caused as profound a fall in blood pressure as was caused by complete resection of the cord in the upper thoracic region. This, they thought, proved that the fall in blood pressure was not due to toxicity of the drug or to paralysis of the bulbar vasomotor center but to paralysis of the vasomotor fibers that regulate the tone of the blood vessels in the splanchnic area. Because these nerve roots originate between T2 and T7, Smith and Porter believed that the main clinical objective was to prevent cephalad diffusion of the drug from reaching this height and paralyzing these nerve roots. [106]

14

Section I - Development of Regional Anesthesia

Chapter 1 - Historical Aspects of Regional Anesthesia

The idea of making the injected solution hyperbaric with glucose to obtain control over the intrathecal spread of the solution originated with Arthur E. Barker. Barker employed stovaine. It was less toxic than cocaine but was slightly irritating and was eventually superseded by procaine. [107]

[108]

Pitkin, in 1928, and Etherington-Wilson, in 1934, experimented with a glass model of the spinal canal to obtain control over the rate of ascent of the drug by making the injected solution hypobaric. Control was achieved by varying the time the model was kept sitting upright after the injection. Pitkin did this by mixing alcohol with the procaine solutions, a mixture he called spinocaine, but he categorically warned against having the patient in the sitting position during injection. He controlled the level of blockade by tilting the table and illustrated this with a figure showing an “altimeter” attachment. [70]

Barker stressed such points of technique as raising the head on pillows. Whenever he injected a heavy fluid intradurally, he kept the level of analgesia below the transverse nipple line. Barker advocated puncture in the midline as being easier and allowing more even spread of the injected fluid than the paramedian approach. He also emphasized that in no case should the analgesic solution be injected unless the cerebrospinal fluid ran satisfactorily. Above all else, perfect asepsis throughout the entire procedure was absolutely necessary. Moreover, no trace of germicides should be left on the skin, because they could be conveyed by the needle into the spinal canal, where their irritating qualities were particularly undesirable. Barker’s rational approach to the use of a hyperbaric solution for spinal anesthesia was apparently forgotten when stovaine was replaced by improved drugs and had to be rediscovered after trials of quasi-isobaric solutions of several new drugs led to unsatisfactory control of levels. The lessons of the past were ignored or forgotten by surgeons and not yet learned by anesthesiologists. Indeed, at that time, there were few anesthesiologists to learn. In 1920, W. G. Hepburn revived Barker’s technique with stovaine, and Sise, an anesthesiologist at the Lahey Clinic, applied it to procaine in 1928 and to tetracaine in 1935. [109]

[110]

Tetracaine’s great advantage as a spinal anesthetic was its relatively prolonged duration of action without undue toxic effects, but this advantage was partially negated by the vagaries of its segmental spread, which resulted from its being used in approximately isobaric solution. Therefore, Sise mixed the solution with an equal or greater volume of 10% glucose and injected it while the patient lay in a lateral position on a table that was tilted head down 10 degrees. The patient was then turned to a supine position with a good-sized pillow inserted under the head and shoulders to flex the cervical spine forward as much as possible; the slope of the table was adjusted during the next few minutes as dictated by the level of analgesia needed. [110]

A refinement of this technique was the saddle-block method described in detail by Adriani and Roman-Vega. Anesthesia deliberately confined to the perineal area was obtained by performing a lumbar puncture and injection of a hyperbaric solution, with the patient sitting on the operating table and remaining so for 35 to 40 seconds after the injection. [111]

The technique of hypobaric spinal anesthesia was published by W. W. Babcock in 1912. He dissolved 80 mg of stovaine in 2 mL of 10% alcohol; thus, a solution was obtained with a specific gravity that was less than 1.000, well below that of the cerebrospinal fluid, which he calculated to be 1.0065. He believed that the anesthesia that resulted was chiefly a nerve root anesthesia and not the “true spinal cord anesthesia” obtained with standard solutions. A method for continuous spinal anesthesia was described by W. T. Lemmon in 1940. It was performed with the aid of a special mattress, a malleable needle, and special tubing, and was proposed for long operations that required abdominal relaxation. In 1907, H. P. Dean wrote of having so arranged the exploring needle that it could be left in situ during the operation and another dose injected without moving the patient more than a slight degree. He proposed that additional injections be made postoperatively to treat pain or abdominal distention. Lemmon’s technique was simplified by Tuohy. He performed continuous spinal anesthesia by means of a ureteral catheter introduced into the subarachnoid space through a needle with a Huber point. [112]

[113]

Tuffier’s favorable experience with spinal anesthesia for surgery on the lower limbs and urogenital organs led O. Kreis of Basel to try it for childbirth. He injected five parturients with 10 mg of cocaine at the L4 to L5 level and claimed that this procedure alleviated pain with little impairment of muscular power or uterine motility; however, he recommended the method particularly for forceps delivery. In the United States, S. Marx quickly followed with several reports praising the efficacy of lumbar cocainization. All of this occurred in the year 1900, but the enthusiasm soon waned. [114]

[115]

15

Section I - Development of Regional Anesthesia

Chapter 1 - Historical Aspects of Regional Anesthesia

Interest in obstetric regional anesthesia was revived when W. Stoeckel developed sacral anesthesia with procaine. The feasibility of injecting a local anesthetic by the caudal route was demonstrated by Fernand Cathelin in 1901. He found that fluids injected into the extradural space through the sacral hiatus rose to a height proportional to the amount and speed of injection. His objective was to develop a method that would be less dangerous but just as effective as subarachnoid lumbar anesthesia. He was successful in reducing the danger, but his efforts to demonstrate the efficacy of the caudal injection for surgical operations were disappointing. [116]

In 1909, Stoeckel described his experience with caudal anesthesia in the management of labor. He wrote that various concentrations of procaine and epinephrine produced predictably varying degrees of success after a single injection. Pain relief averaged 1 to 1½ hours in duration. He warned, however, that the greater the analgesic effect, the greater the hazard of impairing the forces of labor. These reservations, of course, would not apply to the use of caudal anesthesia for surgical operations, and Läwen, in 1910, described how he used Stoeckel’s experience and Cathelin’s ideas to perform a variety of surgical operations in the perineum. [116]

Matas, the eminent American pioneer and historian of regional anesthesia, recorded that Sellheim, injecting close to the posterior roots of T8 to T12 in addition to the ilioinguinal and iliohypogastric nerves, was able to perform abdominal operations successfully. Sellheim was, therefore, credited by Matas as being the originator of the paravertebral method of anesthesia. [58]

Kappis described posterior approaches to the lower seven cervical nerves for the purposes of cervical and brachial plexus block. The method of paravertebral block of the thoracic nerves and the first four lumbar nerves was also described by Kappis and was used in a great many upper abdominal operations. He pointed out that these techniques could be used to treat acute and chronic pain with procaine, or even with alcohol if motor function could be disregarded. Kappis was also responsible for the posterior approach to the splanchnic plexus. [117]

In 1922, Läwen found unilateral paravertebral block of selected spinal nerves useful in the differential diagnosis of intra-abdominal disease. [118]

In 1925, Mandl reported 16 cases of angina pectoris in which he injected procaine, 0.5%, paravertebrally with excellent results. In the next year, Swetlow attempted to destroy the afferent sensory fibers altogether by substituting 85% alcohol for the procaine; for the most part, patients obtained satisfactory relief of pain for several months. [119]

[120]

The pioneer of alcohol injection for the purpose of producing a long-lasting interruption of neural conduction was Schloesser. Schloesser presented the method as a means of managing convulsive facial tic. His patients attained paralysis that lasted from days to months, depending on the quantity of alcohol injected. He suggested that the method would also be useful for supraorbital neuralgia and tic douloureux. [121]

Segmental peridural anesthesia, under the name of metameric anesthesia, was used for the first time in 1921 by Fidel Pagés, a Spanish military surgeon. Dogliotti, however, popularized segmental peridural spinal anesthesia. He emphasized that injecting the anesthetic solution in sufficient quantity (50–60 mL) and under adequate pressure made it quite easy to subject the spinal nerves to the action of the injected fluid throughout their length in the spinal canal and the intervertebral foramina, and even beyond. Dogliotti’s method was easier and, without question, simpler than paravertebral regional block, because only one puncture was needed. He stressed the sudden loss of resistance at the moment when the point of the needle, having pierced the ligamentum flavum, entered the epidural space. The usefulness of this technique was extended further when Curbelo decided to apply the Tuohy armamentarium for continuous spinal anesthesia to continuous segmental peridural anesthesia. In one case, he left the catheter in place for as long as 4 days and administered a total of 10 injections of 15 mL each of 2% procaine solution, producing a continuous sympathetic lumbar block. [122]

[123]

[124]

[125]

It was but a short step from the diagnostic block to the therapeutic block, and the step was indeed taken by von Gaza and by Brunn and Mandl in 1924 in the management of visceral pain. Long-term pain relief by neurolytic injection of alcohol was developed by Swetlow for the interruption of cardiac afferent inflow and subsequently applied to paravertebral sympathetic block in the treatment of severe intractable pain, particularly the pain of malignant disease. Dogliotti, in 1930, took the bold step of injecting absolute alcohol into the subarachnoid space, hoping to produce by simple chemical means a posterior rhizotomy equivalent to that previously attainable only by surgery. At the opposite end of the local anesthetic concentration spectrum, Sarnoff and Arrowood exploited the continuous subarachnoid injection of dilute procaine (0.2%) to obtain a differential block limited to efferent sympathetic fibers and afferent fibers subserving pain. [126]

16

Section I - Development of Regional Anesthesia Conclusion

Chapter 1 - Historical Aspects of Regional Anesthesia

Local anesthesia by chemical means has come to play a great role in surgery. Today, practically no part of the body is inaccessible to this form of pain relief. Whether general or local anesthesia is to be used in an individual case depends on many factors and must be carefully considered by the surgeon. According to Braun and Läwen, the proportion of operations performed under local anesthesia in Germany increased considerably during the first decades of the 20th century; in some clinics, 50% of procedures were performed with regional anesthesia. Demands on anesthetists have increased greatly: They must master several different methods of regional anesthesia as well as the controls that are regularly performed on the patient’s reactions during the operation. These requirements have necessitated special training for anesthetists who practice in modern surgical clinics. [84]

Thus, on the foundation laid by Carl Koller, a new and important branch of medical science has developed. This is an old story about a young man who became fascinated by a great idea and was ready to grasp the opportunity when it presented itself. But it is also an illustration of the truth of Pasteur’s famous saying that chance favors only one whose mind has been prepared. REFERENCES 1. Riese

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A: Dell’ anesthesia e degli anesthetici nella Chirurgia del Medico Evo. Mem 1st Lomb Scienz Matem Natur L4:127–175, 1881.

J: A Method of Preventing and Diminishing Pain in Several Operations of Surgery. London, Cadell, 1784, p 50.

Fort L: Anesthésie produite par la compression. Gaz Hop (Paris) 819–820, 1874.

19. von

Esmarch F: Ueber künstliche Blutleere bei Operationen. Volkmann’s Samml Klin Vortr Chir 1:373–384, 1873.

20. Pernice

L: Ueber Cocainanästhesie. Dtsch Med Wschr 16:287–289, 1898.

21. Lüderitz 22. Boeri

C: Versuche über die Einwirkung des Druckes auf die motorischen und sensiblen Nerven. Z Klin Med 2:97–120, 1881.

G, di Silvestro R: Sur la mode de se comporter des différentes sensibilités sous l’action de divers gents. Arch Ital Biol 31:460–464, 1989.

23. Hunter

J: A treatise on the blood, inflammation, and gun-shot wounds, 1793. In The Works of John Hunter (reprint). London, Longman, 1835,

17

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p 265. 24. Braun

H: Die örtliche Betäubung, ihre wissenschaftlichen Grundlagen und praktische Anwendung. Leipzig, JA Barth, 1935.

25. Killian

H: Lokalanästhesie und Lokalanästhetika. Stuttgart, G. Thieme, 1959.

26. Simpson

JY: Local anaesthesia. Lancet II:39–42, 1848.

27. Arnott

J: I. On cold as a means of producing local insensibility. 2. On cold as a means of producing local anaesthesia in surgical operations. Lancet II:98–99, 287–288, 1848.

28. Richardson

BW: On the influence of extreme cold on nervous fibre. Asclepiad 1:33–37, 1885.

29. Trendelenburg

W: Ueber Langdauernde Nervenausschaltung mit sicherer Regenerations fähigkeit. Z Ges Exp Med 5:371–374, 1917.

30. Trendelenburg

W: Weitere Versuche über langdauernde Nervenausschaltung für chirurgische Zwecke. Z Ges Exp Med 7:251–274, 1919.

31. Waters

RM: The evolution of anesthesia. Mayo Clin Proc 17:428–432, 440–445, 1942.

32. Perthes GC: Ueber die Behandlung der Schmerzzustäande bei Schussneuritis mittels der Vereisungsmethode von W. Trendelenburg. Münch Med Wschr 65:1367–1369, 1918. 33. Macht

DI, Herman NB, Levy CS: A quantitative study of the analgesia produced by opium alkaloids, individually and in combination with each other. J Pharmacol 8:1–37, 1916.

34. Macht

DI, Johnson SL, Bollinger HG: On the peripheral action of the opium alkaloids. Effect on the sensory nerve terminals. J Pharmacol 8:451–463, 1916.

35. Gaedcke

F: Uber das Erythroxylin. Arch Pharm (Weinheim) 132:141–150, 1885.

36. Niemann

A: Ueber eine neue organische Base in den Cocablättern. Göttingen, Inaug-diss, 1860.

36A. Wöhler

F: Ueber eine organische Base in der Coca [preliminary report]. Justus Liebigs Ann Cham 114:213, 1860.

37. Lossen

W: Ueber das Cocain. Ann Chem Pharm 133:351–371, 1865.

38. Singer

C, Underwood EA: A Short History of Medicine, 2nd ed. Oxford, Clarendon Press, 1962, p 349.

39. Leake

CD: The historical development of surgical anesthesia. Sci Monthly 20:304–328, 1925.

40. Bender

GA, Thom RA: Great Moments in Medicine. Detroit, Parke-Davis, 1961.

41. Mortimor 42. Moréno

WG: Peru History of Coca. New York, JH Bvail, 1901.

y Maiz T: Recherches chimiques et physiologiques sur l’Erythroxylum Coca du Pérou. Thèse de Paris, 1868, p 91.

43. Bennett A: An experimental inquiry into the physiological actions of caffeine, theine, guaranine, cocaine, and theobromine. Edinburgh Med J 19:323–341, 1873. 44. Sollmann 45. von

T: A Manual of Pharmacology, 8th ed. Philadelphia and London, WB Saunders, 1957, p 323.

Anrep B: Ueber die physiologische Wirkung des Cocain. Pflügers Arch ges Physiol 21:38–77, 1880.

46. Collin

P: De la Coca et ses véeritables propriétés thérapeutiques. Un Méd Prat Franc 24:239–240, 1877.

47. Einhorn 48. Clark

A: Ueber neue Arzneimittel. Fünfte Abhandlung. Justus Liebigs Ann Chem 371:125–131, 1909.

AJ: Aspects of the history of anaesthetics. BMJ II:1029–1034, 1938.

49. Koller

C: Historical notes on the beginning of local anesthesia. JAMA 90:1742–1743 1928. [The article was also published twice in German in the same journal: Wien Med Wschr 78:601–602, 1928; and again, 84:1179–1180, 1934.]

50. Koller-Becker

H: Carl Koller and cocaine. Psychoanal Q 32:309–373, 1963.

51. Gaertner J: Die Entdeckung der Localanästesie. Der neue Tag, 1919. [The article was also published in Neue freie Presse under Unterhaltung. Quoted from Koller-Becker, 1963, p 331.] 52. Koller

C: Vorläufige Mitteilung über lokale Anästhesierung am Auge. Bericht über die 16. Versammlung der ophthalmologischen Gesellschaft. Heidelberg. Beilageheft zu Klin Mbl Augenh 60–63, 1884.

18

Section I - Development of Regional Anesthesia 53. Koller

Chapter 1 - Historical Aspects of Regional Anesthesia

C: Preliminary report on local anesthesia of the eye. Arch Ophthalmol 12:473–474, 1934.

54. Koller

C: Nachträgliche Bemerkungen über die ersten Anfänge der Lokalanästhesie. Wien Med Wschr 85–708, 1935. [The article was also published in English: Koller C: History of cocaine as a local anesthetic. JAMA 117:1284–1287, 1941.]

55. Jellinek

E: Das Cocain als Anaestheticum und Analgeticum für den Pharynx und Larynx. Wien Med Wschr 34:1334–1348, 1364–1367, 1884.

56. Fränkel

E: Über Cocain als Mittel zur Anästhesierung der Genitalschleimhaut. Wien Med Wschr 34:1535, 1884.

57. Noyes

HD: The Ophthalmologic Congress in Heidelberg. Med Rec 26:417–418, 1884.

58. Matas

R: Local and regional anesthesia. A retrospect and prospect. Am J Surg 65:189–198, 362–379, 1934.

59. Knapp 60. Hall

H: On cocaine and its use in ophthalmic and general surgery. Arch Ophthalmol 13:402–448, 1884.

RJ: Letter to the editor. N Y Med J 41:643, 1884.

61. Fulton

JF: Harvey Cushing. A Biography [Letter from Halsted to Cushing]. Springfield, Ill, CC Thomas, 1946, pp 142–144.

62. Halsted

WS: Practical comments on the use and abuse of cocaine. Suggested by its invariably successful employment in more than a thousand minor operations. N Y Med J 42: 294–295, 1885.

63. MacCallum 64. Corning

WG: William Stewart Halsted Surgeon. Baltimore, The Johns Hopkins Press, 1930, pp 54–57.

JL: On the prolongation of the anaesthetic effects of the hydrochloride of cocaine when subcutaneously injected. N Y Med J 42:317–

319, 1885. 65. Freud

S: Ueber Coca. Cbl Ges Ther 2:289–314, 1885.

65A. Freud

S: Beitrag zur Kenntnis der Cocawirkung. Wien Med Wschr 35:129–133, 1884.

65B. Freud

S: (1885) Ueber die Allgemeinwirkung des Cocains. Med-chir Cbl 20:374–375, 1885.

65C. Freud

S: The Cocaine Papers: 1–26, 35–41 and 45–49. Dunquin Press, Vienna and Zürich, 1884. [English translation was published in 1963.]

66. Löfgren

N: Studies in Local Anesthestics. Xylocaine, a New Synthetic Drug. Thesis I. Stockholm, Haeggström, 1948. [Reprinted, Worcester, Mass, 1958.]

67. Liljestrand 68. Corning 69. Bier

G: Briefe von Carl Koller an Erik Nordenson. Arch Gesch Med 49:280–306, 1965.

JL: A further contribution on local medication of the spinal cord. Med Rec (N Y) 33:291–293, 1888.

A: Versuche über Cocainisieurung des Rückenmarks. Dtsch Z Chir 51, 1899.

70. Pitkin

GP: Controllable spinal anesthesia. Am J Surg 5:537–553, 1928.

71. Sicard

A: Les injections medicamenteuses extra-durales par Voie sacro-coccygienne CR Soc Biol (Paris) 53:396–398, 1901.

72. Cathelin

F: Une nouvelle voie d’injection rachidienne. Méthode des injections épidurales par le procédé du canal sacré. Applications à l’homme. CR Soc Biol (Paris) 53:452–453, 1901.

73. Läwen 74. Gros

A: Uber Extraduralanästhesie für chirurgische Operationen. Dtsch Z Chir 108:1–43, 1910.

O: Ueber die Narkotika und Lokalanästhetika. Arch Exp Path Pharmak 63:80–106, 1910.

75. Läwen

A, von Gaza W: Experimentelle Untersuchungen über Extraduralanästhesie. Dtsch Z Chir 111:289–307, 1911.

76. Reclus

P: De l’anesthésie locale par la cocaine. Gax Hebd Méd Chir 27:146–148, 1890.

77. Schleich

CL: Schmerzlose Operationen. Örtliche Betäubung mit indifferenten Flössigkeiten, 4th ed. Berlin, Springer, 1894.

77A. Schleich

CL: Schmerzlose Operationen. Örtliche Betäubung mit indifferenten Flössigkeiten, 5th ed. Berlin, Springer, 1906.

78. Willstätter 79. Filehne

W: Die local-anästhesirende Wirkung von Benzoylderivaten. Berl Klin Wschr 24:107–108, 1887.

80. Poulsson 81. Ehrlich

R: Ueber die Synthese des Psikains. Münch Med Wschr 71:849–850, 1924.

E: Beiträge zur Kenntniss der pharmakologischen Gruppe des Cocains. Arch Exp Path Pharmak 27:301–313, 1890.

P: Studien in der Cocainreihe. Dtsch Med Wschr 16:717–179, 1890.

19

Section I - Development of Regional Anesthesia 82. Ehrlich

P, Einhorn A: Ueber die physiologische Wirkung der Verbindungen der Cocainreihe. Ber Dtsch Chem Ges 27: 1870–1873, 1894.

83. Laubender 84. Braun

Chapter 1 - Historical Aspects of Regional Anesthesia

W: Lokalanaesthetica. Heffter’s Handb Exp Pharmakol (Erg-werk) 8:1–78, 1939.

H, Läwen A: Die örtliche Betäbung, 8th ed. Leipzig, JA Barth, 1933.

85. Einhorn A, Heinz R: Orthoform. Ein Lokalanaestheticum für Wundschmerz, Brandwunden, Geschwüre, etc. Münch Med Wschr 44:931–934, 1897. 86. Braun

H: Ueber die Bedeutung des Adrenalins für die Chirurgie. Münch Med Wschr 50:352–353, 1903.

87. Einhorn

A, Uhlfelder E: Ueber den p-Aminobenzoesäure-diäthyl-amino- and Piperidoäthylester. Justus Liebigs Ann Chem 371:131–142,

1909. 88. Braun

H: Die Lokalanästhesie, ihre wissenschaftlichen Grundlagen und praktische Anwendung. Leipzig, JA Barth, 1905.

89. Gottlieb

R: Pharmakologische Untersuchungen über die Stereoisomerie der Kokaine. Arch Exp Path Pharmak 97:113–146, 1923.

90. Gottlieb

R: Ueber die pharmakologische Bedeutung des Psikains als Lokalanästhetikum. Münch Med Wschr 71:850–851, 1924.

91. von

Euler H, Erdtman H: Ueber Gramin aus Schwedischen Gerstensippen. Justus Liebigs Ann Chem 520:1–10, 1935.

92. Erdtman

H, Löfgren N: Ueber eine neue Gruppe von lokalanästhetisch wirksamen Verbindungen. á-N-Dialkylaminosäureanilide. Svensk Kem T 49:163–174, 1937.

93. Löfgren

N: Studien über Lokalanästhetica. Ark Kemi Mineral Geol 22:1–30, 1946.

94. Goldberg L: Studies on local anesthetics. Pharmacological properties of homologues and isomers of xylocain (alkyl aminoacyl derivatives). Acta Physiol Scand 18:1–18, 1949. 95. Björn

H: Electrical excitation of teeth and its application to dentistry. Svensk Tandläk-T 39(Suppl 4):1–101, 1946.

96. Björn

H, Huldt S: The efficiency of xylocaine as a dental terminal anesthetic, compared to that of procain. Svensk Tandläk-T 40:831–852,

1947. 97. Gordh 98. Bier

T: Xylocain—a new local analgesic. Anaesthesia 4:4–9, 21, 1949.

A: Ueber einen neuen Weg Localanasthesie an den Gliedmassen zu erzeugen. Arch Klin Chir 86:1007, 1908.

99. Wynter

WE: Four cases of tuberculosus meningitis in which paracentesis of the theca vertebralis was performed for the relief of fluid pressure. Lancet 1:981, 1891.

100. Tuffier

T: Analgesie chirurgicale par l’injection sous-arachnoidienne lombaire de cocaine. CR Soc Biol (11th series) 1:882, 1899.

101. Tuffier T: Anesthesie medullaire chirurgicale par injection sous-arachnoidienne lombaire de cocaine; technique et resultats. Semaine Med 20:167, 1900. 102. Hopkins

GS: Anesthesia by cocainization of the spinal cord. Philadelphia Med J 6:864, 1900.

103. Fowler RG: Cocaine analgesia from subarachnoid injection, with a report of forty-four cases together with a report of a case in which antipyrin was used. Philadelphia Med J 6: 843, 1900. 104. Lee EW: Subarachnoidean injections of cocaine as a substitute for general anesthesia in operations below the diaphragm, with report of seven cases. Philadelphia Med J 6:865, 1900. 105. Gray

HT, Parsons L: Blood pressure variations associated with lumbar puncture and the induction of spinal anesthesia. Q J Med 5:339, 1912.

106. Smith

GS, Porter WT: Spinal anesthesia in the cat. Am J Physiol, 38:108, 1915.

107. Barker 108. De

AE: Clinical experiences with spinal analgesia in 100 cases and some reflections on the procedure. BMJ 1:665, 1907.

Lapersonne F: Un nouvel anesthesique local, la stovaine. Presse Med 12:233, 1904.

109. Hepburn 110. Sise

WG: Stovain spinal analgesia. Am J Surg 34:87, 1920.

LF: Spinal anesthesia for upper and lower abdominal operations. N Engl J Med 199:61, 1928.

111. Adriani

J, Roman-Vega D: Saddle block anesthesia. Am J Surg 71:12, 1946.

112. Lemmon

WT: A method for continuous spinal anesthesia. Ann Surg 111:141, 1940.

20

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113. Dean

HP: Relative value of inhalation and injection methods of inducing anaesthesia. BMJ 2:869, 1970.

114. Kreis

O: Ueber Medullarnarkose bei Gebarenden. Zentralbl Gynakol 24:724, 1900.

115. Marx

S: Analgesia in obstetrics produced by medullary injections of cocain. Philadelphia Med J 6:857, 1900.

116. Stoeckel 117. Kappis

W: Ueber sakrale Anasthesie. Zentralbl Gynaekol 33:1, 1909.

M: Erfahrungen mit Lokalanasthesie bei Bauchoperationen. Verh Dtsch Ges Chir 43:87, 1914.

118. Läwen A: Ueber segmentare Schmerzaufhebung durch paravertebrale Novokaininjektionen zur Differentialdiagnose intra-abdominaler Erkrankungen. Med Wochenschr 69:1423, 1922. 119. Mandl

F: Die Wirkung der paravertebralen Injektion bei “Angina pectoris.” Arch Klin Chir 136:495, 1925.

120. Swetlow

GI: Paravertebral alcohol block in cardiac pain. Am Heart J 1:393, 1926.

121. Schloesser: 122. Pagés

Heilung peripharer Reizzustande sensibler und motorischer Nerven. Klin Monatsbl Augenheilkd 41:244, 1903.

F: Anestesia metamerica. Rev Sanid Milit Argent 11:351–365, 1921.

123. Dogliotti

AM: Eine neue Methode der regionaren Anasthesie: “Die peridurale segmentare Anasthesie.” Zentralbl Chir 58:3141, 1931.

124. Dogliotti

AM: A new method of block anesthesia. Segmental peridural spinal anesthesia. Am J Surg 20:107, 1933.

125. Curbelo 126. Sarnoff

MM: Continuous peridural segmental anesthesia by means of a ureteral catheter. Anesth Analg (Cleve) 28:13, 1949. SJ, Arrowood JG: Differential spinal block. Surgery 620:150, 194.

21

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Chapter 2 -The History of the Development of Techniques in Regional Anesthesia

Chapter 2 - Beyond Blocks: The History of the Development of Techniques in Regional Anesthesia CHRISTOPHER M. BURKLE ROBERT P. SANDS JR. DOUGLAS R. BACON

Regional anesthesia, the art of rendering a part of the body insensible for an operation, traces its roots to Karl Koller of Vienna, who, in 1884, demonstrated the use of topical anesthesia on the eye. However, regional anesthesia would not have progressed much beyond topical application had not many pioneers tried new and different ways of producing regional insensibility. In many ways, the history of techniques in regional anesthesia mirrors the way in which scientific knowledge is obtained: It is an intellectual history of ideas. There are instances in which techniques were developed, discarded, and revived only when “new” local anesthetics or plastic catheters became available, making the technique viable. Other researchers made an intellectual leap by speculating that if the pain of surgery could be ablated by regional anesthetic techniques, such techniques might be used in the treatment of patients with chronic painful conditions. Thus, from surgical anesthetic experience came the first pain clinics. In addition, there was a need to disseminate this new, exciting information to a professional audience. The development of professional organizations devoted to regional anesthesia also underwent this cycle of birth, death, and rebirth. This chapter explores the continuum of regional techniques, from their inception to their current use or abandonment.

Spinal Anesthesia The history of spinal anesthesia demonstrates the cyclical nature of regional anesthetic techniques. The advent of spinal anesthesia has roots that reach much deeper into the past than August Bier’s first administration of cocaine into the subarachnoid space in August 1898. Over 100 years earlier, in 1764, Domenico Cotugno, an Italian anatomist, published an almost complete description of cerebrospinal fluid (CSF) in his dissertation entitled De Ischiade Nervosa Commentarius. This information lay dormant, with little clinical utility, until 1872, when Heinrich Quincke published Zur Physiologie de Cerebrospinalflussigkeit. In this landmark paper, Quincke reported that there had already been a large number of anatomic and experimental examinations performed on the distribution and movement of CSF, citing that Magendie had given attention to Cotugno’s description. Although Quincke has been given credit for having performed the first lumbar puncture, he himself assigned the credit to Essex Wynter who, in 1891, used a Southey tube to perform a lumbar puncture. Although the Southey tube was originally employed to relieve edema of the legs by subcutaneous drainage, Wynter theorized that, by inserting the tube into the subarachnoid space, he could relieve the increased intracranial pressure of tuberculous meningitis. [1]

[2]

[3]

[4]

Also in 1891, Quincke reported his first lumbar puncture in Germany. Two years later, von Ziemssen, a German physician whose main medical interest was infectious disease, reported on the feasibility of injecting drugs by means of a lumbar puncture. He subsequently injected a patient with saline and tetanus antitoxin via the subarachnoid route. In 1895, Quincke published a paper in the annual report of La SociétéFrançaise de Bienfaisance Mutuelle, elaborating on his technique of using lumbar puncture to relieve the pressure of hydrocephalus, based on “the anatomical and experimentally proven fact that the subarachnoid space communicates with the cerebral ventricles.” Later that same year, George Jacoby published his report on the diagnostic use of the lumbar puncture. The technique he described differs little from the procedure that is currently in use. [5]

[6]

[7]

[8]

THE FIRST SPINAL ANESTHETIC? James Corning ( Fig. 2-1 ), a New York City neurologist, heard in 1885 of the local anesthetic properties of cocaine, which had been discovered by the Viennese ophthalmologist, Carl Koller, in 1884. Corning began a series of experiments to determine whether local medication of the spinal cord was within the range of practical achievement. He reasoned that cocaine might be the ideal agent to treat neurologic disease if applied in the vicinity of the venae spinales of the cord. If it were delivered to the spinal region, it could be absorbed and carried to the affected area, having a much greater effect, like that of strychnine when it was injected in the same way. His first subject was a dog. Corning injected cocaine below the spinous processes of two of the inferior dorsal vertebrae. After a few minutes, the dog’s hindquarters became paralyzed. A short while later, he tried the same technique on a young man with seminal incontinence. The young man received 2 mL of a 3% solution of the hydrochloride of cocaine between the spinous processes of T11–12. No effect was seen after 8 minutes, so another 2 mL of the same solution were [9]

22

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injected into the same space. Approximately 10 minutes after the second injection, the man’s legs began to “feel sleepy.” After another 15 to 20 minutes, the intensity of the anesthesia had increased, and although “there were some evidences of the diffusion part of the anesthetic, the impairment of sensibility was principally limited to the lower extremities, the lumbar regions, the penis, and scrotum.” While standing with eyes closed, the man experienced some dizziness, but no incoordination or motor impairment was discernible in his gait. He left the office 1 hour or more after the last injection and seemed “none the worse for the experience.” [10]

Corning performed his experiment and published his paper in 1885. The practicability of dural puncture had not yet been reported, nor would it be made known until Wynter’s and Quincke’s papers appeared in 1891. For that reason, and because CSF was not recovered in the syringe nor mentioned explicitly in his paper, it is believed that Corning performed the first epidural rather than the first spinal administration of anesthetic. [11]

In 1899, 13 years after Corning’s report and 8 years after the first authenticated lumbar puncture, the surgeon Augustus Bier ( Fig. 2-2 ), a professor at the Royal Chirurgical Clinic in Kiel, Germany, used “cocainization of the spinal cord” to provide pain relief for orthopedic operations on the lower extremities and coccyx. He proposed that injected cocaine would spread in the CSF and affect not only the surface of the cord but also the nonmyelinated nerves in the meninges and ganglia. He described the course of six patients ranging in age from 11 to 34 years, who received treatment between August 16 and August 27, 1898. The injections were made in the lumbar area, at an unidentified interspace, with the patients in a lateral recumbent position. He administered a 0.5 mL of a 1% solution of cocaine to the two teenagers, whereas the adults received either 1 mL of a 1% solution or 2 to 3 mL of a 0.5% solution. All of these blocks were successful and proved “that when a relatively small amount of cocaine is injected into the dural sac, large areas of the body can be made insensitive to pain and major operations can be performed in these areas. On the other hand, so many complaints had arisen in association with this method (back and leg pain, vomiting, prolonged headache) that they equaled the complaints usually occurring after general anesthesia.” [12]

[13]

Because of these complaints, Bier decided to experiment on himself. Dr. Hildebrandt, Bier’s assistant, performed the lumbar puncture on Bier after infiltrating the skin and deeper tissues. Bier immediately felt a lancinating pain in one leg; when the syringe did not adapt to the needle, much CSF was lost. Therefore, most of the cocaine did not reach the subarachnoid space, and loss of sensation did not develop, as manifested by Bier’s perception of small skin cuts and needle pricks. [14]

Hildebrandt then volunteered to undergo the same experiment, albeit with a much different outcome. “He first noticed a feeling of warmth and subsequently had no sensual perception to needle pricks to the thigh, tickling of the soles of the feet, a small incision in the thigh, pushing a large-helved needle down to the femur, strong pinching and squeezing with dental forceps, application of a burning cigar, pulling out pubic hairs, a strong blow with an iron hammer against the tibia, vigorous blows with knuckles against the tibia, and strong pressure on a testicle.” Eighteen minutes after the injection, pain sensation was greatly decreased up to the nipple line. After 45 minutes, the effect began to wear off. [14]

After describing the successes in patients and many details of the anesthesia, Bier noted that “other agents related to cocaine might not cause these unpleasant side reactions, or that additions to cocaine might abolish them.…Therefore, it did not seem justified to me to make further experiments on human beings. Experiments with animals might lead to significant results. For these, the dog would be adequate, since it vomits easily, meaning that the important sign of the unpleasant side effects could thus be observed.” In spite of Bier’s reservations, cocainization of the spinal cord attracted widespread attention and immediate use at several centers. [13]

AN AMERICAN TWIST Although Europe was the birthplace of spinal anesthesia, two pioneering surgeons, F. Dudley Tait and Guido E. Caglieri, administered the first spinal anesthetic in America on October 26, 1899. Tait and Caglieri studied 7 cadavers, 11 patients, and an unknown number of cats, dogs, rabbits, guinea pigs, and horses in their efforts to further understand how lumbar puncture could benefit patients. Although they never clearly stated their reasoning, Tait and Caglieri were apparently trying to exploit for some therapeutic gain the lumbar puncture technique discovered independently by Quincke and Wynter. Examination of CSF was undoubtedly useful in certain diagnostic conditions, but the utility of fluid withdrawal or drug injections into the subarachnoid space was still not established. Infectious diseases of the central nervous system, such as syphilis, tuberculosis, tetanus, and gonorrhea were important causes of morbidity around the beginning of the 20th century. Tait and Caglieri experimented in the treatment of tertiary syphilis by subarachnoid injections of mercuric salts and iodides which, when given systemically, were thought to be beneficial in the treatment of syphilis. Their experiments revealed that the

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intravenous administration of these drugs did not lead to subarachnoid accumulation; however, subarachnoid administration did lead to the appearance of these drugs in the bloodstream. [15]

In addition to its usefulness in diagnosis, penetration of the subarachnoid space was reported to have a potential application with administration of spinal anesthesia. The common anesthetic techniques at that time were inhalation of nitrous oxide, chloroform, or ether, or infiltration with dilute concentrations of cocaine. None of these anesthetics provided adequate muscle relaxation. Furthermore, the side effects were serious, ranging from vomiting to prolonged emergence, airway obstruction, and death. Spinal anesthesia presented a technique that permitted the avoidance of these worrisome problems, particularly in ill patients. In April 1900, Tait and Caglieri reported on 11 anesthetic cases in which 5 to 15 mg of cocaine were used intrathecally for procedures below the umbilicus. Two patients reported minor surgical discomfort and three others were outright failures. Regardless, unlike Bier, Tait and Caglieri unequivocally supported the technique of spinal anesthesia. One patient who “had collapsed” with both ether and chloroform anesthesia underwent a bone curettement without complications after intrathecal administration of 10 mg of cocaine. Thus, relative to the constraints under which Tait and Caglieri operated, modest success represented a groundbreaking achievement. [15]

Tait and Caglieri described a few postoperative problems that could be attributed to the administration of cocaine to the subarachnoid space. Some of their practices could have been responsible for this. For example, they recommended the use of a fine needle and slow injection of the cocaine to prevent rostral spread. They also recognized early that the extent of diffusion was influenced by several factors, including the amount of drug injected, the drug’s composition and density, and the pressure under which the drug was injected. The analgesia provided by this procedure was

thought to be sufficient for all operations of the lower limbs and pelvis, and Tait and Caglieri recommended a trial in obstetrics, thus beginning the successful use of the spinal technique during labor, which was later reported by Kreis. They also experimented with the other available derivatives of benzoic acid, eucaine and nirvanin, and found that they offered no advantages over cocaine. One final observation of these investigators is relevant to current practice. When the present day anesthesiologist advises the patient with a postdural puncture headache to “drink plenty of fluids,” it brings to mind Tait and Caglieri’s simple observation that the flow of CSF through an indwelling subarachnoid needle was markedly increased by intravenous administration of saline. A contemporary of Tait and Caglieri, Rudolf Matas of New Orleans ( Fig. 2-3 ), published his report of spinal anesthesia almost simultaneously. Matas agreed with Tait and Caglieri, citing the advantages of spinal over general anesthesia, but he was disappointed with the results. In fact, Matas stopped administering spinal anesthesia until pontocaine became commercially available. Interest in spinal anesthesia waxed and waned over the next decade. In the 1920s, mortality from spinal anesthetics was reported to be as high as one in a hundred patients. Lincoln Sise ( Fig. 2-4 ), working at the Lahey Clinic in Boston, decreased that number to just under one in a thousand. Sise worked hard to delineate the causes of the profound hypotension that accompanied successful spinal anesthesia. He found that ephedrine, given subcutaneously, would block the hypotensive effects of the spinal block. [16]

[17]

[18]

Another problem that plagued spinal anesthesia in the first decades of the 20th century was duration of the block. Procaine lasted about an hour, often less time than the surgeon needed to complete the operation. In 1935, Sise experimented with a new local anesthetic, tetracaine, with a duration of action of about 2 hours. However, tetracaine was unpredictable when injected into the CSF. Blocks would often be too high, leading to respiratory compromise. Sise theorized that it was the baricity of the solution relative to the CSF that caused the block to float. By mixing his tetracaine with 10% dextrose, Sise created a dependable hyperbaric solution. With adjustment of the patient’s position, he could change the height of the block. For example, when the level was too low, placing the patient in the Trendelenburg position raised the level of the block. [18]

Neurologic complications were another concern for patients and anesthesiologists. In the 1920s, it was estimated that 50% of patients suffered debilitating headaches after spinal anesthesia. Sise developed an introducer, a short, large-bore needle that helped facilitate the passage of a smaller needle through the dura and into the subarachnoid space. It would be another 20 years before Leroy Vandam and Robert Dripps published their study of over 9000 spinal anesthetic procedures. [18]

They found that 11% of their patients had postdural puncture headache, with a decreasing incidence with age. Vandam and Dripps correctly identified the risk factors of pregnancy and needle size and concluded that these were due to a decrease in CSF pressure. They also studied long-term neurologic sequelae in regional anesthesia. [19]

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Vandam and Dripps found that outside of postdural puncture headache, neurologic problems were rare. Most of these problems were apparent preoperatively if the anesthesiologist had done a detailed neurologic history. To avoid complications, Vandam and Dripps advocated proper selection of patients. [20]

Perhaps the most famous instances of neurologic complication of regional anesthesia occurred in England on October 13, 1947. That day, two healthy men underwent routine operations: One had a meniscectomy of the knee and the other a radical repair of a hydrocele. Both men developed permanent spastic paralysis after administration of intrathecal anesthesia. Hyperbaric 1:1500 dibucaine was used. At the time, the explanation given was that phenol, which had been used to sterilize the local anesthetic ampules for surgery and which had minute cracks in them, had caused the contamination of the drug. Sir Robert Macintosh supported this theory and testified before the court to this effect. The case had a devastating effect on use of subarachnoid anesthesia, including far-reaching publicity that lingers to this day. Recent scholarship has demonstrated that phenol was unlikely to have been the causative agent; the more likely suspect was the acidic solution used to clean the sterilizer. The fact that Cecil Roe was the first patient anesthetized that Monday morning and that he was more severely affected than Albert Woolley, who was the second case, supports the theory. Finally, pathologic findings support the conclusion that an acidic solution was introduced into the subarachnoid space. [21]

[22]

[23]

[24]

CONTINUOUS SPINAL ANESTHESIA Seven years after Bier’s landmark work on the administration of cocaine via lumbar puncture, Henry Percy Dean, a British surgeon, introduced a modification of the technique called continuous spinal anesthesia. Unfortunately, many of his colleagues who attempted the procedure encountered difficulties such as needle trauma and breakage. Therefore, the technique fell into disfavor, as can be evidenced by the lack of citations referring to continuous spinal anesthesia in the English language medical literature from 1907 to 1939. [25]

[26]

In 1940, all of that changed when William T. Lemmon re-introduced the technique of continuous spinal anesthesia to the anesthesia community with somewhat different results. Lemmon noted that the problems that Dean encountered earlier in the century were still present and that solutions needed to be devised. To do this, he used special equipment for his technique. First, he designed an operating room table mattress that permitted the patient to lie in the supine position without dislodging the needle or tubing. Second, and more importantly, he totally redesigned the spinal needle. His 17-gauge (G) or 18-G needle was constructed of German silver, which made it very malleable. Once the needle was in place, it was connected to the tubing, which was routed through the hole in the mattress to a spot near the patient’s head, where a syringe containing local anesthetic was attached. The tubing was made of hard rubber to prevent bulging on injection and contained exactly the 2 mL of drug that needed to be accounted for when calculating the dose of local anesthetic delivered to the patient. The technique was used with great success on the battlefields during World War II; it was credited, at least in one unit, for decreasing mortality from abdominal wounds from 46% to 12.5%. [27]

Edward B. Tuohy modified the technique when he placed a catheter through the needle into the subarachnoid space to avoid the problem of needle dislodgment from the space. Even with Tuohy’s modification, acceptance of the technique was slow. And, in 1950, Robert Dripps compared the malleable needle technique of Lemmon and the catheter technique of Tuohy with the standard single shot technique used by the majority of practitioners. He compared technical difficulties and absolute failures of all three techniques. Dripps’ results demonstrated that the single injection technique was associated with fewer technical difficulties and absolute failures than the other two. “Because of the number of failures, the technical problems, the degree of trauma, and the increased likelihood of loss of CSF inherent in the methods of continuous spinal anesthesia, it is our belief that such methods should be used less frequently.” Interestingly, with respect to both technical difficulties and absolute failures, the malleable needle was superior to the catheter technique of Tuohy when the two continuous techniques were compared. [28]

[29]

Again, the technique of continuous spinal anesthesia fell into a long period of quiescence. Once again, however, it rose from the ashes! In 1964, Dante Bizzari stated that he feared continuous spinal anesthesia because of the need for large-bore needles and the dural rents they caused. He advocated the use of 20-G or 21-G needles with smaller catheters. Bizzari’s ideas needed technology to catch up with them. In 1987, Hurley and Lambert reported their work on the use of a microcatheter in continuous spinal anesthesia and the decreased incidence of postdural puncture headaches. [30]

[31]

Small-gauge continuous spinal anesthesia quickly grew in popularity. However, problems soon arose. Rigler and colleagues reported on patients developing cauda equina syndrome after receiving treatment via a microcatheter. Maldistribution of local anesthetic was thought to be responsible. Because of the high resistance of the small lumen

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of the microcatheter, it was widely believed that the local anesthetic did not diffuse in the subarachnoid space. It appeared that if the initial dose of local anesthetic failed to provide an adequate block, a second dose would often be given. This resulted in a restricted block, which appeared to be linked to the cauda equina syndrome. [32]

The Food and Drug Administration (FDA) acted on the initial reports of cauda equina syndrome and issued stringent guidelines regarding microcatheter use. Unfortunately, the incidence of cauda equina syndrome did not decline, and, in 1992, all microcatheters were withdrawn from use in the United States by the FDA. Thus, at the time this chapter was written, those practicing the technique of continuous spinal anesthesia had reverted to large-bore catheters until the FDA should complete studies of a new catheter.

Epidural Anesthesia Although Corning may have administered the first epidural anesthetic, Jean Athanase Sicard and Fernand Cathelin in 1901 independently published their account of peridural anesthesia. They approached the epidural space through the sacral hiatus, giving what now would be described as a caudal anesthetic. Marin Théodore Tuffier attempted a lumbar epidural block that same year but had difficulty locating the space. Twenty years later, Fidel Pages described the intraspinous approach to the epidural space and reported satisfactory anesthesia for intra-abdominal procedures. In the early 1930s, Archile Mario Dogliotti, building on Jansen’s discovery of negative pressure in the epidural space, described a practical technique for administering lumbar segmental anesthesia. Using Dogliotti’s work as a foundation, Gutierrez, in 1932, described the hanging drop technique to identify the epidural space. [33]

[34]

[35]

A year earlier, Eugene Aburel placed a silk ureteral catheter in the epidural space and used it to block the pain of women in labor. During World War II in America, Robert Hingson was assigned to care for the pregnant wives of United States Coast Guard seamen. Stationed at a U.S. public heath hospital, Hingson wanted to develop a method whereby he could alleviate the pain of labor in these women. Unaware of Aburel’s work, Hingson took Lemmon’s malleable needle and placed it sacrally, deep to the peridural ligament. This safe and effective method of producing painless childbirth became popularly known as continuous caudal anesthesia. In 1949, Manuel Martinez Curbello modified a silk catheter for continuous spinal anesthesia and inserted it into the epidural space, thus creating the first continuous epidural block. By 1962, the first polyvinyl catheter with a closed tip was introduced, making the continuous epidural block much easier to perform correctly. [36]

[37]

[38]

[39]

Controversy concerning use of epidural analgesia in labor continued. Opponents of the practice claimed it increased the number of instrumental deliveries, but proponents claimed that it did not. By the early 1990s, the combination of dilute local anesthetic and narcotic was demonstrated to be no different from any other form of obstetric pain relief. Currently, epidural analgesia has been combined with subarachnoid narcotics to ease the pain of labor. Combined spinal-epidural anesthesia is one of the leading techniques on obstetric floors at the dawn of the 21st century. [40]

[41]

Brachial Plexus Block In 1884, less than a year after the discovery of the anesthetic properties of cocaine, William Halsted performed the first regional blockade of the brachial plexus. His technique involved surgical exposure of the plexus in the neck with subsequent intraneural blocking of individual nerves. Effectively providing complete anesthesia to the upper extremity, the procedure itself was, at times, nearly as extensive as the surgery for which it was being provided. Unfortunately, an addiction to cocaine, the very drug that Halsted used to block the plexus, befell him, limiting his ability to popularize his approach. [42]

[43] [44]

It was not until 1887, when George Crile exposed the brachial plexus behind the sternocleidomastoid muscle to help control tetanic spasms in a young boy, that the block was used with some regularity. While he was at the Cleveland Clinic, Crile expanded the use of the brachial plexus block to include surgical anesthesia for upper extremity procedures. His original article of 1902, published in The Journal of the American Medical Association, spoke favorably of the block as being superior hemodynamically to general anesthesia for amputations of the shoulder joint. It is noteworthy that at this time in history, shoulder amputations were dangerous surgeries, with large blood loss potential and high subsequent mortality. A procedure that could effectively provide anesthesia as well as limit inherent surgical risk would be a popular discovery. [45]

[46]

[47]

Not until 1911 was the first percutaneous approach to the brachial plexus described by Hirschel. His axillary approach involved injection both below and above the axillary artery, a novel technique still employed with modifications in today’s practice. His knowledge of the anatomy of the brachial plexus stemmed from his

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experience in performing axillary dissections during radical mastectomy procedures. Despite the fact that he injected local anesthetic in a continuum from the entry of the skin up to the posterior section of the axillary artery, Hirschel never reported complications of intravascular injection. Because he understood the importance of retaining a strong concentration of anesthetic in the area of the nerves for as long a period as possible, Hirschel employed a mechanical blockade against dissipation of the anesthetic by use of a rubber ball that was held in place under the pectoral muscles by elastic bandages. Later, he found that simply increasing the volume of local anesthetic resulted in the same efficacy. [45]

In the same year that Hirschel popularized his percutaneous approach to blocking the brachial plexus in the axilla, Kulenkampff in Germany described the first “blind” supraclavicular approach to blocking the brachial plexus. Interestingly, he perfected his technique by trying the block on himself. Others who tried to duplicate Hirschel’s technique for blocking the brachial plexus in the axilla were unable to meet the same level of success that he had described. One explanation was that the axilla technique lacked precision compared with the supraclavicular approach to the plexus. [45]

Greater precision and perhaps improved success rates for blocking the brachial plexus at the axilla were not far off. Capelle in Germany in 1917 wrote of a simplified perivascular approach to blocking the plexus. His knowledge of the anatomy of the brachial plexus in the region of the axilla did not include an understanding of a fascial compartment; however, he was aware that the nerves serving the upper extremity did pass proximal to the axillary artery. Reding in 1921 is thought to have been the first to highlight the importance of the neurovascular sheath in the plexus block at the axilla. His descriptions of the anatomy of the brachial plexus within the axilla include discussion of a fascial sheath surrounding a bundle of nerves. Reding was also aware that the musculocutaneous nerve was not contained within the sheath and that blocking this nerve required injection of local anesthetic within the coracobrachialis muscle. [45]

The techniques of Capelle and Reding were largely ignored, whereas the supraclavicular approach described by Kulenkampff remained popular. It was not until 1958 that Preston Burnham, an orthopedic surgeon, revived the neurovascular sheath approach for blocking the brachial plexus. While repairing an axillary laceration in a child, Burnham noted that the nerves entering the axilla were proximal to the axillary artery. Additionally, a fascial sheath surrounded both nerves and vasculature. If the sheath were entered with one pass of a needle, multiple nerves could be bathed with local anesthetic. Modifications to Burnham’s perivascular approach were made over the years to include increasing the volume of the local anesthetic to be used in order to ensure a more “solid” block. However, Burnham’s initial work in developing the technique of blocking multiple nerves with fewer injections simplified this procedure and subsequently established the popularity that this technique enjoys today.

Preemptive Analgesia George Crile at the Cleveland Clinic came up with the idea that pain could be controlled through the use of regional anesthesia combined with a light general anesthetic. The approach that Crile took to the brachial plexus, for example, became known as “Crile’s technique,” and through its use alone, or as an adjunct to light general anesthesia, he was able to effectively block a patient’s stress response to surgery. He also found that patients did not need deep ether anesthesia with its attendant pulmonary risks for intra-abdominal surgery. It is these findings that helped prompt his belief that there was “anoci-association” between effective anesthesia and hemodynamic changes that occur with surgical procedures. Indeed, it was Crile’s search for a method of anesthesia and surgery without shock that led him to combine regional and general anesthesia. [48]

[49]

To follow Crile’s technique completely was cumbersome and time-consuming. Patients had to be kept quiet preoperatively. Intraoperatively, the plexus of innervating nerves was often dissected under local anesthesia. Crile admonished surgeons to handle tissue carefully and gently. Rough handling caused shock. Gradually, as better local anesthetics made other forms of regional anesthesia reliable and—to some extent—as anesthesia became professionalized, Crile’s technique was abandoned. Especially after the introduction of muscle relaxants by Harold Griffith in 1941, and as shock became better understood after World War II, there was little need for the elaborate planning and slow surgery demanded by anoci-association. [44]

However, in 1983, C. J. Woolf published his animal model experimentation, which demonstrated a central component to post-injury pain hypersensitivity. Investigation confirmed that the central component in the animal model was real and could be blocked by regional anesthetic techniques. The ensuing human studies have been less clear. However, it appears that a block of the affected nerves needs to be present during surgery to blunt the central [50]

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component. What is clear is that regional anesthetic techniques have been demonstrated to aid patients’ recovery from surgery, and regional analgesia is a “new” direction in the evolution of regional anesthetic techniques. [51]

Dissemination of Information Professional interaction is critical for the exchange of ideas and the dissemination of new techniques. Gaston Labat ( Fig. 2-5 ), who left Paris in 1920 and traveled to the Mayo Clinic to bring regional anesthetic techniques there, spent 9 months training the surgeons of the clinic in regional anesthesia. The most notable accomplishment during his time at the Mayo Clinic was the production of Regional Anesthesia. This was the first American textbook to be devoted to regional anesthesia and was immensely popular; the second printing was greater than the first, a rarity in medical publishing. After leaving Rochester, Minnesota, Labat settled in New York City and was affiliated with New York University and Bellevue Hospital. He taught regional anesthesia courses and also administered anesthesia. [52]

[53]

[54]

In 1923, the American Society of Regional Anesthesia (ASRA) was created in New York City. Originally, the society was founded to honor Labat, and the group was a mixture of surgeons, neurosurgeons, and physician anesthetists. Early meetings focused on regional anesthetic techniques, complications, and the matching of blocks to surgical procedures. The proceedings of the meeting and papers presented were published until 1932 in Current Researches in Anesthesia and Analgesia. In 1933, Paul Wood was elected secretary of the organization ( Fig. 2-6 ). He began to mimeograph the minutes and send them to members across the country who could not attend the New York City meetings. Thus, ASRA became a truly national society, and the papers presented before it had excellent exposure to their intended audience. [55]

[56]

[57]

[58]

In the early 1930s, ASRA’s meetings took a slightly different direction. Papers, such as James White’s report on the use of procaine block to predict the therapeutic value of surgical resection in relieving pain and Philip Woodbridge’s review of therapeutic blocks for chronic pain, began to dominate the program ( Fig. 2-7 ). Thus, regional anesthetic techniques were translated into the emerging new field of pain management. Emery Rovenstine ( Fig. 2-8 ) became president of ASRA in 1935 and moved the organization further into pain management. The 1936 clinical demonstrations, held in conjunction with a meeting of ASRA, were three quarters related to pain management. [59]

[60]

[35]

Rovenstine was an active participant in the decision by ASRA to cosponsor the American Board of Anesthesiology ( Fig. 2-9 ). As the necessary second national organization required by the American Medical Association, ASRA was in a unique position to ensure that regional anesthesia was considered a part of the curriculum of every anesthesiologist. On the first written examination, the entire anatomy section was devoted to questions germane to regional anesthesia. There were regional anesthesia questions in the pathology and pharmacology sections as well. Unfortunately, by 1939, interest in the organization had waned, and by 1941, the society was enfolded into the American Society of Anesthesiologists. [61]

[62]

In 1975, several prominent anesthesiologists, among them Alon Winnie, P. Prithvi Raj, and John Rolwson, perceived the need to reintroduce regional anesthetic techniques to anesthesiologists. Without knowledge of the original society, they organized the American Society of Regional Anesthesia. Within 6 months of its organization, the group held a meeting in Phoenix, Arizona, on the day before the International Anesthesia Research Society meeting. The society already had 300 members. Its avowed purpose was to educate and disseminate regional anesthetic techniques. [63]

Within a year of the founding of the society, a journal was published. Regional Anesthesia, now Regional Anesthesia and Pain Medicine, is an important journal covering a wide range of topics germane to regional anesthesia. In addition to an independent 3-day meeting, there are many forums available where a member of ASRA can learn about regional anesthesia. ASRA’s annual meeting was one of the first to have a hands-on workshop demonstrating how to do blocks under the tutelage of meeting faculty members who had mastered the technique. In 2000, ASRA celebrated its 25th anniversary. Regional anesthesia is alive and well and is entering the 21st century in a manner that Gaston Labat could never have imagined.

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Pain Comes of Age Rovenstine’s interest in regional anesthesia and pain medicine was not simply political. He ran a “block” clinic where he tried to help patients with chronic pain problems by applying regional anesthetic techniques. Ralph Waters ( Fig. 2-10 ), his mentor and friend, once chided him by saying that he should not spend “…all of his time in consultation work in regard to diagnostic and therapeutic blocks.” Rovenstine responded that the work in the pain clinic was what he found most stimulating professionally, and that the operating room had lost some of its appeal. The practice of pain medicine and the ability to help patients whose cases were often thought to be hopeless made his work exciting. [64]

[65]

In treating soldiers with pain problems after World War II, John Bonica found the same rewards as Rovenstine. He saw that regional anesthetics provided relief to his patients, but often the pain would return when the local anesthetics “wore off,” or the anesthetics were not at all effective. Bonica noted that some patients in this group needed neurologic evaluation. Often, they also benefited from the intervention of trained mental health professionals, but coordination of care was a problem. From these observations, the idea of a multidisciplinary pain clinic arose. [66]

Bonica would be well remembered for the concept of the multidisciplinary pain clinic, but that was his only accomplishment. In 1953, Bonica published the first edition of his now classic textbook, The Management of Pain. Within the confines of the text, Bonica clearly lays out which blocks work for which painful conditions. In addition, Bonica was active politically and became president of the American Society of Anesthesiologists and the World Federation of Societies of Anesthesiologists. Through his work in organized medicine, he brought pain issues to the forefront of anesthesiology, including regional anesthetic techniques.

[67]

Conclusions The history of techniques in regional anesthesia is replete with names that are instantly recognized as well as those that are somewhat more obscure. And although one person often is awarded credit for the discovery or popularization of a technique, it takes many anesthesiologists to properly apply the method. Al Winnie entitled his Labat address, “Nothing New Under the Sun,” and promptly demonstrated that the issues that were responsible for the formation of the first ASRA were present more than 50 years later when the second was formed. He also traced the history of various regional anesthetic techniques, demonstrating that the late 20th century “discoverer,” without knowledge of the history of regional anesthesia, might have only reinvented what a colleague had done at the beginning of the century. [63]

At the dawn of the 21st century, regional anesthesia and the techniques for accomplishing it are alive and well. From the operating room to the pain clinic and beyond, regional anesthesia is evolving and will remain an important part of patient care. Those who are the Biers, the Criles, and the Cornings of today will leave a rich legacy of caring for patients in ways that we can only begin to imagine. REFERENCES 1. Cotugno

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2. Quincke

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3. Vandam

L: On the origins of intrathecal anesthesia. Reg Anesth Pain Med 23:335–339, 1998.

4. Wynter

WE: Four cases of tuberculous meningitis in which paracentesis of the theca vertebralis was performed. Lancet 1:981–982, 1891.

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GF: The first spinal anesthesia. Who deserves the laurels? Reg Anesth 16:429–30, 1994.

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A: Versuche uber Cocainisirung des Ruckenmarkes. Dtsch Ztschr Chir 51:362–369, 1899.

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LD, Dripps RD: Long-term follow-up of patients who received 10,098 spinal anesthetics. JAMA 161:586–591, 1956.

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LD, Dripps RD: Exacerbation of pre-existing neurologic disease after spinal anesthesia. N Engl J Med 255:843–849, 1956.

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JR, Hutter CDD, Clayton KC: The Woolley and Roe case. Br J Anaesth 84:121–126, 2000.

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HP: The importance of anesthesia by lumbar injections in operations for acute abdominal disease. BMJ 1:1086–1090, 1906.

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R, Lambert D: Continuous spinal anesthesia with a microcatheter technique. Reg Anesth 12:54–58, 1987.

M, Drasner K, Krejcie T, et al: Cauda equina syndrome after continuous spinal anesthesia. Anesth Analg 275–281, 1991.

33. Bromage

PR: Epidural Analgesia. Philadelphia, WB Saunders, 1978, pp 1–7.

34. Dogliotti

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35. Lund

PC: Peridural Analgesia and Anesthesia. Springfield, Ill, Charles C Thomas, 1966, pp 3–10.

36. Aburel

E: L’anesthésié locale continue (prolongée) en obstétrique. Bull Soc Obstet Gynecol (Paris) 20:35–9, 1931.

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MM: Continuous peridural segmental anesthesia by means of a ureteral catheter. Anesth Analg 28:13–23, 1949.

39. Lee

JA: A new catheter for continuous extradural analgesia. Anaesthesia 17:248–250, 1962.

40. Vertommen

JD, Vandermeulen E, Van Aken H, et al: The effects of the addition of sufentanil to 0.125% bupivacaine on the quality of analgesia during labor and on the incidence of instrumental deliveries. Anesthesiology 74:809–814, 1991.

41. Gogarten

W, Van Aken H: A century of regional analgesia in obsetrics. Anesth Analg 91:773–775, 2000.

42. Winnie

AP: The early history of regional anesthesia in the United States. In Scott DB, McClure, Wildsmith JAW (eds): Regional Anesthesia 1884–1984. Sodertalje, Sweden, Information Consulting Medical, 1984, pp 35–38.

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43. Fink

BR: History of neural blockade. In Cousins MJ, Bridenbaugh PO (eds): Neural Blockade, 2nd ed. London, JB Lippincott, 1988 pp 3–21.

44. Olch

PD: William S. Halstead and local anesthesia: Contributions and complications. Anesthesiology 42:479–486, 1975.

45. Winnie

AP: Plexus Anesthesia—Perivascular Techniques of Brachial Plexus Block. Philadelphia, WB Saunders, 1983, p 68.

46. Gwathmey

JT: Anesthesia. New York, D. Appleton, 1914, p 490.

47. Bacon DR: Regional anesthesia and chronic pain therapy: A history. In Brown DL (ed): Regional Anesthesia and Analgesia. Philadelphia, WB Saunders, 1996, pp 10–22. 48. Crile

GW: Anoci-association in relation to oeprations on the gall bladder and stomach. JAMA 63:1335–1337, 1914.

49. Crile

GW: An experimental and clinical research into cocain and eucain. JAMA 38:491–499, 1902.

50. Woolf

CJ: Evidence for a central component of post injury pain hypersensitivity. Nature 308:686–688, 1983.

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G: Regional Anesthesia: Its Technic and Clinical Application. Philadelphia, WB Saunders, 1922.

53. Advertisement

for the New York University Bellevue Hospital regional anesthesia course. Curr Res Anesth Analg 4:13, 1925.

54. Bill from Gaston Labat, M.D., to Mrs. P.S. Rosenheim, November 16, 1927. Wood Library-Museum of Anesthesiology Collection, Gaston Labat Vertical File, Park Ridge, Ill. 55. Brown

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of Meeting of the American Society of Regional Anesthesia, 1925–1939. The Collected Papers of Paul Wood, M.D. The Wood Library-Museum Collection, Park Ridge, Ill.

57. Labat

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58. Bacon

DR, Reddy V, Murphy OT: Regional anesthesia and chronic pain management in the 1920s and 30s. Reg Anesth 20:185–192, 1995.

59. White

JC: Diagnostic novocaine block of sensory and sympathetic nerves. Am J Surg 9:264–277, 1930.

60. Woodbridge 61. Bacon

PD: Therapeutic nerve block with procaine and alcohol. Am J Surg 9:278–288, 1930.

DR, Darwish H, Emery A: Rovenstine and regional anesthesia. Reg Anesth 22:273–279, 1997.

62. Bacon

DR, Lema MJ: To define a speciality: A brief history of the American Board of Anesthesiology’s first written examination. J Clin Anesth 4:489–497, 1992.

63. Winnie

AP: Nothing new under the sun. Reg Anesth 7:95–102, 1982.

64. Letter from Ralph M. Waters, M.D., to Emery Rovenstine, M.D., July 5, 1944. The Collected Papers of Ralph M. Waters, M.D. Steenbock Library Collection, University of Wisconsin Archive, Madison, Wis. 65. Letter

from Emery A. Rovenstine, M.D., to Ralph M. Waters, M.D., July 8, 1944. The Collected Papers of Ralph M. Waters, M.D. Steenbock Library Collection, University of Wisconsin Archive, Madison, Wis.

66. Thompson 67. Bonica

D: Pain relief’s founding father. Time. June 11, 1984.

JJ: The Management of Pain. Philadelphia, Lea & Febiger, 1953.

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Section II - General Considerations for Regional Anesthesia Diego Beltrutti

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Chapter 3 - Economic Impact of Regional Anesthesia GIUSTINO VARRASSI FRANCO MARINANGELI FRANCESCO DONATELLI ANTONELLA PALADINI

One key approach to evaluating medical practice in the future will be based on assessing the effectiveness of the intervention in relation to the cost of providing it. Attempts to evaluate the effectiveness of medical interventions are hardly new. Nearly a century ago, E. A. Codman, M.D., at the Massachusetts General Hospital in Boston, urged that patients should be followed up long enough to determine the success of the treatment. But the efforts today go beyond developing clinical evidence of effectiveness; cost is also a factor. For example, in determining the cost of drug therapy, one must consider not just the price of the drug but also the expense involved in its administration, whether it is given in hospital or to an outpatient, the pharmacist’s time in preparing the prescription, and so on.

The Need for Economic Evaluation The increased interest in cost derives from the fact that in the economically developed countries health coverage is becoming more and more expensive, and the resources absorbed by national healthcare, when extracted from the rest of the economic system, represent a remarkable portion of the gross domestic product. It was reported that U.S. healthcare expenditures in 1998 totaled $838.5 billion, or 14% of the gross domestic products, and more than 40 cents of each dollar spent on healthcare is provided by the government. [1]

The factors mostly responsible for this phenomenon are the laws that rule each type of market. These laws are based on supply and demand. The latter encompasses the increasing attention given to well-being, quality of life, and the needs of an aging population, and the former expresses the development of more advanced medical technology. On the one hand, consumers often find it difficult to correlate their needs with the complex nature of the goods offered, thus delegating decision making to the physician; on the other hand, particularly in industrialized countries, individuals, regardless of their economic condition, have been conditioned to expect a guaranteed right to healthcare, with their communities and governments assuming a large portion of the financial burden. Where this has happened, as in the United States, the citizen has almost always met the costs of illness by means of recourse to private insurance. The result is that the abiding presence of the third-party payer prevents the high price from exercising its action of rationing. Thus, it is the physician and not the consumer who carries out the decision making, often being influenced by factors other than the needs of the patient. Even more remarkable is the fact that neither the physician nor the patient bears the direct economic consequences of the choices made, often preventing the correct distribution of the resources destined for the healthcare system. Hence, it became increasingly necessary to find means capable of creating a more efficient distribution of the budget at the disposal of the healthcare system. Beginning in the year 1960, an attempt was made to develop criteria, tools, and methods that would allow the evaluation, from an economic point of view, of the investments, programs, and products in the healthcare system. Since then, an increasing number of studies that reveal the economic consequences of a specific healthcare choice in the different physician-surgical disciplines have been published in various scientific magazines. For example, studies of ICU use have attempted to identify the types of patients who can benefit maximally from ICU admission. Patients who are not predicted to benefit from ICU services may be excluded from them. This change in practice is intended to save roughly $60 billion per year spent on ICUs in the United States, a figure that represents approximately 24% of all inpatient hospital costs, 9% of overall healthcare expenditures, and 1.1% of the gross national product. [2]

[3] [4]

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Economic Analysis Methods Used in Healthcare Two characteristics are important in economic analysis, each operating from the sectors of activity to which it is applied. The first characteristic is constituted by the resources employed (the costs) and by the results obtained (the consequences). Few of us would be ready to pay a given price for a parcel without knowing its contents. Moreover, few of us would acquire a package, even knowing and desiring its content, before knowing its cost. In both cases, it is the correlation between the costs and the results that influences the decision. Regarding the second characteristic, economic analysis is based upon the available choices. Because one cannot provide reliable effective outcome, the scarcity of resources makes us choose the options based mostly on explicit criteria. The economic analyst strives to identify this set of criteria, which may be useful to the physician for making decisions. Economic analysis can be defined as comparative analysis, in terms of costs and consequences of the series of alternative actions generated by each program. Its primary task, even when applied to the sanitary services sector, consists, therefore, in identifying, measuring, evaluating, and comparing costs and effects of the alternative actions considered. It is possible to outline the various types of economic analysis. In Table 3-1 , two questions are asked: “Are two or more alternatives being compared?” and “Are both the costs and the consequences of each alternative being examined?” The possible answers define a matrix of six boxes, each of which characterizes a situation being evaluated. In boxes 1A, 1B, and 2, only one program is taken into consideration, with no comparison made between different alternatives. In 1A, only the consequences are examined; hence, the box identifies the description of the results obtained, and in 1B, because only the costs are examined, the box is classified as the description of the costs. In box 2, the costs and results produced are described. Boxes 3A and 3B classify situations in which there are two or more alternatives to be compared but in which either the costs or the effects of each alternative are not examined. In 3A, only the consequences of each alternative are compared (evaluations of theoretical or real effectiveness). In 3B, only the costs of the alternatives are examined (analysis of the costs). These analyses do not satisfy the requisites necessary for an economic evaluation; for this reason, it is defined as a partial evaluation. This, however, does not imply that these studies are not important. In fact, they represent important intermediary stages for the comprehension of the costs and consequences of the services or of the programs. Certainly, however, they are not sufficient to solve the problem of efficiency; for this reason, it is necessary to employ the techniques of economic evaluation listed in box 4: • Cost minimization • Cost-effectiveness • Cost-benefit analysis • Cost of utility

COST MINIMIZATION The minimization of the costs consists of comparing two or more alternatives that have identical effects in terms of health but different consumption modalities of the resources necessary to achieve them. It is the simplest method for evaluating efficiency because it highlights, among different alternatives retained of equal effect, which option has the lowest consumption of resources without giving particular attention to the measurement of the same effects. The purpose of this analysis is to answer, for instance, the question, Which therapeutic program for myofascial pain costs less?” The cost of two or more treatments for which a complete equivalence of the effects was ascertained or hypothesized are compared with the aim of identifying the most convenient one.

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Chapter 3 - Economic Impact of Regional Anesthesia TABLE 3-1 -- HAVE COSTS AND CONSEQUENCES FOR EACH INTERVENTION BEEN EVALUATED? No

Have two or more alternatives been compared?

N O

Y E S

Yes

Only the consequences

Only the costs

Costs and consequences

1A Partial evaluation Description of results

1B Partial evaluation Description of costs

2 Partial evaluation Description costs/results

3A Partial evaluation Evaluation of the efficacy

3B Partial evaluation Cost analysis

4 Complete evaluation Cost minimization Cost effectiveness Cost benefit analysis Cost of utility

A comparison of outpatient surgery with inpatient treatment of hernias or hemorrhoids may also be suitable for a cost minimization analysis. If there is strong evidence to suggest that there are no great differences in clinical outcomes for these two defined groups of patients, one can concentrate on identifying the lesser cost option. Much too often, it is assumed that two programs have identical results. If this were really the case, there would be no difference between the minimization of the costs in boxes 3B and 4 of Table 3-1 . It would be wise, however, to furnish some proof to ensure that the results of the two alternatives are equivalent or that they present irrelevant differences.

COST-EFFECTIVENESS Cost-effectiveness analysis compares two or more alternatives that have identical effects from the qualitative point of view but different effects from a quantitative point of view and that involve different modalities of resource consumption necessary to achieve them. The choice does not fall automatically on the least expensive program, except when the best result is also the least expensive choice. A comparison based on cost per unit is always done before the choice is made. For example, there is a range of treatments available for the control of hypertension. These vary in terms of their outcomes, side effects, and so on, but they may all be measured primarily in terms of the reduction in diastolic blood pressure (mm Hg) they achieve. In practice, this analysis measures the cost to reach a determined therapeutic objective, measured in physical units, such as lowered Visual Analogic Scale (VAS) score, increase in the degrees of excursion of an articulation, or years of life earned. The lower the cost of a physical unit obtained, the higher the efficacy of a treatment.

COST-BENEFIT ANALYSIS Cost-benefit analysis evaluates two or more relief alternatives whose effects are not necessarily identical or that lead to a single common effect. This type of analysis tries to go beyond the considerations of the specific effects, individualizing a modality of measurement of all the results of the considered program. One of these measures is the monetary unit that quantifies, in monetary terms, the benefits of the program. It also facilitates cost comparison. Successively, the costs of a pharmacologic treatment are compared with the economic benefits (savings of resources for the reduction of morbidity and mortality rates). The net benefits are calculated from the difference between the total benefits (savings) and the total costs. The greater the savings and the lower the costs of a treatment, the more beneficial it is. Each alternative is compared with the alternative of doing nothing, characterized by additional void costs (i.e., by the maintenance of the status quo). It implicitly allows comparison of each alternative with the choice not to do anything, a choice without costs or benefits. Unlike the analysis of minimization of costs and analysis of cost-effectiveness, this technique of analysis does not subtend any option for a determined objective that could be rejected if the results do not satisfy the preset criteria.

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COST OF UTILITY Another measure of the value of a program, preferred by many analysts, but more difficult to obtain, is utility. Utility refers to the value of one specific level of the state of health and can be measured on the basis of individual or societal preferences for a set of results produced by the healthcare services. The analysis of utility is a relatively new technique in the field of evaluation of services, but it is considered very promising because it even takes into account the quality of life in judging the results of a treatment program. At the same time, it has a common denominator that makes the costs and results of different programs homogeneous and comparable. This common denominator, usually expressed in the formula of days of health or years of life earned and balanced with the relative quality of life, is obtained case per case by multiplying the duration of the result by a coefficient of relative utility of the state of health reached.

Cost Analysis Assessment of cost is essential when performing any evaluation of the economic impact of a healthcare intervention and is similar for all four methods of analysis. Definition of the cost accounting terms are listed in Table 3-2 . Cost assessment varies according to the perspective of the person making the assessment. Common perspectives considered in healthcare cost analyses include those of society as a whole, those of health insurance companies or other payers, those of healthcare providers, and those of the patient. What is relevant from one perspective may be irrelevant from another. Many healthcare economic analysts recommend that wide-ranging policy decisions on drug use should be based on cost assessments that take the widest possible perspective (i.e., society as a whole). Cost considerations from a narrower point of view may overlook shifting cost from one segment of society to another (e.g., early discharge shifts recovery costs from [5] [6]

TABLE 3-2 -- DEFINITIONS OF COMMONLY USED COSTS Term

Definition

Costs

Sacrifice measured as the price paid for the irreversible use of a resource

Direct costs

Cost of the material and labor used for production

Indirect costs

Costs related to the consequences of an event on society or on an individual

Average costs

Total costs divided by the number of units produced

Fixed costs

Costs that remain the same regardless of the number of goods or services produced

Marginal costs

Change in costs for producing one additional unit of output

Variable costs

Costs that change with the number of services provided

the healthcare system itself to patients, their families, and their primary care physicians).

[7]

The total costs associated with a medical intervention consist of direct and indirect costs. The direct costs of a particular treatment include not only the acquisition cost of the amount of drug administered but also the costs of drug wastage, equipment for therapy administration (e.g., intravenous sets, syringes), pharmacy dispensing costs, and the costs of managing any drug-induced side effects. From the patient’s perspective, total costs include nonmedical, direct, out-of-pocket costs (e.g., transportation to the site of therapy, family lodging, home help care) along with indirect costs of wages lost by the patient and the family member who is the caregiver. [8]

The term indirect costs is used differently by physicians, accountants, and healthcare economists. Although some physicians refer to costs of managing side effects and delayed recovery as indirect costs, most healthcare Accountants include all fixed costs in their economists would describe these as associated direct costs. calculation of indirect costs, whereas economists usually refer to indirect costs as the costs related to lost productivity. [9]

[10] [11]

[12]

COSTS OF ANESTHESIA Expenditures controlled by anesthesia providers represent 3% to 5% of the total healthcare costs of the United States. The cost implications of anesthesia care are complex. Not only are there significant costs associated with [13]

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the delivery of anesthesia care (e.g., cost of drugs, equipment, supplies, provider fees), but there can be additional costs associated with care (e.g., perioperative testing, consultation with other providers, complications). Macario and coworkers, reporting on a study elucidating the proportion of anesthesia costs relative to the major hospital departments involved in surgical care, estimated that intraoperative anesthesia hospital costs constituted 5.6% of the total hospital cost of an inpatient surgical procedure. The true fraction of resources consumed was probably higher because some costs outside the operating room (e.g., preoperative laboratory testing) were not allocated to anesthesia but may have been occasioned by decisions related to anesthesia care. [14]

In this study, 49% of total hospital costs were variable and 57% were direct. The largest hospital cost category was the operating room (33%) followed by the patient ward (31%). The greatest savings occurred if interventions addressed variable costs (e.g., intravenous supplies). Even if this study had been performed in a single university hospital using a well-known cost accounting application, and even if the results were not necessarily transferable to other institutions with other cost categories, the proportions of hospital departmental costs are likely to be generalized to other hospitals. It is possible to divide cost components and cost determinants. Cost components include those expenditures that, added together, result in the dollar cost of anesthesia. These cost components accrue directly to patients and payers and are observed in patient bills and records. Cost determinants are the factors that influence the cost components of anesthesia and are difficult to measure directly. Some costs accrue only to society in general and are best studied as determinants and measured in terms of tradeoff. The major charges for anesthesia are derived from three sources: provider services, technology, and site or facility. Minor charges are derived from payer source and side effects. The two major determinants affecting costs of provider services are the supply and availability of providers and their geographic locations. Technology includes the methods for achieving adequate anesthesia. The methods differ among the three basic types of anesthesia: general, regional, and monitored care. The costs of provider services differ insignificantly among these three types, but there are major differences in the costs of technology. Charges for anesthesia technology have three determinants: disposable supplies, equipment, and anesthetic drugs and agents. Some technologies do require skills that may add from $300 to $1000 to the cost of an anesthetic. Complications such as congestive heart failure or the requirement of an ICU stay are very expensive, but whether new techniques prevent them in a cost-efficient fashion is uncertain. The term facility includes the geographic location where anesthesia is performed and all of its associated contextual and environmental features, such as the following: • Elective versus emergency treatment, which determines whether the patient can shop for a surgeon and surgical facility. • Political and legal policies, which determine where anesthesia practitioners can practice and the exclusiveness or competitiveness of these practices. • The organizational structure, which encompasses the policies, procedures, and philosophies of the surgical facility and that affects the way anesthesia is administered (i.e., how much preoperative laboratory work is required, to what extent preoperative consultations are encouraged, and who provides postoperative pain control. • Patient demographics, which include the physical, social, and financial diversity of the general patient population. Patient demographics determine, in part, the level of services needed and the amount of costshifting from full-paying patients required for the facility and provider to continue in business.

Time in Regional Anesthesia The time spent in the healthcare structures, represented by the period spent in the operating room, the ICU, or the ward, constitutes one of the most important variables to study in an examination of the economic impact of any new anesthesia procedure. This is because the major economic impact of the healthcare assistance is made not by materials and equipment but especially by the personnel’s work, which needs to be well organized. In the literature, no studies exist that have dealt with this question from all points of view. In the study by Tessler and coworkers, for example, the authors sought to compare the time efficiency of spinal versus general anesthesia. The purpose of the study was to determine the frequency of converting failed spinal [15]

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anesthesia to general anesthesia and the amount perioperative time needed for patients undergoing spinal or general anesthesia for vaginal hysterectomy. These operations were all elective and required no additional invasive monitoring. This arrangement allowed a pure comparison of anesthetic induction time (spinal vs. general) and a comparison of overall perioperative time that may be related to the choice of anesthetic technique. Their results indicated that spinal anesthesia and general anesthesia were equally time efficient for that type of surgery. The patients in the spinal anesthesia group remained in the postanesthesia care unit (PACU) an average of 27 minutes longer per patient than those receiving general anesthesia alone. However, at their institution, complete recovery from motor block due to spinal anesthesia is a PACU discharge criterion, and this would explain their finding. Other anesthesiologists do not believe full recovery from motor block after spinal anesthesia is necessary before discharge from the PACU. [16]

This study, regardless of costs, does not give any information on the different economic impact that the two different techniques of anesthesia could have. Moreover, the impact (importance, significance) of the 27 minutes spent in the PACU per patient for those undergoing spinal anesthesia still remains unclear. In the light of other criteria of dismissal from the PACU, the results could be inverted. Another study was designed to ascertain whether interscalene block is reliable and efficient for use in same-day surgery compared with general anesthesia for shoulder arthroscopy. The authors retrospectively reviewed patients treated at the University of Connecticut over a 42-month period in the same-day surgery unit. They found that compared with general anesthesia, regional anesthesia required significantly less total nonsurgical intraoperative time use (53 ± 12 vs. 62 ± 13 min) and also decreased PACU stay (72 ± 24 vs. 102 ± 40 min). Interscalene block anesthesia resulted in significantly fewer unplanned admissions requiring therapy for severe pain, sedation, or nausea/vomiting than general anesthesia (0 vs. 13) and an acceptable failure rate (8.7%). [17]

In this case also, the study did not evaluate the various economic consequences of a different clinical choice but concluded only that interscalene block should be considered as a viable alternative to general anesthesia for shoulder arthroscopy in ambulatory surgery patients. Among the studies that have considered the economic consequences of different therapies is that of Nakamura and coworkers. This retrospective study evaluated 67 consecutive patients who underwent an arthroscopically assisted, autogenous bone-patellar ligament-bone anterior cruciate ligament reconstruction that was supervised by the same surgeon. General endotracheal anesthesia was used for 36 patients, and a femoral sciatic nerve block was used in 31 patients. Patients who received regional anesthesia required a significantly longer recovery room stay than those who received general anesthesia. Most of the patients who received general anesthesia had inpatient procedures. In the general anesthesia group, 31 of 36 patients spent at least one night in the hospital. Three of 31 patients who received regional anesthesia required hospital admission. There were no differences in anesthesia-related complications between the groups. The cost saving of performing anterior cruciate ligament reconstruction under regional anesthesia compared with that of general anesthesia was calculated at $2907 per patient and predominantly reflected the outpatient approach used in these cases. Moreover, the use of regional anesthesia was not found to compromise operating room efficiency. [18]

Another study was performed to assess safety, efficacy, and hospital costs related to general anesthesia and regional anesthesia for carotid endarterectomy (CEA). The authors found that patients who received general anesthesia for CEA spent an average of 1.2 days in the PACU and 6.1 days in a regular hospital bed, for an average cost of $4547. The patients who underwent CEA under regional anesthesia had an average of 0.1 PACU day and 4.1 regular hospital days, for a cost of $2067. Regional anesthesia saved $2480 per patient and $124,000 in this study group, with no increase in the rate of mortality and morbidity. [19]

In these studies, the different economic consequences that are reflected on the patient and on the society in general after the administration of the different anesthesiologic techniques remain unknown. Choice of anesthetic may affect the recovery rate of gastrointestinal function and, thus, duration and cost of hospitalization after colonic surgery. A universal complication after major intra-abdominal surgery is postoperative ileus, which prolongs hospital stays and is estimated to have an annual cumulative U.S. healthcare cost of $750 million. Previous studies suggest that multiple factors may affect the rate of postoperative recovery of gastrointestinal function after abdominal surgery. For example, recovery of postoperative gastrointestinal function may be promoted by early oral feeding, by use of low-fat nutrition, by early patient activity, and by administration of nonsteroidal anti-inflammatory agents. The use of epidural analgesia, especially with local anesthetics, may accelerate the recovery of gastrointestinal function through blockade of inhibitory sympathetic reflexes. [20]

[21] [22]

[23]

[25]

[26] [27]

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Liu and coworkers performed a prospective, randomized, double-blind study to examine the effects of different techniques of anesthesia and analgesia on recovery of gastrointestinal function and subsequent duration and cost of hospitalization. Fifty-four patients undergoing partial colectomy procedures were randomized into four groups. All groups received a standardized general anesthetic. Group MB received a preoperative bolus of epidural bupivacaine and morphine followed by an infusion of morphine and bupivacaine. Group M received a preoperative bolus of epidural morphine followed by an infusion of morphine. Group B received a preoperative bolus of bupivacaine followed by an infusion of bupivacaine. Group P received a preoperative bolus of intravenous morphine followed by intravenous patient-controlled morphine postoperatively. [28]

The authors found that epidural analgesia with bupivacaine and morphine provided the best balance of analgesia and side effects. At the same time, this combination of pain relief accelerated postoperative recovery of gastrointestinal function and time to fulfillment of discharge criteria after colon surgery in relatively healthy patients within the context of a multimodal recovery program. Based on average charges at the institution, the use of epidural morphine and bupivacaine potentially generated a net savings of $1200 per patient compared with the use of epidural or patient-controlled analgesia (PCA) morphine. In contrast, a major study found that patients who received epidural bupivacaine did not experience the improved recovery of bowel function experienced by those who were given systemic opioids. However, in this study, epidural local anesthetic was administered for only 24 hours and then patients were provided with analgesia via parenteral or epidural opioids during the time in which gastrointestinal function was beginning to recover. Hence, it seems likely that early discontinuation of epidural local anesthetic administration may account for this negative finding. [29]

In summary, these data support, but do not conclusively prove, that regional anesthesia results in a superior recovery compared to general anesthesia. However, several questions need to be answered. Although the patient may leave the hospital or surgical center sooner after receiving regional anesthesia, how does the patient treat pain at home once the block has worn off? Who, and at which cost, will take care of the patient? Few studies performed a comparison of differences in time efficiency, costs, charges, and complications among regional techniques. Riley and coworkers compared spinal and epidural anesthesia for cesarean delivery with respect to time spent in the operating room and the PACU, complications, and requirements for additional analgesia. The authors found that significantly less time elapsed from entry into the operating room until surgical incision with spinal anesthesia compared with epidural anesthesia. Thus, patients who received spinal anesthesia spent a shorter total time in the operating room than those who received epidural anesthesia. PACU times were not statistically different between the groups. Cost analysis revealed that patients would have been charged an average of $260 more for operating room use and anesthesia professional fees with epidural anesthesia. Charges to patients who had spinal anesthesia were significantly less than those to patients who had epidural anesthesia; however, patient charges do not reflect the true costs of medical procedures and are meaningless in managed or capitated systems. Examining costs is a better way to compare economic advantages among techniques. In this study, the differences in direct costs between the techniques was relatively small (approximately $20). In contrast, the increased indirect costs associated with epidural anesthesia may be of greater consequence. The additional time taken to perform the epidural block occupies not only the anesthesiologist but also the obstetrician, surgical assistant, and nurses. In addition, the operating room is occupied for a longer period, which may be significant in a busy obstetric service. Patient discomfort can also be considered as an additional indirect cost of epidural anesthesia. [30]

Complications in Regional Anesthesia The act of placing an epidural catheter may determine some of the complications with epidural anesthesia. The most common complication from placement of epidural catheters is accidental dural puncture with resultant postdural puncture headache (PDPH). Large surveys encompassing 51,000 epidural catheter placements performed during the Subsequent development of past three decades suggest that the incidence of dural puncture is 0.16% to 1.3%. PDPH depends on several factors and ranges from 16% to 86%. [31] [32]

[33]

Less frequent complications include paresthesias. The incidence of transient paresthesia varies from 5% to 25%.

[34]

Neurologic damage, which may be long-lasting or even permanent, is the most feared complication of regional anesthesia. There are several causes of such damage, such as trauma (needle, catheter, injection), arteriosclerosis, hypotension, the accidental injection of toxic substances such as povidone-iodine (Betadine), hypocoagulation, and bacteremia. The incidence of these complications is likely to be 0.01% to 0.001%. [34]

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Paraplegia appears to result most commonly from the formation of an epidural hematoma. Puncture of epidural vessels during placement of epidural catheters occurs in approximately 3% to 12% of cases. The incidence of symptomatic epidural hematoma associated with epidural analgesia is difficult to estimate, but combined case series of more than 100,000 epidural anesthetics have been reported without a single epidural hematoma. Currently, the risk of epidural hematoma formation after administration of epidural analgesia appears to be increased if patients are receiving anticoagulant agents or have a coagulation disorder. However, several large series have documented safe use of epidural analgesia in patients receiving antiplatelet therapy, warfarin sodium, and high or low doses of heparin. [35]

[36]

[37]

[36] [37] [38]

[39]

[40]

[41] [42]

Evaluation of the economic consequences of such complications is not simple. The rarity with which they occur renders their economic weight almost uninfluential for the healthcare structures. Administration of local epidural anesthetics for surgical anesthesia frequently results in multiple hemodynamic changes, including decreases in chronotropism, inotropism, dromotropism, systemic vascular resistance, cardiac output, and myocardial oxygen consumption. The economic consequences of these hemodynamic changes are far from being calculated. [43]

Another dangerous complication of epidural administration of opioids is delayed respiratory depression. Although virtually all opioids commonly used for epidural analgesia have been reported to cause respiratory depression, morphine is associated with the highest risk. Nonetheless, the incidence of delayed respiratory depression after epidural administration is small. In a prospective survey of 1062 patients receiving epidural analgesia, there were 1131 episodes in which a local anesthetic and opioid mixture was used, and 160 instances in which opioids alone were used. Local anesthetic was not used without opioids. Twenty-three percent of catheters were removed prematurely because of catheter-related problems including accidental dislodgment (13%) and skin site inflammation (5.3%). No epidural abscess or hematoma was identified. In 14% of the total number of episodes, there was either no demonstrable block or complications occurred that required a change of solution: 30% of this group were salvaged after intervention by the acute pain service. The incidence of respiratory depression was 0.24%. There was no case of delayed respiratory depression. [44]

[45]

For epidural analgesia, fentanyl, because of its greater lipophilic nature, offers a number of advantages over morphine, including a lower incidence of side effects and reduced risk of delayed-onset respiratory depression. The relatively short duration of action of epidural fentanyl makes this agent more ideally suited for continuous infusion or patient-controlled epidural analgesia (PCEA). [46]

Although morphine and fentanyl remain the predominant epidural opioids, sufentanil offers some unique advantages. Because of its greater lipophilic action and µ-receptor binding capacity, sufentanil has a faster onset of action and longer duration than epidural fentanyl. Compared with morphine, sufentanil has been associated with a lower incidence of side effects, particularly delayed respiratory depression. [47]

[47]

Combined case surveys including more than 20,000 patients suggest that the incidence of this complication is less than 1%. Even in this case, the related economic impact of this complication has not been calculated. [48]

Outcome and Regional Anesthesia Perioperative morbidity and mortality rates are mainly influenced by the type and duration of surgery as well as the patient’s preoperative state of health. Anesthesia, however, may also result in severe perioperative pathophysiologic changes, which may be either desirable (e.g., analgesia, vasodilatation in vascular surgery) or detrimental (e.g., hypothermia, ventilatory depression) and which may differ depending on the anesthetic technique used (e.g., general anesthesia vs. regional anesthesia). Epidural anesthesia has been reported to exert beneficial effects in surgical procedures. In a retrospective study of 90 consecutive high-risk thoracic surgical procedures performed using a combined technique of epidural anesthesia with light general anesthesia, the outcome of this technique has been examined. The mortality rate for the group of patients was 2.2% due to myocardial infarction occurring on postoperative days 3 and 4. Morbidity developed in 3.3% of the patients, including the 48-hour requirement of mechanical ventilation in one patient and pneumonia in two other patients. This approach appears to be preferable to use of general anesthesia alone, in which American Society of Anesthesiologists (ASA) class II patients have a predicted mortality rate of 5.4% for elective high-risk procedure. [49]

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On the contrary, in another study comparing general anesthesia combined with epidural anesthesia with general anesthesia for major abdominal surgery, results were equivocal. In fact, the authors found only transient quantifiable differences in recovery characteristics. [50]

Two major periodical reviews of the effects of regional anesthesia on postsurgical morbidity rate and postoperative organ dysfunction have been published. The former concluded that regional anesthesia appears to reduce the early postoperative mortality rate after acute hip surgery for fracture, but long-term survival is dependent on factors other than the choice of anesthesia. The large amount of data suggests that regional anesthesia should be used whenever possible. The latter, a more recent review, confirms what the previous study underlined: Reduced mortality rate appears to have been demonstrated under an epidural regimen for postoperative analgesia in high-risk patients undergoing thoracic, abdominal, and vascular procedures. [51]

[52]

Several studies have attempted to identify the most appropriate anesthetic technique for patients with hip fracture. A significantly lower mortality rate for spinal anesthesia compared with general anesthesia was demonstrated by one group of researchers, but this has not been confirmed. In the largest published study on patients undergoing anesthesia for hip fracture surgery, 1333 patients were studied prospectively to assess the effects on outcome of general and spinal anesthesia. It was demonstrated that the excess mortality rate in some groups was correlated with age and preexisting medical conditions rather than with the type of anesthesia, and there were no significant differences between the groups in the length of hospital stay. [53]

[54] [55]

[56]

In another study, the mortality rate after surgical correction of upper femoral fractures was investigated in 578 patients randomly allocated to receive spinal or general anesthesia. Thirty days after surgery, the mortality rate was 6% after spinal anesthesia and 8% after general anesthesia. Six months to 2 years after surgery the mortality rate was identical in the two groups. The estimated blood loss was smaller in patients receiving spinal anesthesia. Regardless of the anesthetic technique, a high short-term mortality rate was related to age, male sex, and trochanteric fracture, whereas excess long-term mortality rate was related to male sex and high ASA scores. However, the patients in this study had a much shorter period in hospital than the patients in other studies. At the same time, mortality rate during the first year has been reduced from 27% to 19%, suggesting the possibility of a beneficial effect of early ambulation and discharge. [57]

[58]

The perioperative morbidity rate may be modifiable in high-risk patients by the anesthesiologist’s choice of either regional or general anesthesia. Outcomes between epidural and general anesthesia have been compared, with a study made of 100 patients scheduled for elective vascular reconstruction of the lower extremities who were randomized to receive either epidural anesthesia followed by epidural analgesia or general anesthesia followed by intravenous PCA. Cardiac ischemia, myocardial infarction, unstable angina, and cardiac death were identified by a cardiologist. Other major types of morbidity were determined at the time of hospital discharge and at 1 and 6 months after surgery. The major finding of this study was that the rate of reoperation for graft occlusion was higher in patients randomized to receive general anesthesia than in those randomized to receive epidural anesthesia, but no statistically significant differences were found in overall incidence of death, major cardiac disease, or myocardial ischemia. [59]

These findings have been confirmed in the largest prospective randomized trial to date, which was designed to evaluate the effects of regional anesthesia techniques (spinal or epidural) versus general anesthesia on perioperative cardiac morbidity rate and overall mortality rate in patients undergoing peripheral vascular surgery. The authors, in fact, found that the choice of anesthesia, when correctly delivered, does not significantly influence cardiac morbidity and overall mortality rates in patients undergoing peripheral vascular surgery, but it decreases the incidence of peripheral vascular graft thrombosis. [60]

Also, general anesthesia in carotid endarterectomy has not caused an increase in either mortality or morbidity rates. Nevertheless, patients who underwent carotid endarterectomy under regional anesthesia saved $2480 each.

[61]

Therefore, many trials that aimed at comparing the impact of different anesthetic techniques on the incidence of postoperative complaints have been performed in the past. No significant advantage of either technique has been identified up to now with respect to postoperative mortality rate or severe morbidity. This finding may be due to at least three factors; • Many side effects related to anesthesia—due to close postoperative monitoring—are detected and treated early in the postoperative phase (e.g., in the recovery room), thereby preventing serious complications. • Postoperative mortality rate, related exclusively to anesthesia, is probably so low that huge patient numbers would be required to demonstrate any significant differences between different techniques.

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• Besides the factor of anesthesia, many other factors (e.g., anesthetists) contribute to the anesthesia-related morbidity and mortality rates, which are scarcely quantified. The fact that clear advantages for a single technique have not yet been demonstrated must not, however, result in anesthetic nihilism. Rather, there may be good reasons in the individual patient (e.g., lack of a recovery room) to prefer one anesthetic technique or drug over another, in order to lower the individual’s anesthesia-related risk. Intraoperative blood loss has been attributed to multiple clinical variables, including age, physical status, type of surgery, surgeon, and anatomic and physiologic differences between patients. Nearly 12 million red blood cell units are transfused to approximately 3.5 million patients annually in the United States. Approximately 20% of all homologous blood transfusions have resulted in some adverse effect in the recipient. The unit cost has varied from $60 to $150. In another study, the mean cost for all blood components transfused per patient has been evaluated to be $397 ± $244. The advantages of regional anesthesia with regard to intraoperative blood loss compared with those of general anesthesia have long been debated. Although the literature has not demonstrated less bleeding with either anesthetic technique, it is commonly believed that epidural or spinal anesthesia results in less intraoperative bleeding. [62]

[64]

[65]

[63]

[66]

[67]

[68]

[69]

[70]

[56] [57]

More correctly, it seems that positive pressure ventilation increases bleeding during general anesthesia. This was demonstrated by comparing the mean blood loss in 100 patients receiving either epidural anesthesia, combined epidural and general anesthesia, or general anesthesia alone. Mean blood loss in the epidural anesthesia group was significantly less than that in either the combined epidural and general anesthesia group or the general anesthesia alone group. Significantly less blood was transfused during surgery in the epidural group compared with the remaining two groups. [71]

The decrease in blood loss associated with epidural anesthesia with lower transfusion requirements results in significantly reduced frequency of deep venous thrombosis compared with results after general anesthesia. Venous thromboembolic disease is still one of the main causes of postoperative morbidity and death. It is also commonly believed in this case that continuous lumbar epidural anesthesia could exert a beneficial effect in reducing the incidence of such an event. Possible explanations for these differences include increased circulation in the lower extremities, less tendency for intravascular clotting to occur, and more efficient fibrinolysis in association with epidural anesthesia. [72]

The socioeconomic consequences of routine administration of low-molecular-weight heparin (LMWH) as thromboprophylaxis in patients undergoing total hip arthroplasty has been evaluated on the basis of data from a Despite the higher direct costs associated with LMWH, this regimen was more costnumber of clinical studies. effective in preventing thromboembolic complication than no prophylaxis, dextran 70, or low-dose unfractionated heparin. [73] [74]

[73] [74]

Analgesic Consumption and Regional Anesthesia The consumption of analgesic drugs in the postoperative period is another important factor in evaluating the economic impact of an anesthesiologic technique. Epidural local anesthetics may be superior to systemic opioids in the dose range used and in reducing postoperative analgesic requirements because they decrease pain perception in patients. The changes in central neuron excitability induced by a noxious injury stimulus usually outlast the stimulus duration and may persist beyond the expected tissue healing period. Consequently, it has been suggested that surgery in humans may lead to alterations in response properties of central neurons, as in sensitization, similar to the ones produced in experimental animals, resulting in amplification and prolongation of postoperative pain. To date, relatively few studies have examined the effects of intraoperative neuraxial block with either local anesthetics or opioids on postoperative analgesic requirements. One of these studies compared postoperative pain and analgesic demand in patients who underwent radical prostatectomy and received general anesthesia alone and in those who underwent prostatectomy and received epidural anesthesia with bupivacaine, either alone or in combination with general anesthesia. During surgery, patients in the epidural group received a significantly greater epidural bupivacaine dose compared with the epidural general anesthesia group. On postoperative day 1, PCA requirements in the three groups were similar. On postoperative day 2, PCA demand in the epidural general anesthesia group and in the general anesthesia group was significantly greater than in the epidural anesthesia group. The same differences continued on postoperative days 3 and 4. The results were not statistically analyzed because only seven patients still received epidural PCA on postoperative day 5. [75]

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Other studies[ ] [ ] have confirmed these findings, suggesting that analgesic requirements, time of postoperative surveillance, and frequency of treatment of postoperative complaints after both lower abdominal surgery and lower limb surgery can be significantly decreased if surgery is performed with use of subarachnoid anesthesia. Furthermore, the results were more interesting when general anesthesia was compared with triple nerve block (three in one) during surgical correction of fractured femur neck. The nerve blocks significantly reduced the quantity of opioid administered after the operation; 48% of these patients required no additional analgesia in the first 24 hours. 76

77

[78]

Conclusions Anesthesia costs are a small portion of the overall costs associated with a surgical patient’s hospital encounter. Greater cost savings may come with improving operating room efficiency as well as those processes of care that reduce length of hospital stay. Many studies have observed better pain relief with epidural analgesia than with systemic opioids. analgesia is particularly evident when local anesthetics and opioids are combined.

[79] [80]

Improved

[80]

Improved analgesia, however, may not be the only mechanism for improved outcome, at least not through a direct cause-and-effect-relationship. Epidurally administered analgesics may also produce beneficial effects through other mechanisms such as inhibition of efferent pathways or inhibition of neural reflex arcs. This study indicates that use of regional anesthesia and analgesia may be associated with reductions in incidence and severity of many perioperative physiologic perturbations. Perioperative coagulability can be decreased with epidural analgesia, and this effect may significantly reduce the incidence of venous and arterial thromboses. Similarly significant improvements in gastrointestinal motility may result in a more rapid functional recovery from surgery. Despite the obvious need, there are few studies of the costs and economic consequences of alternative anesthetic strategies. Healthcare and cost containment strategies and policies often are developed and implemented before their wider effects are assessed and understood. When designing outcome studies, it is necessary to strike a balance between two opposing goals: first, the scientific need to investigate effects of a single intervention by keeping all other aspects of care constant; and second, the clinical reality that postoperative recovery is a multifactorial event and that a solitary intervention is unlikely to alter the outcome. Although many of these outcomes are relatively subjective and difficult to evaluate, it is necessary to expand the horizon beyond the intraoperative or even intrahospital period to see whether and to what degree clinical interventions influence ultimate patient recovery. The changing economic environment means that it is no longer sufficient for anesthesiologists merely to determine the best method of postoperative analgesia or merely to believe that patients will do better. In the future, it will be necessary to demonstrate that every kind of anesthetic-analgesic technique is cost-effective. REFERENCES 1. Final

accounting of 1998 health spending. Bus Health 18:10–11, 2000.

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CM, Teller LE, Gross JB, et al: New discharge criteria decrease recovery room time after subarachnoid block. Anesthesiology 70:640–643, 1989.

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JG, Rosenblum M, Shea KP, et al: A retrospective comparison of interscalene block and general anesthesia for ambulatory surgery shoulder arthroscopy. Reg Anesth 20:62–68, 1995.

18. Nakamura SJ, Conte-Hernandez A, Galloway MT: The efficacy of regional anesthesia outpatient anterior cruciate ligament reconstruction. Arthroscopy 13:699–703, 1997. 19. Godin

MS, Bell WH, Schwedler M, et al: Cost effectiveness of regional anesthesia in carotid endarterectomy. Am Surg 55:656–659, 1989.

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Moiniche S, Bulow S, Hesselfedt P, et al: Convalescence and hospital stay after colonic surgery during balanced analgesia, enforced oral feeding and mobilization. Eur J Surg 7:628–633, 1995. 25. Grass JA, Sakima NT, Valley M, et al: Assessment of ketorolac as an adjuvant to fentanyl patient controlled epidural analgesia after radical retropubic prostatectomy. Anesthesiology 78:642–648, 1993. 26. Ahn H, Bronge A, Johansson K, et al: Effect of continuous postoperative epidural analgesia on intestinal motility. Br J Surg 75:1176–1178, 1988. 27. Jayr C, Thomas H, Rey A, et al: Postoperative pulmonary complications. Epidural analgesia using bupivacaine opioids versus parenteral opioids. Anesthesiology 78:666–676, 1993. 28. Liu SS, Carpenter RL, Mackey DC, et al: Effects of perioperative analgesic technique on rate of recovery after colon surgery. Anesthesiology 83:757–765, 1995. 29. Wallin G, Cassuto J, Hogstrom S, et al: Failure of epidural anesthesia to prevent postoperative ileus. Anesthesiology 65:292–297, 1986. 30. Riley ET, Cohen SE, Macario A, et al: Spinal versus epidural anesthesia for cesarean section: A comparison of time efficiency, costs, charges and complications. Anesth Analg 80:709–712, 1995. 31. Tanaka K, Watanabe R, Harada T, et al: Extensive application of epidural anesthesia and analgesia in a university hospital: Incidence of complications related to technique. Reg Anesth 18:34–38, 1993. 32. Stride PC, Cooper GM: Dural taps revisited: A 20 year survey from Birmingham Maternity Hospital. Anesthesia 48:247–255, 1993. 33. Kopacz DS, Neal JM, Pollok JE: The regional anesthesia “learning curve.” What is the minimum number of epidural and spinal blocks to reach consistency? Reg Anesth 21:182–190, 1996. 34. Kane RF: Neurodeficits following epidural or spinal anesthesia. Anesth Analg 60:150–161, 1981. 35. Schmidt A, Nolte H: Subdural and epidural hematomas following epidural anesthesia: A literature review. Anesthesist 41:276–284, 1992. 36. Schwander D, Bachmann F: Heparin and spinal or epidural anesthesia: A decision analysis. Ann Fr Anesth Reanim 10:284–296, 1991. 37. Sage DJ: Epidurals, spinals and bleeding disorders in pregnancy: A review. Anaesth Intensive Care 18:319–326, 1990. 38. Jorgensen LN: Lumbar analgesia in patients receiving anticoagulant therapy: Pro et contra. Ugeskr Laeger 153:1491–1494, 1991. 39. Horlocker TT, Wedel DJ, Offord KP: Does preoperative antiplatelet therapy increase risk of hemorrhagic complications associated with regional anesthesia? Anesth Analg 70:631–634, 1990.

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40. Odoom JA, Sih IL: Epidural analgesia and anticoagulant therapy. Anaesthesia 38:254–259, 1983. 41. Willie JP, Jorgensen LN, Rasmussen LS: Lumbar regional anaesthesia and prophylactic anticoagulant therapy: Is the combination safe? Anaesthesia 46:623–627, 1991. 42. Bergqvist D, Linblad B, Matzsch T: Low molecular weight heparin for thromboprophylaxis and epidural/spinal anesthesia: Is there a risk? Acta Anaesthesiol Scand 36:605–609, 1992. 43. Cousins MJ, Bromage PR: Epidural neural blockade, neural blockade in clinical anesthesia and management of pain. Cousins MJ, Bridenbaugh PO (eds): Neural Blockade. Philadelphia, JB Lippincott, 1988, pp 253–260. 44. Morgan M: The rational use of intrathecal and extradural opioids. Br J Anaesth 63:165–188, 1989. 45. Burstal R, Wegener F, Hayes C, Lantry G: Epidural analgesia: Prospective audit of 1062 patients. Anaesth Intensive Care 26:165–172, 1998. 46. Grass JA: Fentanyl: clinical use as postoperative analgesic— epidural/intrathecal route. J Pain Symptom Manage 7:419–430, 1992. 47. Grass JA: Sufentanil: Clinical use as postoperative analgesic— Epidural/intrathecal route. J Pain Symptom Manage 7:271–286, 1992. 48. Morgan M: Epidural and intrathecal opioids. Anaesth Intensive Care 15:60–67, 1987. 49. Temeck B, Schafer W, Park WJ, et al: Epidural anesthesia in patients undergoing thoracic surgery. Arch Surg 124:415–418, 1989. 50. Handley GH, Silbert BS, Mooney PH, et al: Combined general and epidural anesthesia versus general anesthesia for major abdominal surgery: Postanesthesia recovery characteristics. Reg Anesth 22:435–441, 1997. 51. Scott NB, Kehlet H: Regional anaesthesia and surgical morbidity. Br J Surg 75:299–304, 1988. 52. Liu S, Carpenter R, Ncal JM: Epidural anaesthesia and analgesia. Their role in postoperative outcome. Anesthesiology 82:1474–1506, 1995. 53. McLaren AD, Stockwell MC, Reid VT: Anaesthetic techniques for surgical correction of fractured neck of femur. Anaesthesia 33:10–14, 1978. 54. Davis FM, Woolner DF, Frampton C, et al: Prospective, multicentre trial of mortality following general or spinal anaesthesia for hip fracture surgery in the elderly. Br J Anaesth 59:1080–1088, 1987. 55. Moore DP, Quinlan W: Mortality and morbidity associated with hip fractures. Irish J Med Sci 158:40–42, 1989. 56. Sutcliffe AJ: Mortality after spinal and general anaesthesia for surgical fixation of hip fractures. Anaesthesia 49:237–240, 1994. 57. Valentin N, Lomholt B, Jensen JS, et al: Spinal or general anaesthesia for surgery of the fractured hip? Br J Anaesth 58:284–291, 1986. 58. McKenzie PJ, Wishart HY, Dewar KM, et al: Comparison of the effects of spinal anaesthesia and general anaesthesia on postoperative oxygenation and perioperative mortality. Br J Anaesth 52:49, 1980. 59. Christopherson R, Beattie C, Frank SM, et al: Perioperative morbidity in patients randomized to epidural or general anesthesia for lower extremity vascular surgery. Anesthesiology 79:422–434, 1993. 60. Bode RH, Lewis KP, Zarich SW: Cardiac outcome after peripheral vascular surgery. Anesthesiology 84:3–13, 1996. 61. Godin MS, Bell WH, Schwedler M, et al: Cost-effectiveness of regional anesthesia in carotid endarterectomy. Am Surg 55:656–659, 1989. 62. Chin SP, Abou Madi MN, Eurin B, et al: Blood loss in total hip replacement: Extradural vs phenoperidine analgesia. Br J Anaesth 54:491– 495, 1982. 63. Moir DD: Blood loss during major vaginal surgery. A statistical study of the influence of general anaesthesia and epidural analgesia. Br J Anaesth 52:1117–1121, 1968. 64. Thorburn J: Subarachnoid blockade and total hip replacement. Effect of ephedrine on intraoperative blood loss. Br J Anaesth 57:290–293, 1985. 65. Sorenson RM, Pace NL: Anesthetic techniques during surgical repairs of femoral neck fractures. A meta analysis. Anesthesiology 77:1095– 1104, 1992. 66. Valley MA, Bourke DL, Hamill MP, et al: Time course of sympathetic blockade during epidural anesthesia: Laser Doppler flowmetry studies of regional skin perfusion. Anesth Analg 76:289–294, 1993. 67. Surgenor DM, Wallace EL, Hao SHS, et al: Collection and transfusion of blood in the United States, 1982–1988. N Engl J Med 322:1646– 1651, 1990. 68. Walker RH: Special report: transfusion risks. Am J Clin Pathol 88:374–378, 1987. 69. Kyriopoulos JE, Michail-Merianou V, Gitona M: Blood transfusion economics in Greece. Transfus Clin Biol 2:387–394, 1995. 70. Goodnough LT, Soegiarso RW, Birkmeyer JD, Welch HG: Economic impact of inappropriate blood transfusions in coronary artery bypass graft surgery. Am J Med 94:509–514, 1993.

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71. Shir Y, Raja S, Frank S, et al: Intraoperative blood loss during radical retropubic prostatectomy: Epidural versus general anesthesia. Urology 45:993–999, 1995. 72. Modig J, Borg T, Karlstrom G, et al: Thromboembolism after total hip replacement: Role of epidural and general anesthesia. Anesth Analg 62:174–180, 1983. 73. Borris LC, Lassen MR: Thromboprophylaxis with low molecular weight heparin after major orthopaedic surgery is cost effective. Drugs 52(Suppl 7):42–46, 1996. 74. Bergqvist D, Matzsch TShir Y: Cost-effectiveness of the prevention of postoperative thromboembolism. Orthopade 22:140–143, 1993. 75. Raja S, Frank S: The effect of epidural versus general anesthesia on postoperative pain and analgesic requirements in patients undergoing radical prostatectomy. Anesthesiology 80:49–56, 1994. 76. Wang JJ, Ho ST, Liu HS, et al: The effect of spinal versus general anesthesia on postoperative pain and analgesic requirements in patients undergoing lower abdominal surgery. Reg Anesth 21:281–286, 1996. 77. Standl T, Eckert S, Schulte J, et al: Postoperative complaints after spinal and thiopentone-isoflurane anaesthesia in patients undergoing orthopaedic surgery. Acta Anaesthesiol Scand 40:222–226, 1996. 78. Hood G, Gerrish SP: Postoperative analgesia after triple nerve block for fractured neck of femur. Anaesthesia 46:138–140, 1991. 79. Benzon HT, Wong HY, Belavic AM, et al: A randomized double-blind comparison of epidural fentanyl infusion versus patient controlled analgesia with morphine for postthoracotomy pain. Anesth Analg 76:316–322, 1992. 80. Negre I, Gueneron JP, Jamali SJ, et al: Preoperative analgesia with epidural morphine. Anesth Analg 79:298–302, 1994.

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Chapter 4 - Organization of an Acute Pain Service and Pain Management

Chapter 4 - Organization of an Acute Pain Service and Pain Management GIUSTINO VARRASSI FRANCESCO DONATELLI FRANCO MARINANGELI ANTONELLA PALADINI NARINDER RAWAL

In spite of increasing interest in pain and its management, most patients undergoing surgery do not receive adequate analgesia. Recent surveys show that a large proportion of patients still receive inadequate postsurgical analgesia; this problem is international in character. Analgesia techniques such as patient-controlled analgesia (PCA), spinal opioids alone or in combination with local anesthetics, and other regional analgesic techniques provide superior pain relief compared with intermittent intramuscular (IM) injection of opioids. However, such techniques carry their own risks and, therefore, require special monitoring. The first line of defense against serious complications is an organization that provides appropriate education and policies that permit nurses and physicians to safely care for patients. National guidelines for management of postoperative pain have been published in several countries; however, the impact of these guidelines on patient care is unclear. The available data are not encouraging. In the United Kingdom, 4 to 5 years after publication of professional guidelines, less than half of the hospitals surveyed had implemented a key recommendation to introduce an acute pain service (APS); the principal obstacles were financial constraints and newly qualified doctors who were still undereducated about the management of acute pain. Thus, pain relief remained inadequate. Similar problems have been identified in the United States, in Germany, and in 17 European nations. One of the many reasons for their limited impact is the complexity of the published guidelines. [1]

[2]

[3] [4]

[5]

[6]

The APS, using a multidisciplinary team approach, has received widespread acceptance and formal support from many institutions and organizations such as the United Kingdom Royal Colleges in 1990, the Australian Faculty of Anaesthetists in 1991, the U.S. Acute Pain Management Guideline Panel in 1992, the International Association for Study of Pain in 1992, and the German Society of Anaesthesiologists and Surgeons in 1997. The key recommendations of the United Kingdom Working Party are shown in Table 4-1 . Similar recommendations have been made by other institutions. [7]

[8]

[9]

[10]

[5]

Postoperative Pain Management Postoperative pain can be partially or completely relieved by either or both of the following methods: • Systemic administration of analgesics • Regional analgesia achieved with analgesics or local anesthetics

SYSTEMIC ADMINISTRATION OF ANALGESICS Nonopioid analgesics are an important class of drugs in the management of postoperative pain. A nonsteroidal antiinflammatory drug (NSAID) or acetaminophen as the sole analgesic may be adequate in the treatment of mild postoperative pain, and for moderate to severe

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TABLE 4-1 -- UNITED KINGDOM WORKING PARTY KEY RECOMMENDATIONS 1. Need for education and training in changing antiquated staff attitudes and practice, together with adequate resources. 2. Systematic recording of patients’ pain, as with blood pressure/ heart rate. 3. A named member of staff to be responsible for a hospital policy toward postoperative analgesia, subject to continuous audit and appraisal. 4. All major hospitals performing surgery should introduce an acute pain service using a multi-disciplinary team approach with input of medical, nursing, pharmaceutical and psychological expertise. The anesthetist has a primary role to play. 5. There is a need for powerful, safe analgesics and long-acting nontoxic local anesthetics. Modified from Royal College of Surgeons of England and the College of Anaesthetists Commission on the Provision of Surgical Services. Report of the Working Party on Pain after Surgery. London, September 1990.

pain these drugs can produce significant analgesia to reduce opioid requirements by 20% to 40%.

[11]

This effect is not surprising, because much of the pain is a result of the liberation of algogenic substances whose synthesis is impaired by NSAIDs. These drugs act through a mechanism of cyclooxygenase inhibition, a step in the synthesis of prostaglandins. The decreased concentration of prostaglandins blocks the transduction of the painful stimulus at the levels of the nociceptor, where the tissue injury is converted into an electrical signal. The mechanism of action of acetaminophen is still incompletely understood. There are several hypotheses suggesting a central inhibitory effect on prostaglandin interactions, a central serotoninergic effect, effects on nitric oxide mechanisms, and possible peripheral anti-inflammatory activity. [12] [13] [14] [15] [16]

The use of NSAIDs or acetaminophen as adjunctive therapy to opioid analgesics can significantly potentiate analgesia without increasing opioid-related effects because their mechanisms of action are completely different, and the two types of drugs block transmission of pain at different levels. NSAIDs must be used with caution in patients with a history of renal insufficiency, peptic ulcer, or hepatic disease. The introduction of NSAIDs formulated for parenteral administration (ketorolac) has significantly increased the use of these analgesics in the early perioperative period. Ketorolac is the most commonly used intravenous (IV) NSAID in the management of postoperative pain. It has been demonstrated to produce potent analgesia in adults at doses of 7.5 mg to 30 mg every 6 hours. Higher doses do not provide significantly better analgesia. Older patients and those at risk for NSAID-related complications should be treated with the lowest effective doses (7.5 mg to 15 mg every 6 h). [17]

[18]

When oral administration is possible, it is preferred because it is less expensive but not less effective than IV administration. In this case, the most frequently used NSAID is ibuprofen in doses of 1600 to 3200 mg per 24 hours administered in divided doses every 6 to 8 hours. To enhance the gastrointestinal tolerance of orally administered NSAIDs, these drugs should be taken with food. Acetaminophen is usually administrated at doses of 4 to 6 mg per 24 hours in divided doses. It has been associated with a significant opioid-sparing effect of up to 40%, especially in patients undergoing orthopedic surgery. [19]

In a double-blind study, propacetamol and ketorolac combined with PCA morphine show similar analgesic efficacy after gynecologic surgery. Morphine consumption and pain scores were comparable in both groups of patients. The authors concluded that propacetamol is as effective as ketorolac and has an excellent tolerability after gynecologic surgery. [20]

Contraindications for acetaminophen use are related primarily to hepatotoxicity when used in high doses or in patients with preexisting liver disease and possible nephrotoxicity. Opioid analgesic administration remains the most commonly used method of delivery of postoperative analgesia. The immense popularity and widespread use of these drugs are a result of their ready availability in most countries, their ease of use, their low cost, and, when properly used, their effective relief of pain. Unfortunately, as previously mentioned, these drugs are often improperly used. Consequently, many patients do not derive effective pain relief. The most common errors are routine administration without regard to the intensity of the pain and associated phenomena, the emotional makeup, the physical status, and the age of the patient. These errors occur because of the traditional practice of ordering narcotics pro re nata, without first evaluating the efficacy of the initial dose. Different narcotics in different individuals show a great variability in analgesic efficacy and in side effects. To eliminate variability in the peak plasma concentration and in the time taken to reach this peak, narcotics should be given intravenously rather than intramuscularly. In addition to eliminating the variability of absorption, the IV route has important advantages:

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• Rapid onset of action • Early occurrence of the peak effects, which facilitates the titration • Rapid decline of the blood concentration upon withdrawal of the drug, which limits the occurrence of undesirable effects The most important feature of providing optimal analgesia with systemic opioid analgesics involves the titration of the drug dose to the individual patient’s analgesic requirement. Because individual opioid analgesic dosage needs can vary widely, titration to individual patient requirements is essential. In the immediate postoperative period, opioid analgesia may be initially established through the intermittent IV injection of opioid (2 to 5 mg morphine equivalents) every 10 minutes. In some patients, this initial IV titration may require 15 to 20 mg of morphine equivalents or more to establish analgesia. After this initial IV titration, analgesia is more easily maintained with small, intermittent doses of opioid throughout the postoperative period. Although this technique may provide the best pharmacologic model for titration of opioid dose and analgesic effect, it is labor-intensive, requiring immediate access and administration of opioid analgesic doses on patient demand. The best option for systemic narcotic analgesia is use of a system that permits “on demand” PCA. The patient must be thoroughly informed about the procedure and given instruction in how to use the device. Individual analgesic consumption remains almost constant throughout the PCA period. Most patients establish and maintain a pseudosteady state plasma concentration by triggering new doses as the plasma concentration drops to a critical level of minimum effective analgesic concentration. The safety of PCA, especially in relation to respiratory depression, has been addressed by a number of investigators. serial blood gas analyses showed normal values in patients using PCA. The quality of analgesia In two studies, with PCA has been consistently reported as superior or equal to that attained with use of IM opioids. Less PCA opioid use compared with that of IM control groups is frequently observed, and satisfaction of patients and nurses is high. The principal advantages of PCA to patients are high-quality analgesia, autonomy, elimination of delay in decisions to medicate for pain, and freedom from painful intramuscular medication. It may take less nurse time to provide for the analgesic needs of postoperative patients using PCA. [21] [22]

The prescription of PCA involves physician-determined selection of: • Opioid analgesic • Dose on demand • Lockout interval • A 1-hour (or 4-hour) total dose limit Morphine, meperidine, and hydromorphone are among the most commonly prescribed opioid analgesics for PCA. In a patient with an uncomplicated medical history and no previous history of adverse reaction to opioid administration, there is little evidence to support improved efficacy or reduced side effects of any opioid analgesic over those of morphine. [23]

Several studies have investigated the appropriate PCA dose. A dose of between 1.0 and 2.0 mg of morphine (or morphine equivalents) has generally been found to be the most appropriate starting dose for postoperative pain. The dose should be reassessed with respect to analgesic effect and side effects throughout the first several hours of PCA therapy, and it should be adjusted to patient-specific analgesic requirements. [24]

The lockout interval is the minimum time interval between delivery of successive dose demands. This should be determined according to the time needed to reach peak analgesic effect for the opioid dose. For most opioid analgesics, the peak time is approximately 10 minutes. The 1-hour (or 4-hour) dose limit is a secondary overriding safety parameter that limits the total dose delivered within a specified period of time. The use of postoperative systemic opioid analgesia can range from providing pain relief with only opioid analgesics throughout the entire postoperative period to a combination with other techniques. Such a multimodal approach includes the use of locoregional analgesia and opioid and nonopioid analgesics. The concomitant use of other analgesic techniques that allow reduced dosage and administration of opioid analgesics appears to have significant benefits in terms of reducing postoperative morbidity associated with opioid medication related side effects. A report of adverse drug events leading to increased hospital morbidity rates and lengths of stay identified opioid analgesics as among the most common drugs involved in hospital medical-related complications. [25]

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SPINAL ANALGESIA Spinal analgesia refers to the use of opioids and analgesic concentrations of local anesthetics to produce pain relief by either intrathecal or epidural administration. The epidural route has been used much more extensively for postoperative pain control. Reasons include popularity of the technique along with, or in combination with, light general anesthesia during surgery; willingness to leave an epidural catheter in place for extended periods to maintain analgesia; familiarity with postoperative analgesia using epidural local anesthetics; and freedom from the risk of post-lumbar puncture headache. Spinal opioid analgesia, or selective analgesia, is produced by modulation of nociceptive transmission at the level of the spinal dorsal horn in the absence of sensory, motor, or sympathetic neural blockade. Segmental analgesia is produced by the epidural administration of local anesthetics and opioid analgesics, in that the extent of analgesia spread is related to the spinal segmental level of administration and the volume and concentration of local anesthetic or opioid administered. Spinal anesthesia used for surgery produces positive respiratory, cardiovascular, and neuroendocrine effects; reduced thromboembolic complications and blood loss; and reduced convalescence. These observations have been extended to postoperative pain management. Patients receiving postoperative epidural morphine have reported superior analgesia, earlier ambulation, fewer pulmonary complications, earlier return of bowel function, and earlier discharge from the hospital than patients receiving IM morphine. In another study, patients were randomized in two groups: The first received general anesthesia and IV opioids for postoperative pain management, and the second group received combined general/epidural anesthesia and epidural opioids for postoperative pain. Mortality rate, overall complication rate, infection rate, time to extubation, and hospital costs were significantly lower in the epidural group. [26]

[27]

Preservative-free morphine was the first opioid to gain approval by the U.S. Food and Drug Administration (FDA) for epidural and intrathecal use. Its duration of action is longer than that of other opioid analgesics as a result of its hydrophilic physiochemical properties. Although experience with morphine has primarily involved intermittent injection, it has been used with success as a continuous infusion. Effective doses may range from less than 0.1 to 1.5 mg per hour. Its early use in relatively large doses was associated with reports of cases of severe and delayed respiratory depression, and this led to exploration of the use of less hydrophilic opioid analgesics, including meperidine, fentanyl, and sufentanil. A lipophilic drug such as fentanyl is useful when rapid onset of epidural analgesia is important. Intermittent epidural boluses of 50 to 75 µg can be used to promptly achieve analgesia in the immediate postoperative period if the initial epidural morphine dose is not adequate. Used as the sole opioid, a 25- to 100-µg epidural bolus can be followed by a continuous infusion of 25 to 100 µg per hour with an accurately calibrated pump. As with other opioids, respiratory depression can occur. Until it is possible to identify and eliminate the factors that occasionally lead to severe respiratory depression in patients receiving intraspinal opioids, it must be assumed that all patients offered these techniques are at risk. To prevent serious injury or death, there is no substitute for a high level of vigilance. A nurse trained to check at frequent intervals the rate and depth of respiration as well as the general status and level of consciousness may provide this level of care. Respiratory rate alone is not an adequate indicator of ventilatory status in postoperative patients receiving epidural opioids. A more global assessment is necessary, particularly during the first 24 hours of treatment. This evaluation should include assessment of the level of consciousness, because increasing sedation (presumably due to central drug effect and CO2 narcosis) has been noted with advanced respiratory depression. [28]

For maximal analgesic effect with minimal drug injection, the epidural catheter should be placed at a spinal cord level corresponding to the dermatomal distribution of the surgical pain stimulus. With the epidural catheter advanced 3 cm to 5 cm beyond the needle tip into the epidural space, the corresponding vertebral levels for optimal epidural catheter placement for various surgical procedures are as follows: • C7–T2 for upper extremity surgery • T4–8 for thoracic surgery • T8–10 for upper abdominal surgery • T10–12 for lower abdominal and pelvic surgery

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• L2–4 for lower extremity surgery As previously stated, the combination of epidurally administered analgesic concentration of local anesthetics and opioid analgesics can be expected to produce the greatest balance of analgesia as well as the fewest postoperative side effects after numerous major surgical procedures. Bupivacaine, in analgesic concentrations up to 0.25%, is the most commonly used local anesthetic agent. Infusions of bupivacaine concentrated greater than 0.125% via lumbar epidural catheter are frequently associated with lower extremity motor blockade. [29]

There is considerable interest in combining the potent analgesic effects of drugs delivered into the epidural space with the pharmacologic and nonpharmacologic advantages of patient participation associated with the PCA concept. All the commonly used opioid analgesics have been used for patient-controlled epidural analgesia (PCEA) alone or in combination with bupivacaine. Some favor the use of the more lipophilic opioid analgesics for PCEA because of the more rapid onset of effect. [30] [31]

Role of the Acute Pain Nurse As a result of advances in pain management techniques and technology, anesthesiologists are now offering patients new and highly effective forms of postoperative analgesia. However, it is the responsibility of trained bedside nurses to deliver these analgesic therapies and to monitor and treat associated adverse effects. Because anesthesiologists generally have limited understanding of ward policies, an acute pain nurse (APN) can serve as an important link between anesthesiologists and bedside nurses. Increasingly, specialist nurses with particular training in pain management are being appointed, frequently as part of an acute pain team or pain management service. They make an invaluable contribution to patient care, bridging the gap between doctors and nurses and their areas of knowledge and responsibility. They can help to direct resources, educate nurses and doctors in pain management techniques, give necessary support to the primary nurse, and help to initiate and supervise analgesia. Some APNs are nurse anesthetists with special training in pain management ( Table 4–2 ).

THE NURSE’S ROLE IN PATIENT EDUCATION Nurses are in a unique position to help patients in pain, because they spend more time with patients than any other health team member does. As new techniques of pain management are developed, nurses must update their knowledge to provide safe and effective care. Many nurses who are already overwhelmed with new techniques and equipment may react with skepticism and resistance to changes in the traditional approaches to pain management. Even if the changes will eventually save nursing time, new techniques or pieces of equipment, such as epidural anesthesia and

TABLE 4-2 -- ORGANIZATION OF ACUTE PAIN SERVICES AT ÖREBRO MEDICAL CENTER HOSPITAL, ÖREBRO, SWEDEN Health Care Member “Pain Representatives”

Responsibility

• Acute pain anesthesiologist

Responsible for coordinating hospital- wide acute pain services and in- service teaching

• Section anesthesiologist

Responsible for pre-, peri- and postoperative care (including postoperative pain) for his/her surgical section

• “Pain representative” ward surgeon

Formally responsible for pain management for his/her surgical ward.

• “Pain representative” day nurse

Responsible for implementation of pain management guidelines and monitoring routines on the ward *

• “Pain representative” night nurse • Acute pain nurse (nurse anesthetist)

• Daily rounds of all surgical wards • Check visual analogue scale (VAS) recording on charts (every patient VAS≤3) • “Trouble-shoot” technical problems (PCA, epidural) • Refer problem patients to section anesthesiologist (link between surgical ward and anesthesiologist) • Daily “bedside” teaching of ward nurses

This organization benefits about 20,000 patients a year (VAS≤3) and has been functioning satisfactorily since 1991. Cost per patient is U.S. $2 to

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TABLE 4-2 -- ORGANIZATION OF ACUTE PAIN SERVICES AT ÖREBRO MEDICAL CENTER HOSPITAL, ÖREBRO, SWEDEN Health Care Member “Pain Representatives”

Responsibility

$3 (excluding drug and equipment costs). * Patients are treated on the basis of standard orders and protocols devel oped jointly by chiefs of anesthesiology, surgery, and nursing sections. Pain representatives meet every 3 months to discuss and implement improvements in surgical ward pain management routines.

PCA, are stressful for the staff nurses until they become familiar with them. Background knowledge, skills, and experience of nursing staff influence pain management. Many responsibilities for pain management rest with the nurse who cares directly for the patient; however, many nurses have, in fact, had little formal education on the subject of pain management. The nurse on the ward must be informed of the requirements of an analgesic technique and confident about putting them into practice. This proficiency can be achieved through education and experience in a supportive environment. Protocols should be constructed in conjunction with nursing colleagues and modified as necessary to allow for local nursing practices. Nursing education is widely recognized as an important priority in pain management. Postgraduate training courses on pain management for practicing nurses are increasingly available, and education on pain management is becoming more prominent in basic nursing training. Educational devices such as algorithms to guide analgesic administration can lead to substantial improvements in quality of pain relief. The attitude of the staff toward pain management has an important influence on the effectiveness of pain relief. The APS is best served by developing a small range of standard analgesic techniques to achieve a common level of understanding, familiarity, and confidence. [1]

[2]

Patients are unlikely to be aware of the standard of care they can expect to receive or what they can demand, and their attitudes toward pain and analgesia are believed to influence strongly the effectiveness of their pain relief. Inadequate patient education is associated with a low standard of postoperative pain relief. Patient education is particularly important when drugs are administered by techniques such as PCA. [32]

It is essential that pain be made visible. Pain should be routinely documented in the patient’s notes in a manner similar to that used to record blood pressure and heart rate. This process should be simple and convenient for nursing and medical staff. Documentation also provides data for audit and facilitates review and improvement of care.

AUDIT OF THE ACUTE PAIN SERVICE An audit should be carried out regularly with regard to the process of pain management, patient experience, and cost; the service should be modified according to the outcome. It is essential that pain be regularly evaluated to ensure that it is effectively managed. The minimum standard should be at least an annual determination of the number of patients whose pain scores were above the predetermined threshold, and the reasons for the elevated scores should be identified. The audit method should be developed to meet local conditions. The outcome of an audit should be reviewed regularly, and the service should be modified to rectify any shortfalls identified. Adverse effects of treatment should also be assessed and documented, and the dose or dose interval should be adjusted accordingly.

ACUTE PAIN SERVICE IN THE UNITED STATES Although the concept of the APS was first introduced in Europe, the APS seems to be better established in the United States. Most major institutions in the United States have an anesthesiology-based APS. The comprehensive pain management teams usually consist of staff and resident anesthesiologists, specially trained nurses, pharmacists, and physiotherapists. Sometimes, biomedical and infusion pump dispensing personnel are included. Secretarial and billing personnel are also a part of the APS in the United States. Patients under the care of an APS are visited and assessed regularly by members of the team. Although pain management is often very satisfactory, the economic costs of such [33]

[34]

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services are high; therefore, the benefits are not available to all surgical patients because of reimbursement regulations. Anesthesiologist-based APS organization models usually provide high technology pain management services. This approach is not surprising because anesthesiologists have special expertise in the field of advanced analgesic techniques such as epidural anesthesia and PCA. Therefore, most APSs in the United States are essentially PCA and epidural services. Although the implementation of an anesthesiologist-based APS has had a considerable impact on pain management on surgical wards, only a small percentage of patients receive the benefits of an APS. A good APS organization is one that ensures optimal pain management for every patient who undergoes surgery, including children and those undergoing surgery on an ambulatory basis. Furthermore, the record of the U.S. APS in implementing hospital-wide quality assurance measures such as frequent recording of pain intensity and recording of treatment efficacy (visual analogue scale [VAS] before and after treatment) has been generally unimpressive so far. Additionally, the costs of a U.S. APS are very high. It is not surprising that such costs are being increasingly questioned by healthcare payers. Downsizing of many APSs is taking place in the United States; further reductions are predicted by many. The fee-for-service reimbursement system seems to be reversing the gains made by the introduction of the APS. A more important issue with U.S. anesthesiologist-based APS is a lack of continuity, because the anesthesiologist performing the preoperative evaluation (which includes patient information about the proposed postoperative analgesic technique) and epidural block (operating room anesthesiologist) is not the same physician who provides pain management postoperatively (APS anesthesiologist). The role of an anesthesiologist in any APS model is pivotal. However, in my opinion, such a role is professionally more satisfying as a teacher, supervisor, pain expert, and performer of regional blocks in a APN-based anesthesiologist-supervised model.

DEVELOPMENT OF AN ACUTE PAIN NURSE SERVICE It is becoming increasingly clear that simpler and less expensive models must be developed if the aim is to improve the quality of postoperative analgesia for every patient who undergoes surgery. The organization should also include patients who undergo outpatient surgery. Furthermore, in countries with state-financed health services and budgetary restraints, the overstaffed U.S.-style anesthesiology-based comprehensive, multidisciplinary, postoperative pain control teams appear unrealistic for most institutions. At Örebro Medical Center Hospital, our pain nurse-based, anesthesiologist-supervised model is based on the concept that postoperative pain relief can be greatly improved by provision of inservice training for surgical nursing staff, optimal use of systemic opioids, and the use of regional analgesia techniques and PCA in selected patients. Regular recording of each patient’s pain intensity by VAS every 3 hours and recording of treatment efficacy on the vital signs chart form the cornerstone of this model. A VAS higher than 3 is promptly treated. Participation by the surgeon and ward nurse is crucial in this organization. A specially trained APN makes daily rounds of all surgery departments. The APN’s duties are described in Table 4–2 . In this organization, the treatment of individual patients is based on standard orders and protocols developed jointly by the section anesthesiologist, the surgeon, and the ward nurse. This approach gives nurses the flexibility to administer analgesics when necessary. The section anesthesiologist has the overall responsibility for preoperative, perioperative, and postoperative anesthesia care of these patients; this responsibility includes postoperative pain management. The anesthesiologist selects the patients for special pain therapies, such as PCA and epidural or peripheral nerve blocks, based on departmental policy. During regular working hours, this anesthesiologist is available for consultation or any emergency; during other shifts, the anesthesiologist on call has the same function. The “pain representatives” from each surgical ward meet four times a year under anesthesiologist and APN supervision to discuss improvements in APS. In the organization described here, the only additional cost is that of the APN. At our hospital, where about 18,000 to 20,000 surgical procedures are performed each year, our low-cost ($2 to $3 per patient excluding drug and equipment costs) organization is designed to benefit all these patients. This organization has been functioning satisfactorily since 1991; it can easily be modified for nonsurgical wards. The safety of newer techniques such as PCA, peripheral nerve blocks, and epidural analgesia on surgical wards is dependent on nurse and physician education. An independent audit in 1996 showed that 95% of the surgical patients were satisfied with their postoperative pain management. [35]

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Challenges for the Future The need for multidisciplinary APS teams involving anesthesiologists, surgeons, nurses, and other staff to optimize postoperative pain management is not in doubt. An APS addresses important issues such as improvement in quality of analgesia and efficacy and safety of (current and future) analgesic techniques. Any future APS organization will have to include the following: Regular pain assessment and documentation (“make pain visible”); outpatients and children; active cooperation with surgeons and ward nurses for development of protocols; and bedside teaching of ward nurses for provision of safe and cost-effective analgesic techniques such as PCA and epidural and peripheral nerve blocks. These components are relatively noncontroversial; the challenge is to incorporate them in an APS model that exploits the full potential of invasive and expensive techniques such as epidermal anesthesia for aggressive postoperative patient mobilization, which can be expected to improve outcome. The current system of acute pain management often does not integrate pain management with the overall perioperative care and postoperative rehabilitation of the patient. The role of cooperation and a team approach featuring interaction among anesthesiologists, APNs, surgeons, ward nurses, and physiotherapists will become increasingly important. The role of a good APS in developing cost-effective pain treatment strategies for different surgical procedures cannot be overemphasized. A designated staff member should be responsible for implementing pain management policies in each unit. Patients should be fully informed preoperatively about the range of treatments available and their adverse effects. Patients undergoing outpatient surgery should have their pain assessed and documented in the same way as inpatients. Outpatients should be given a contact number so that they can discuss their pain relief needs after discharge and review written information about the use of analgesics.

Summary In spite of unprecedented interest in understanding pain mechanisms and pain management, a significant number of patients continue to experience unacceptable levels of pain after surgery. Surveys show that there has been no apparent improvement since the first study in 1952. It is increasingly clear that the solution to the problems of postoperative pain management will be found not so much in the development of new techniques but in the development of an organization to exploit existing expertise. [36]

The most obvious members of an acute pain team are anesthesiologists, surgeons, nurses, and physiotherapists. Protocols encourage consistent standards of safe and effective care and should be used as a framework to individualize treatment. The concept of skilled pain therapists collaborating to provide improved postoperative analgesia within the framework of an organized APS appears to be universally applicable. APS models have been described from the United States, the United Kingdom, Germany, Switzerland, and Sweden. The U.S. model, which consists of anesthesiologist-based comprehensive pain management teams, is quite effective but too selective and too expensive. It is not transferable to Europe. A recent U.K. survey showed that there is a large degree of variation in what is thought to constitute an APS in the United Kingdom. A nurse-based, anesthesiologist-supervised APS in which pain is evaluated in every patient who undergoes surgery has been developed in Sweden. Pain higher than 3 on the 10-grade VAS is promptly treated. Clearly, neither the anesthesiologist nor the APN guarantees good pain management on wards; the quality of ward nursing is most important. In this low-cost model, the anesthesiologist’s role is teaching and training ward nurses, supervising the APN, and selecting patients for special pain therapies such as PCA and epidural and peripheral nerve blocks. All senior anesthesiologists (section chiefs) working in the operating room are part of this APS. [37]

The means of providing satisfactory analgesia are already present in most hospitals. Careful planning and a multidisciplinary approach to pain management will ensure that resources are optimally used and that the quality of pain management is consistently maintained. REFERENCES 1. Gould TH, Crosby DL, Harmer M, et al: Policy for controlling pain after surgery: Effect of sequential changes in management. BMJ 305:1165– 1166, 1992. 2. Oats

JDL, Snowman SL, Jason DWH: Failure of pain relief after surgery. Attitudes of ward staff and patients to postoperative analgesia. Anesthesia 49:755–758, 1994.

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3. Warbled

CA, Kahn CH: Acute pain management. Programs in US hospitals and experiences and attitudes among US adults. Anesthesiology 83:1090–1094, 1995.

4. Tittle M, McMillan SC: Pain and pain-related side effects in an ICU and on a surgical unit: Nurses’ management. Am J Crit Care 3:25–30, 1994. 5. Ulf

H, Neugebauer E, Maier C: Die Behandlung akuter perioperativer und posttraumatischer Schmerzen. Empfehlungen einer interdisziplinaeren Expertenkommission. Stuttgart, G. Thieme, 1997.

6. Rawal

N, Allvin R, EuroPain Acute Pain Working Party: Acute pain services in Europe: A 17-nation survey of 105 hospitals. Eur J Anaesth 15:354–363, 1998.

7. Royal

College of Surgeons of England and the College of Anaesthetists Commission on the Provision of Surgical Services: Report of the Working Party on Pain after Surgery. London, September 1990.

8. National

Health and Medical Research Council (Australia): Management of Severe Pain. Canberra, Australia, NHMRC, 1988.

9. U.S.

Department of Health and Human Services: Acute Pain Management. Clinical Practice Guidelines. AHCPR Publications No 92-0032. Washington, DC, U.S. Department of Health and Human Services, 1992.

10. International

Association for the Study of Pain (IASP): Management of Acute Pain. A Practical Guide. Task Force on Acute Pain. Seattle, IASP Publications, 1992.

11. Joris

J: Efficacy of nonsteroidal anti-inflammatory drugs in postoperative pain. Acta Anaesthesiol Belg 47:115–123, 1996.

12. Piguet

V, Desmeules J, Dayer P: Lack of acetaminophen ceiling effect on R-III nociceptive flexion reflex. Eur J Clin Pharmacol 53:321–324,

1998. 13. Pelissier

T, Alloui A, Caussade F: Paracetamol exerts a spinal antinociceptive effect involving an indirect interaction with 5hydroxytryptamine-3 receptors: In vivo and in vitro evidence. J Pharmacol Exp Ther 278:8–14, 1996.

14.

Raffa RB, Codd EE: Lack of binding of acetaminophen to 5-HT receptor or uptake sites. Life Sci 59:L37–L40, 1996.

15. Bjorkman R: Central antinociceptive effects of non-steroidal antiinflammatory drugs and paracetamol: Experimental studies in the rat. Acta Anaesthesiol Scand 103(Suppl):1–144, 1995. 16. Honer P, Buritova, J Besson JM: Aspirin and acetaminophen reduced both Fos expression in rat lumbar spinal cord and inflammatory sign produced by carrageenan inflammation. Pain 63:365–375, 1995. 17. Mather LE: Do the pharmacodynamics of the nonsteroidal antiinflammatory drugs suggest a role in the management of postoperative pain? Drugs 44(Suppl 5):1–12, 1998. 18. Reuben SS, Connelly NR, Lurie S, et al: Dose-response of ketorolac as an adjunct to patient controlled analgesia morphine in patients after spinal fusion surgery. Anesth Analg 87:98–102, 1998. 19. Peduto VA, Ballabio M, Stefanini S: Efficacy of propacetamol in the treatment of postoperative pain: Morphine-sparing effect in orthopedic surgery. Italian Collaborative Group on Propacetamol. Acta Anaesthesiol Scand 42:293–298, 1998. 20. Varrassi G, Marinangeli F, Agro F, et al: A double blind evaluation of propacetamol versus ketorolac in combination with patient controlled analgesia morphine: Analgesic efficacy and tolerability after gynecologic surgery. Anesth Analg 88:611–616, 1999. 21. White WD, Pearce DJ, Norman J: Postoperative analgesia: A comparison of intravenous on-demand fentanyl with epidural bupivacaine. BMJ 2:166, 1979. 22. Tamsen A, Hartvig P, Fagerlund C: Patient-controlled analgesic therapy: Clinical experience. Acta Anaesthesiol Scand 26(suppl 74):157, 1982. 23. Plummer JL, Owen H, Ilsley AH, et al: Morphine patient-controlled analgesia is superior to meperidine patient-controlled analgesia for postoperative pain. Anesth Analg 84:794-799, 1997. 24. Owen H, Plummer JL, Armstrong I, et al: Variables of patient-controlled analgesia: 1. Bolus size. Anaesthesia 44:7–10, 1989. 25. Classen DC, Pestotnik SL, Evans RS, et al: Adverse drug events in hospitalized patients: Excess length of stay, extra costs, and attributable mortality. JAMA 277:301–306, 1997. 26. Rawal N, Sjostrand U, Christofferson E, et al: Comparison of intramuscular and epidural morphine for postoperative analgesia in the grossly obese: Influence on postoperative ambulation and pulmonary function. Anesth Analg 63:583, 1984. 27. Yeager MP, Glass DD, Neff RK, et al: Epidural anesthesia and analgesia in high risk surgical patients. Anesthesiology 66:729, 1987. 28. Rawal N, Wattwil M: Respiratory depression after epidural morphine—an experimental and clinical study. Anesth Analg 63:8, 1984. 29. Liu SS, Carpenter RL, Mackey DC, et al: Effects of perioperative analgesic technique on rate of recovery after colon surgery. Anesthesiology

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83:757–765, 1995. 30. Veercauteren MP, Van Den Bergh L, Kartawiadi SL, et al: Addition of bupivacaine to sufentanil in patient-controlled analgesia after lower limb surgery in young adults. Reg Anesth Pain Med 23:182–188, 1998. 31. Liu SS, Allen HW, Olsson GL: Patient-controlled epidural analgesia with bupivacaine and fentanyl on hospital wards: Prospective experience with 1,030 surgical patients. Anesthesiology 88:124–129, 1998. 32. Kuhn S, Cooke K, Collins M, et al: Perceptions of pain relief after surgery. BMJ:300:1687–1690, 1990. 33. Maier C, Kibbel K, Mercker S, Wulf H: Postoperative pain therapy at general nursing stations. An analysis of eight year’s experience at an anesthesiological acute pain service. Anaesthesist:43:385–397, 1994. 34. Ready LB: How many acute pain services are there in the US and who is managing patient-controlled analgesia? (Letter) Anesthesiology:82:322, 1995. 35. Rawal N, Berggren L: Organization of acute pain services—a low cost model. Pain:57:117–123, 1994. 36. Papper EM, Brodie BB, Rovenstine EA: Postoperative pain, its use in the comparative evaluation of analgesics. Surgery 32:107–109, 1952. 37. Windsor AM, Glynn CJ, Mason DG: National provision of acute pain services. Anaesthesia:51:228–231, 1996.

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Chapter 5 - Organization of Chronic Pain Services RICARDO RUIZ-LÓPEZ DIEGO BELTRUTTI

Since the initial organization of pain centers carried out in the 1960s by J. J. Bonica in the United States, S. Lipton in the United Kingdom, and a few other specialists in Western countries, the enormous necessity of this type of health service has become clear, along with the difficulty of its comprehensive organizational approach in order to be effective for the diagnosis and therapy of this patient population. [1] [2] [3] [4]

The foundation in 1974 of the International Association for the Study of Pain (IASP) strengthened the development of pain facilities in the United States and around the world. Consequently, in response to the proliferation of pain centers during the last 2 decades, various medical associations have defined and classified the types of such facilities. [5] [6] [7]

According to the scope of the therapeutic approach, pain centers can be classified into three models: 1. 2. 3.

Pain centers following the medical model, in which pain is treated as a symptom of a disease to be diagnosed Pain centers working with the behavioral model, in which pain behavior and associated impaired function are considered as important as the underlying pathophysiology Pain centers with a predominant focus on the cognitive-behavioral model, in which patients are considered to develop aberrant convictions in regard to their functional capacities and prognoses [8]

Today, particularly in Europe and Australasia, chronic pain conditions are treated by a combination of intervention and the behavioral-rehabilitation model, as reports of the efficacy of cognitive-behavioral programs for the treatment of chronic pain conditions have shown variable outcomes in comparison with the selection criteria of interventional approaches, which are better defined. [9] [10] [11] [12] [13]

In the United States, all three models have been established during the past three decades, although recent changes introduced in managed healthcare have modified in many cases the approach of preexisting pain facilities. This chapter will cover the following topics: • Pain treatment facilities • Pain medicine as a new specialty • Administrative issues Appendixes with related recommendations can be found at the end of the chapter.

Pain Treatment Facilities Pain treatment facilities were established to treat chronic, refractory pain related to conventional medical, surgical, and rehabilitative modalities. Multidisciplinary pain centers were developed to treat specifically a group of patients mainly suffering from chronic back pain that did not improve with conventional treatment, causing them to remain disabled. These patients showed, in addition to the existence of chronic pain, behavioral and psychosocial impairment that required the intervention of a multidisciplinary team approach that would deal with the patient’s problem simultaneously. Regardless of the therapeutic approach, the lack of regulation of pain centers and the various clinical structures that used the term indiscriminately forced the American Society of Anesthesiology (ASA) and the IASP to classify the different pain facilities according to their professional composition, modalities of treatment, organization, pain conditions being treated, clinical or basic research, and teaching potential. Thus, the ASA classifies pain centers into four types : [6]

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Major comprehensive pain centers Comprehensive pain centers Modality-oriented pain clinics Syndrome-oriented pain clinics

Overall, it is important to note that the function and organization of these pain centers rely greatly on the training, beliefs, expertise, and specialty of the director; the composition of the staff; and the type of institution. [1]

The variation in staff makeup and available therapeutic modalities has caused both physicians and the public to have misinformation about differences among the pain syndromes and the types of pain centers or clinics. Another step in the process of defining chronic pain services was reached by the Commission on Accreditation of Rehabilitation Facilities (CARF) with the establishment of a certification process for pain clinics for one type of treatment model (i.e., chronic pain management programs). [10] [14]

Because of this lack of definition, the IASP established guidelines and characteristics for four types of pain treatment facilities ( Table 5-1 , Appendix 5-1 ). [15]

This classification makes a clear distinction between the multidisciplinary pain centers and clinics (MPC) and those facilities without multidisciplinary orientation. The only difference between the multidisciplinary pain centers and multidisciplinary pain clinics is that the former have to develop research and teaching activities. Nevertheless, both types of centers must provide inpatient and outpatient treatment, and the teams must contain diversified staff members, including more than one physician specialty and a psychologist or psychiatrist.

TABLE 5-1 -- INTERNATIONAL ASSOCIATION FOR THE STUDY OF PAIN CLASSIFICATION OF PAIN FACILITIES Modality-oriented clinic Provides specific type of treatment (e.g., nerve blocks, transcutaneous nerve stimulation, acupuncture, biofeedback) May have one or more healthcare disciplines Does not provide an integrated, comprehensive approach Pain clinic Focuses on the diagnosis and management of patients with chronic pain or may specialize in specific diagnoses or pain related to a specific region of the body Does not provide comprehensive assessment or treatment Institution offering appropriate consultative and therapeutic services would qualify but never an isolated solo practitioner. Multidisciplinary pain clinic Specializes in the multidisciplinary diagnosis and management of patients with chronic pain or may specialize in specific diagnoses or pain related to a specific region of the body Staffed by physicians of different specialties and other healthcare providers Differs from a multidisciplinary pain center only because it does not include research and teaching Multidisciplinary pain center Organization of healthcare professionals and basic scientists that includes research, teaching, and patient care in acute and chronic pain Typically a component of a medical school or a teaching hospital Clinical programs supervised by an appropriately trained and licensed director Staffed by a minimum of physician, psychologist, occupational therapist, physical therapist, and registered nurse Services provide integrated care based on interdisciplinary assessment and management Offers both inpatient and outpatient programs Adapted from Loeser JD: Desirable characteristics for pain treatment facilities: Report of the IASP taskforce. In Bond MR, Charlton JE, Woof CJ (eds): Pain Research and Clinical Management, vol. 4. 1991, pp. 411–415.

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Pain Medicine: A New Specialty Scientific inquiry into the anatomy and physiology of pain perception increased, and with the discovery of opiate receptors in animal and human tissues, the actions of peptides on endogenous opioid receptors, the development of new therapies for the alleviation of pain, and the classification and description of chronic pain syndromes, some essential pieces were added that support modern pain therapy. [16] [17] [18]

The emerging specialty of pain medicine has been increasingly recognized over the last 2 decades by medical organizations, regulatory agencies, and third-party payers. This specialty is formed by a distinct and unique body of knowledge and a defined clinical application that supports a clinical practice. Moreover, pain medicine has fostered growth of scholarly knowledge and research and fills a recognized gap in health professional training ( Table 5-2 ). In its official policy statement, the American Academy of Pain Medicine (AAPM) defines pain medicine as follows:

The specialty of pain medicine is concerned with the prevention, evaluation, diagnosis, treatment, and rehabilitation of painful disorders. Such disorders may have pain and associated symptoms arising from a discrete cause, such as postoperative pain or pain associated with a malignancy, or may be syndromes in which pain constitutes the primary problem, such as neuropathic pains or headaches. The diagnosis of painful syndromes relies on interpretation of historical data; review of previous laboratory, imaging, and electro-diagnostic studies; behavioral, social, occupational, and avocational assessment; interview and examination by the pain specialist; and may require specialized diagnostic procedures, including central and peripheral neural blockade or monitored drug infusions. The special needs of the pediatric and geriatric populations are considered when formulating a comprehensive treatment plan for these patients. The pain physician serves as a consultant to other physicians, but is often the principal treating physician and may provide care at various levels, such as direct treatment, prescribing medication, prescribing rehabilitative services, performing pain-relieving procedures, counseling of patients and families, (directing a) multidisciplinary team, (coordinating) care with other healthcare providers, and (providing) consultative services to public and private agencies pursuant to optimal healthcare delivery to the patient suffering from a painful disorder. The pain physician may work in a variety of settings and is competent to treat the entire range of painful disorders encountered in the delivery of quality healthcare.

However, the official establishment of pain medicine as a medical specialty needs a process of accreditation that could be obtained, as in other specialties, through any of several, well-defined medical boards. Until now, in the United States only one medical association—the American Board of Pain Medicine

TABLE 5-2 -- PAIN MEDICINE: OPERATIONAL CRITERIA A distinct and unique body of knowledge as evidenced by texts and journals; clinical applicability sufficient to support a clinical practice Ability to generate scholarly knowledge and support research Ability to meet numerical standards for training programs, trainees, and practicing diplomats De facto recognition as clear subject area by governmental bodies (e.g., NIH, NCI, AHCPR) and nongovernmental organizations (e.g., WHO, IASP, AAPM, APS, WIP) Fills a recognized gap in health professional training Adapted from Carr DB, Aronoff GM: The future of pain management. In Aronoff GM (ed): Evaluation and Treatment of Chronic Pain, 3rd ed. Baltimore, Williams & Wilkins, 1998. AAPM, American Academy of Pain Medicine; AHCPR, Agency for Health Care Policy; APS, acute pain service; IASP, International Association for the Study of Pain; NCI, National Cancer Institute; NIH, National Institutes of Health; WIP, World Institute of Pain, WHO, World Health Organization.

(ABPM), recognized by the American Medical Association—offers training and accreditation in pain medicine

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through rigorous procedures. The ABPM has been granted full recognition in California by the American Board of Medical Specialties. In Europe, the situation differs because there is no medical association that links the numerous countries through the territory, and the lack of homogeneous legislation represents a practical barrier for the recognition of any new medical specialty. Only a few exceptions to this situation exist, such as in Turkey, where there has been official recognition of treatment of pain as a medical specialty since 1993, with specific resources for training, research, education, and clinical practice throughout the country. In the rest of the world, academic regulatory obstacles and paucity of resources limit the process of accreditation and the recognition of this specialty. In an effort to strengthen a world initiative in the process of education and training of physicians interested or involved in pain medicine, the World Institute of Pain (WIP), an international association of pain centers founded in 1994, defines different goals that meet a common interest for pain physicians: 1. 2. 3. 4. 5. 6. 7.

Educate and train personnel of member pain centers, including local hands-on training, international seminars, and exchange of clinicians. Update pain centers with state of the art pain information, including a newsletter, scientific seminars, interlinked telecommunications, and publication of a journal and books. Develop common protocols for efficacy and outcome studies. Communicate administrative and patient-related matters on a regular basis by way of a newsletter, a telephone hookup, a world directory of pain centers (region by region), and video conferencing (including patient consultation). Categorize and credential pain centers by mail correspondence, local information, and the industry’s medical representatives. Develop an examination process for pain centers to test trainees and provide information about the examination process. Encourage interested industrial parties to provide information on pain medicine to each region of the world; bring local pain physicians into contact with industry for education about new techniques and training in their use; and formulate a fellowship training program.

Despite the fact that pain clinicians are treating chronic pain on a daily basis, education on pain is absent at the various levels of the medical career, whether at medical schools or at postgraduate levels. Formal education and training are essential so that fellowship programs can be set up to precede the establishment of full residency programs in pain medicine. Residency programs should include specific training in the different areas involved in the field, including surgical training for interventional procedures and education in the important fields related to management of chronic pain and cancer pain, such as psychology, oncology, and symptomatic relief. Many issues and questions remain to be answered or resolved by the scientific community. These include but are not limited to such areas as the epidemiologic figures on chronic pain, whether associated with disability or not; the existence of pain in degenerative syndromes and in advanced incurable diseases; the predisposing factors for suffering pain; the neuromatrix of pain transmission and modulation; the role of the autonomic nervous system in the neurophysiology of pain; the development of more selective drugs for central and peripheral nervous system action; the role of affectivity and the psychological processes that are involved in the perception of pain and suffering; the development of more selective and minimally invasive techniques for pain control; the improvement in understanding the maturation and aging of the nervous system; and the measurement, assessment, and validation of pain. Finally, some attention is due to the administrative issues burdening the clinical practice of pain medicine, because many difficulties have appeared that complement the above-mentioned situations.

Administrative Issues The increasing public demand on healthcare services is rapidly changing the shape and characteristics of pain facilities, much as in other medical specialties in which providers of healthcare services are at the crossroads between pressure exerted by consumers and the managed care rules. [19]

Patients have acquired an enormous amount of information through the media; specifically, the Internet is becoming the most popular means of information gathering. In addition, the public has a growing skepticism about the

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traditional sources of medical information. Chronic pain patients are a very vulnerable population with a large percentage of malpractice victims. Many of them in desperation look for relief by trying pseudoscientific approaches, typically by self-referral. In that scenario, demystification of medicine through health education that provides accurate information to patients and families is a principal goal of the pain physician. The lack of understanding by the patient of the diagnostic evaluation, treatment modalities, and prognosis contributes to confusion among patients and health providers. Healthcare systems have finite resources; that is, the innovations in pain management are viewed quite favorably by insurers and policy makers who see potential cost savings in a patient’s rapid return to normal function after surgery or in home care rather than hospital care for a patient with a chronic or terminal illness. [20]

Several Western countries, including the United Kingdom, Canada, and Australia, require economic justification for approval of any new drug, and there is an increasing trend to apply these criteria to clinical trials by means of cost analyses through diverse perspectives. Extrapolating this concept to the area of pain management, studies should be developed in terms of cost-benefit analysis of therapies and their cost-effectiveness and cost of use, in which benefit is defined in terms of quality of life. [21] [22]

However, findings that can be applied to many medical disciplines in regard to managed care seem to be distorted in the environment of patients with chronic and complex illnesses. These persons often require advanced comprehensive care services, well beyond what the primary care physician can generally provide. Such patients often require well-trained subspecialists or referral to complex comprehensive systems of care. The cost of such services is often far beyond the customary cost, and only by assuming the challenge of normalization and accreditation of health services can pain medicine survive. [23] [24]

Pain physicians must be aware that there is a need for moving away from treatment algorithms to a strategy based on levels of care. REFERENCES 1. Bonica JJ: Evolution of pain programs. In GM Aronoff (ed): Pain Centers: A Revolution in Health Care. New York, Raven Press, 1988, pp 9– 32. 2. Crue BL, Pinsky JJ: Chronic pain syndrome: Four aspects of the problem. In Ng LKY (ed): New Approaches to the Treatment of Chronic Pain: A Review of Multidisciplinary Pain Clinics and Pain Centers. Rockville, Md: National Institutes of Drug Abuse, 1981, pp 137–168. 3. Seres

JL, Newman RI: Results of treatment of chronic low-back pain at the Portland Pain Center. J Neurosurg 45:32–36, 1976.

4. Rosomoff

HL, Rosomoff RS: Comprehensive multidsciplinary pain center approach of the treatment of low back pain. Neurosurg Clin North Am 2:877–890, 1991.

5. Brena

SF: Pain control facilities: Patterns of operation and problems of organization in the USA. Clin Anesth 3:183–195, 1985.

6. Modell

J: Directory of Pain Clinics. Oak Ridge, Ill, American Society of Anesthesiologists, 1977.

7. Curron

H: International Directory of Pain Centers/Clinics. Oak Ridge, Ill, The American Society of Anesthesiologists, 1979.

8. Long

DM: The Development of the Comprehensive Pain Treatment Program at Johns Hopkins. In Cohen MJM, Campbell JN (eds): Pain Treatment Centers at a Crossroads: A Practical and Conceptual Reappraisal. Seattle, IASP Press, 1996.

9. Flor

H, Fydrich T, Turk DC: Efficacy of multidisciplinary pain treatment centers: A meta-analytic review. Pain 49:221–230, 1992.

10. Aronoff 11. Wells 12. Turk

GM, Evans WO, Enders PL: A review of follow-up studies of multidisciplinary pain units. Pain 16:1–11, 1982.

JCD, Miles JB: Pain clinics and pain clinic treatment. Br Med Bull 47:762–785, 1991.

DC, Rudy TE, Sorkin BA: Neglected topics in chronic pain treatment outcomes studies: Determination of success. Pain 53:3–16, 1993.

13. Sanders

SH, Brena SF: Pain management program in the United States: A problem of image and credibility. Focus Pain 1:3, 1993.

14. Commission

on Accreditation of Rehabilitation Facilities: Program evaluation in chronic pain management programs. Tucson, CARF, 1987.

15. International Association for the Study of Pain: Desirable characteristics for pain treatment facilities and standards for physician fellowship in pain management. Seattle, IASP, 1990. 16. Ghia

JN: Development and organization of pain centers. In Raj PP (ed): Practical Management of Pain, 2nd ed. St. Louis, Mosby, 1992, pp

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16–39. 17. Schwartz

DP: Appropriate referral to inpatient vs. outpatient pain management programs: A cliniciaňs guide, Pain Dig 1:2–6, 1991.

18. Merskey H, Bogduk N (eds): Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definition of Pain Terms, 2nd ed. Seattle, IASP Press, 1994. 19. King

RB, Moore B: Managed care: Past, present and future. Arch Neurol 53:851–855, 1996.

20. Carr

DB, Aronoff GM: The future of pain management. In Aronoff GM (ed): Evaluation and Treatment of Chronic Pain. Baltimore, William & Wilkins, 1998.

21. Bootman

LJ, Townsend RJ, McGhan WF (eds): Principles of pharmaeconomics, 2nd ed. Cincinnati, Whitney, 1995.

22. Ruiz-López

R: Continuous care of cancer pain patients. In Aronoff GM (ed): Evaluation and Treatment of Chronic Pain, 3rd ed. Baltimore, Williams & Wilkins, 1998.

23. http://www.jcaho.org/standard/pm_npfrm.html 24. Chapman

CR: New JCAHO standards for pain management: Carpe diem! APS Bull 10:2–3, July/Aug 2000.

APPENDIX 1: Desirable Characteristics of Pain Treatment Facilities

[15]

DEFINITION OF TERMS The following terms are defined briefly in this section; a more complete description of the characteristics of each type of facility appears in subsequent portions of this chapter. 1. 2.

3.

4.

5.

Pain Treatment Facility. This generic term is used to describe all forms of pain treatment facilities without regard to personnel involved or types of patients served. Pain unit is a synonym for pain treatment facility. Multidisciplinary Pain Center. This organization of healthcare professionals and basic scientists includes research, teaching, and patient care related to acute and chronic pain. This type of center is the largest and most complex of the pain treatment facilities and ideally would exist as a component of a medical school or teaching hospital. Clinical programs must be supervised by an appropriately trained and licensed clinical director. A wide array of healthcare specialists is required, such as physicians, psychologists, nurses, physical therapists, occupational therapists, vocational counselors, social workers, and other specialized healthcare providers. The range of disciplines required of healthcare providers is a function of the varieties of patients seen and the healthcare resources of the community. The members of the treatment team must communicate with each other on a regular basis, both about specific patients and about overall development. Healthcare services in a multidisciplinary pain clinic must be integrated and based upon multidisciplinary assessment and management of the patient. Inpatient and outpatient programs are offered in such a facility. Multidisciplinary Pain Clinic. This healthcare delivery facility is staffed by physicians of different specialties and other nonphysician healthcare providers who specialize in the diagnosis and management of patients with chronic pain. This type of facility differs from a multidisciplinary pain center only because it does not include research and teaching activities in its regular programs. A multidisciplinary pain clinic may have diagnostic and treatment facilities to serve outpatients, inpatients, or both groups. Pain Clinic. This clinic is a healthcare delivery facility that focuses on the diagnosis and management of patients with chronic pain. A pain clinic may specialize in specific diagnoses or in pains related to a specific region of the body. A pain clinic may be large or small, but it should never be a label for a solo practitioner. A single physician functioning within a complex healthcare institution that offers appropriate consultative and therapeutic services could qualify as a pain clinic if chronic pain patients were suitably assessed and managed. The absence of interdisciplinary assessment and management distinguishes this type of facility from a multidisciplinary pain center or clinic. Pain clinics can, and should be encouraged to, carry out research, but it is not a required characteristic of this type of facility. Modality-Oriented Clinic. This healthcare facility offers a specific type of treatment and does not provide comprehensive assessment or management. Examples include nerve block clinic, transcutaneous nerve stimulation clinic, acupuncture clinic, and biofeedback clinic. Such a facility may have one or more healthcare providers with different professional training; because of its limited treatment options and the lack of an integrated, comprehensive approach, it does not qualify for the term “multidisciplinary.”

DESIRABLE CHARACTERISTICS OF A MULTIDISCIPLINARY PAIN CENTER

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6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.

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A multidisciplinary pain center (MPC) should have on its staff a variety of healthcare providers capable of assessing and treating physical, psychosocial, medical, vocational, and social aspects of chronic pain. These therapists work with occupational therapists, vocational counselors, social workers, and any other type of healthcare professional who can make a contribution to patient diagnosis or treatment. At least three medical specialties should be represented on the staff of a multidisciplinary pain center. If one of the physicians is not a psychiatrist, physicians from two specialties and a clinical psychologist are the minimum required. An MPC must be able to assess and treat both the physical and the psychosocial aspects of a patient’s complaints. The need for other types of healthcare providers should be determined on the basis of the population served by the MPC. The healthcare professionals should communicate with each other on a regular basis both about individual patients and about the programs offered in the pain treatment facility. There should be a director or coordinator of the MPC. He or she need not be a physician, but if not, there should be a director of medical services who is responsible for monitoring the medical services provided. The MPC should offer diagnostic and therapeutic services that include medication management, referral for appropriate medical consultation, review of prior medical records and diagnostic tests, physical examination, psychological assessment and treatment, physical therapy, vocational assessment and counseling, and other services as appropriate. The MPC should have a designated space for its activities. The MPC should include facilities for inpatient and outpatient services. The MPC should maintain records on its patients so as to be able to assess individual treatment outcomes and to evaluate overall program effectiveness. The MPC should have adequate support staff to carry out its activities. Healthcare providers active in an MPC should have appropriate knowledge of both the basic sciences and clinical practices relevant to chronic pain patients. The MPC should have a medically trained professional available to deal with patient referrals and emergencies. All healthcare providers in an MPC should be appropriately licensed in the country or state in which they practice. The MPC should be able to deal with a wide variety of chronic pain patients, including those with pain resulting from cancer and other diseases. An MPC should establish protocols for patient management and assess their efficacy periodically. An MPC should see an adequate number and variety of patients for its professional staff to maintain their skills in diagnosis and treatment. Members of an MPC should carry out research on chronic pain. This does not mean that everyone should be doing both research and patient care. Some function only in one arena, but the institution should have ongoing research activities. The MPC should be active in educational programs for a wide variety of healthcare providers, including undergraduate, graduate, and postdoctoral levels. The MPC should be part of or closely affiliated with a major health sciences educational or research institution.

DESIRABLE CHARACTERISTICS OF A MULTIDISCIPLINARY PAIN CLINIC The distinction between an MPC and a multidisciplinary pain clinic is that the former has research and teaching components that need not be present in the latter. Hence, items 15, 16, and 17 in the foregoing list are not required for a multidisciplinary pain clinic. All other items should be present.

DESIRABLE CHARACTERISTICS OF A PAIN CLINIC 1. 2. 3. 4. 5. 6. 7.

A pain clinic should have access to and regular interaction with at least three types of medical specialties or healthcare providers. If one of the physicians is not a psychiatrist, a clinical psychologist is essential. The healthcare providers should communicate with each other on a regular basis both about individual patients and about programs offered in the pain treatment facility. There should be a director or coordinator of the pain clinic. If he or she is not a physician, there should be a director of medical services who is responsible for the monitoring of medical services provided to the patients. The pain clinic should offer both diagnostic and therapeutic services. The pain clinic should have designated space for its activities. The pain clinic should maintain records on its patients so as to be able to assess individual treatment outcomes and to evaluate overall program effectiveness. The pain clinic should have adequate support staff to carry out its activities.

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8.

Healthcare providers working in a pain clinic should have appropriate knowledge of both the basic sciences and clinical practices relevant to pain patients. 9. The pain clinic should have trained healthcare professionals available to deal with patient referrals and emergencies. 10. All healthcare providers in a pain clinic should be appropriately licensed in the country and state in which they practice.

APPENDIX 2: Joint Commission on Accreditation of Healthcare Organizations Standards for Pain Management [21] [22]

The new standards for pain assessment and management of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) apply to ambulatory care facilities, healthcare networks, behavioral healthcare facilities, home care, hospitals, long-term care organizations, long-term care pharmacies, and managed behavioral healthcare organizations. These standards recognize pain as a condition that requires specific assessment and management and is finally recognized inside the main frame of patient rights with consequent organizational responsibilities. In summary, the standards point out the various aspects of pain care with which the healthcare organizations must comply: • Explicit recognition of the right of patients to appropriate assessment and management of pain. • Screening for the existence of pain and assessment of the nature and intensity of pain in all patients. • Recording the results of the assessment in a way that facilitates regular reassessment and follow-up. • Determining and ensuring staff competency in pain assessment and management, and addressing pain assessment and management in the orientation of all new staff. • Establishing policies and procedures that support the appropriate prescription or ordering of effective pain medications. • Educating patients and their families about effective pain management. • Addressing patient needs for symptom management in the discharge planning process. • Maintaining a pain control performance improvement plan. These new standards have started to be scored for compliance in 2001, and many key professional organizations and accredited healthcare organizations will discuss their experiences in managing pain in order to finalize the guidelines. APPENDIX 3: Standards for Physician Fellowship in Pain Management 1. 2. 3.

4.

[23]

Definition. A physician fellowship in pain management is a specialized postgraduate program of study in assessing and managing patients with chronic pain of all types and understanding the sciences basic to the practice of pain management. Duration. A fellowship in pain management should require a minimum of 1 year of full-time clinical training. Additional research training may be desirable, depending on the fellow’s career goals, but should not erode the clinical training period. Prerequisites for Fellowship in Pain Management. To be eligible for a fellowship in pain management, the candidate must be board-eligible or board-certified in one of the recognized specialties of medicine; furthermore, the specialty area must involve experience with patient care. The fellow must be a graduate of an approved school of medicine. The fellow must provide at least three letters of a reference and a curriculum vitae when applying for a fellowship position. The fellow must be licensed to practice medicine by the appropriate governmental agencies. Resources. The fellowship must occur within a medical institution capable of providing a suitable educational environment. At least three recognized patient care specialty areas must be offered at the same institution. The institution must have a medical library with appropriate resources for this level of training. The clinical pain treatment program or its parent institution must be accredited by the appropriate governmental agencies. The pain treatment facility must have suitable space allocated for its clinical and educational activities. It must have a sufficient volume and variety of patients to provide the fellow or fellows with adequate educational opportunities. The pain treatment facility must see at least 100 new patients per year per fellow; there must be at least 500 patient visits per year per fellow. Pain treatment facilities that specialize in one region of the body or one type of disease are by themselves not adequate as a training resource.

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Director. There must be a designated director of the pain management fellowship. The director shall be a physician who participates in the diagnosis and treatment of patients within the pain management facility offering the fellowship in pain management. The director of the fellowship need not be the administrative or medical chief of the pain treatment facility, but the fellowship director and administrative and medical chiefs, if they are not the same, must demonstrate the ability to interact in such a way as to be conducive to the education of fellows. The director shall be responsible for the design and implementation of the fellowship; he or she shall be responsible for certifying that a fellow has successfully completed his or her training period and has mastered the requisite knowledge, skills, and attitudes. The director must be a member of the International Association for the Study of Pain (IASP) and a national chapter. It is desirable that the director have extensive experience in the management of patients with the complaint of pain; it is also desirable that he or she have educational and administrative experience above and beyond the fellowship in pain management. The director shall be responsible for maintaining an up-to-date file on each fellow, documenting his or her educational progress and any deficiencies. Faculty. There shall be at least three members of the pain treatment facility staff who are designated as faculty in addition to the director. Faculty members shall be appropriately certified in a patient care specialty. If one of the faculty is not a psychiatrist, an additional faculty member must be a licensed clinical psychologist who has expertise in pain management. Faculty members shall also be members of the IASP and a national chapter. Faculty members of a fellowship in pain management shall represent at least three healthcare delivery specialties. Other types of healthcare providers in addition to physicians and psychologists may also be members of the faculty. Faculty members must spend a major part of their professional time working within the pain treatment facility.

CLINICAL TRAINING SUBJECTS Although not every fellow will be fully trained in every area listed here, every fellow should at least have had some exposure to patients whose care involves all these areas. I.

II.

III.

IV.

Medical diagnosis and therapy A. History and physical examination B. Measurement of pain C. Physical therapies D. Vocational and rehabilitation assessment and management E. Participation in multidisciplinary assessment and treatment F. Anesthesiologic procedures (when appropriate for the fellow’s prior training) G. Surgical procedures (when appropriate for the fellow’s training) H. Other procedures appropriate to the fellow’s prior specialty training Psychological diagnosis and therapy A. Use of diagnostic tests B. Collection of data from interview and standard forms C. Comprehensive assessment D. Treatment options 1. Individual, group, and family psychotherapy 2. Cognitive-behavioral therapies 3. Biofeedback and relaxation techniques 4. Hypnotherapy Pharmacotherapy A. Analgesics 1. Nonopioids 2. Opioids 3. Adjunctive drugs B. Antidepressants C. Sedative-hypnotics D. Benzodiazepines E. Others Specific types of painful conditions to be included in the fellow’s educational program A. Pain associated with cancer, including issues of death and dying, palliative care, and hospice care B. Postoperative and post-trauma pain C. Pain associated with nervous system injuries D. Pain associated with chronic disease E. Pain of unknown causation

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F. Pain in children G. Pain in the elderly Regional pain syndrome to be included in the fellow’s educational program A. Headache B. Facial pain syndromes C. Neck and upper back pain D. Low-back pain E. Extremity pain syndromes F. Pelvic and perineal pain

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Chapter 6 - Organization of Palliative Care Services RICARDO RUIZ-LÓPEZ DIEGO BELTRUTTI ATHINA N. VADALOUCA MAURO S. NICOSCIA

During the past decade, medical ethical considerations regarding the consequences of developments in healthcare and medical oncology have led to the general assumption in Western societies that promoting the quality of life (QOL) and alleviating suffering are almost as important as preserving life. [1]

Moreover, the increasing concerns about economic growth and development of healthcare and the perception that healthcare policies are determined on the basis of cost-benefit analysis, lay a solid groundwork for the implementation of multidisciplinary and interdisciplinary teams for the management of patients with advanced diseases, whose QOL is considered the principal goal of medical therapy. Palliative care units and hospices are found today in every country of the Western world. There are practical variations in most countries because these services have been modified appropriately to meet specific cultural needs and models of local healthcare systems. This chapter covers the definition of QOL, the relief of pain and other symptoms as a major issue in the management of cancer pain, the structure and functions of the palliative care team, and the integration of levels of care.

Definition of Quality of Life The concept of QOL was introduced as one of the goals of medical treatment in the late 1970s as a result of surveys This concept emerges from the development of Western health policies over the conducted in the United States. past 50 years, ranging from restoration of welfare to objectives related to psychosocial needs. [2] [3] [4]

Although there is no universally accepted definition for this concept, QOL could be considered the functional effect of an illness and its therapy on a patient as perceived by the patient. The World Health Organization’;s definition of health as being “a state of complete physical, mental, and social well-being and not merely the absence of disease” focuses on the issue of the wholeness of life and the importance of the psychosocial component. [5]

Although some definitions indicate that terms such as happiness and satisfaction are integral elements, others mention that measures of sociopersonal balance or QOL should include physical, social, and emotional functions, attitudes toward illness, and personal features of the patient’;s daily life, including family interactions and the cost of illness. Some definitions of QOL treat it as related to the individual’;s own perception, emphasizing that the breadth of the term covers many aspects of life. [6]

[7]

When applied to patients with cancer pain, the term should encompass different clinical dimensions, providing a framework in which physical toxicity (physical impairment, body image, and function) as well as psychological, social, spiritual, cultural, and philosophical factors interact in a way specifically individualized to the patient and changing with the evolution of the disease. Therefore, QOL measures the difference, during a particular period of time, between the individual’;s hopes and expectations and the individual’;s actual experience. According to Calman, four stages of action are required to modify the QOL: [8] [9]

1. 2.

[9]

The problems and priorities of the individual must be assessed and defined. The patient should be fully involved in formulating the plan of care. This step involves a comprehensive discussion with patient and family and requires the patient’;s insight into the dynamics of the situation.

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The action plan must be implemented by either the patient or the caring team. This goal may be accomplished by lessening the patient’;s physical symptoms, altering the patient’;s psychological status, or reducing expectations but allowing the patient to retain hope. An evaluation must be made of the results of the intervention and the patient’;s situation must be reassessed. TABLE 6-1 -- COMMONLY IDENTIFIED DIMENSIONS OF QUALITY OF LIFE

Physical concerns

Treatment satisfaction

Functional ability

Future orientation

Family well-being

Sexuality/intimacy

Emotional well-being

Occupational functioning

Spirituality

Social functioning

From Cella DF, Tulsky DS: Measuring quality of life today: Methodologi cal aspects. Oncology 4:29–38, 1990.

A comprehensive view of palliative medicine requires that QOL be considered with regard to the specific disease and the treatment of symptoms. This involves not only patients in advanced stages of the disease but also those in the early stages, when more aggressive therapies are usually performed. Calman described QOL in relation to the size of the gap between an individual’;s expectations and the reality of those expectations: the smaller the gap, the better the QOL. According to this model, a patient’;s QOL can be influenced either by a change in the actual condition or by a change in expectations. There are many ways of conceptualizing QOL, and, during the past years, a number of questionnaires have been developed. Cella and Tulsky define 10 distinct issues to be measured, although these dimensions need to be categorized and validated in a hierarchy model ( Table 6-1 ). [8]

The Relief of Pain and Other Symptoms as a Major Issue in Cancer Care Various surveys show that pain is experienced by 30% to 60% of cancer patients during the active period of the therapy and by more than 75% of patients with advanced disease. Thus, alleviation of pain is directly linked to achievement of QOL, because pain interferes with physical functioning and social interaction and is associated with psychological distress. [10]

[11] [12] [13]

Continuous pain can interfere with the patient’;s ability to eat, sleep, think, and interact with others. Unbearable pain, whether “difficult” or “refractory,” is a major risk factor in cancer-related suicide. [14]

[15]

[16] [17]

The effective alleviation of pain in cancer and other advanced stages of degenerative diseases is acknowledged by the World Health Organization (WHO) as a major goal of medicine and medical care, requiring knowledge of ethical principles and specific training in pain medicine. [18]

The right to alleviation of avoidable pain is derived from the universal concepts of maximal respect for human beings and is attached to the concept of human ethics. Thus, the relief of pain in cancer and other progressive diseases in advanced stages is a collaborative task among the different agents involved in patient care. This interaction includes government agencies, medical and nursing schools, hospitals, healthcare organizations, physicians, nurses, and other health professionals. The selection of potentially harmful therapies that may occasionally prolong life, such as radical radiotherapy or systemic chemotherapy in patients with advanced incurable disease, may cause harm to most patients, and ethical issues may not be properly addressed. In such cases, treatment protocols must be planned, comprehensible patientfamily information packages must be provided, and clearly worded consent procedures must be offered. Emphasis on QOL criteria is considered essential. [19] [20] [21] [22] [23] [24] [25] [26]

Leaders in both palliative care and other aspects of cancer are reluctant to encourage integration of their respective areas. Oncologists and palliative medicine physicians may think that collaboration or clinical integration could distort therapeutic objectives and lead to dilution of resources. This confusion can provoke an unfair situation that affects both patients and families, being a source of misinformation and establishing an unavoidable barrier to appropriate care. [27]

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The relief of pain and palliation of symptoms has been traditionally considered as a medical treatment for the last days of life, when symptoms are much more prominent and more difficult to control. The WHO, in its definition of palliative care, states: “Palliative care … affirms life and regards dying as a normal process, … neither hastens nor postpones death, … provides relief from pain and other distressing symptoms, … integrates the psychological and the spiritual aspects of care, … offers a support system to help patients live as actively as possible until death, … offers a support system to help the family cope during the patient’;s illness and in their own bereavement.” This expanded definition of palliative care relates to the previous WHO definition which affirms, “The goal of palliative care is achievement of the best quality of life for patients and their families. Many aspects of palliative care are also applicable earlier in the course of the illness in conjunction with the anticancer treatment.” [18]

Structure and Functions of the Pain and Palliative Care Team Specialized care of persons with cancer and other irreversible diseases has undergone major changes during the past three decades ( Table 6-2 ). Although the concept of medical effectiveness can be greatly modified by both physicians’; attitudes and environmental concerns, the organizational issues and the philosophy of a modern pain and palliative care team are not dissimilar

TABLE 6-2 -- SCHEMATIC ORGANIZATION AMONG PAIN AND PALLIATIVE CARE SERVICES; LEVELS OF CARE AND PATIENTS

From Ruiz-López R: Continuous care of cancer pain patients. In Aronoff GM (ed): Evaluation and Treatment of Chronic Pain. 3rd ed. Baltimore, Williams & Wilkins, 1998.

to those postulated by J. J. Bonica in his early work, when he stated, “Complex pain problems can be treated more effectively by a multidisciplinary/interdisciplinary team, each member of which contributes with his or her specialized knowledge and skills to the common goal of making a correct diagnosis and developing the most effective therapeutic strategy.” [28]

The development of the hospice movement over the past 50 years has provided interdisciplinary care to patients and families at home, establishing inpatient units for palliative care in local hospitals or in specialized institutions. In either type of setting, the multidisciplinary/interdisciplinary team plays a major role in providing medical treatment and psychosocial support as well as attending to the spiritual needs of patients and their families. [29] [30] [31]

[32]

[33] [34] [35]

THE MULTIDISCIPLINARY TEAM Multidisciplinary care of cancer pain patients must be active and continuous. Their physical, psychological, social, and spiritual needs should be considered, because the multiple issues that these patients and their families encounter usually exceed the expertise of a single practitioner or caregiver. In this type of team, members with diverse training interact as a group of individuals, with the common purpose of working together and sharing the main goal of improving the QOL of the patient. Team members have particular expertise and training and make individual decisions within their area of responsibility. Teamwork does not mean

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joining healthcare workers together in one room; nor is it the same as collaboration. Information must be the key issue for interaction of members and must be shared by the vehicle of the clinical record. [36]

Structure of a Multidisciplinary Team

The structure of the multidisciplinary team varies with the development of the program of care, its objectives and goals, the availability of resources, and the type of setting, be it in home, hospice, or hospital. The patient and family should be considered as members of the team. PHYSICIAN

The most important challenge—and the first to be considered—is the relief of pain and other symptoms. Thus, the physician plays a central role on the team. The physician must be competent in general medicine, know the principles and practice of care, and understand malignant disease and any other disease represented in the patient population, such as acquired immunodeficiency syndrome or degenerative neurologic diseases. Ideally, the physician should have specific training in palliative medicine and skills in pain management, including surgical and anesthesiologic procedures. This assertion suggests that a team must be comprised of physicians from a wide variety of specialized backgrounds, such as anesthesiology, neurosurgery, oncology, psychiatry, internal medicine, and family medicine among others. Physicians may play various roles, which include managing pain and symptoms for an individual patient, being responsible for medical assessment and coordination, training and supporting the multidisciplinary team, and ensuring coordination of care of the individual patient. Other physicians may act only as consultants, being coordinated by the attending physician of the patient. PSYCHOLOGIST

The role of the psychologist is to perform a first evaluation of the status of patient and family, focusing on personal problems of illness, disability, and impending death. The psychologist must deal with the patient’;s and relatives’; emotional needs. The psychologist should cover the patient’;s and family’s understanding of diagnosis, prognosis, and expectations, the strengths and resources available to the family, the problems precipitated by the terminal illness, past losses and the way they were handled, particular cultural factors, and expectations and plans for the future. The psychologist should help the team when there is dysfunction within the family and participate in the patient’s symptom control by teaching and assessing relaxation techniques, imagery, distraction techniques, and strategies for coping. NURSE

The nurse is the team member who is most likely to visit the patient and family at home or in the inpatient institution. The nurse’s role begins with examination of the details of physical care: bathing, control of odor, pressure areas, mouth care, bladder care, bowel care, diet, and fluids. The nurse also provides any information needed to maintain good hygiene. The nurse’s other responsibilities include organizing the patient’s environment to minimize loss of control, observing what brings comfort and relief, reporting the patient’s response to medical treatments or secondary effects, and instructing the patient and family about the medication plan. SOCIAL WORKER

The social worker’s goals are to assist the patient to develop skills in dealing with the social problems of illness, disability, and impending death; to link the patient with the community; and to establish practical aid for peer support. CHAPLAIN

A sympathetic chaplain who is a skilled listener is a key team member. Sometimes, the patient has feelings of guilt about past events, a sense of meaninglessness, and a perception that life is unjust. Faith may be questioned. The role of the chaplain is to listen, facilitate past recollection, deal with regrets, offer spiritual counseling, and help to make the patient ready for what lies ahead.

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For a patient with an established tradition of religious rituals and sacraments, the chaplain’s role on the team can be very meaningful. Therefore, pastoral counseling should be made available, and pastoral care members should become familiar with information about community resources that provide spiritual care and support. PHYSICAL THERAPIST

Rather than attempting to improve the patient’s function, the goal of the palliative care physiotherapist is to help plan activity oriented to maximizing the patient’s diminishing resources. This can be accomplished by active or passive range of motion exercises that the bedridden patient can perform to prevent contractures and improve circulation, massage to relax aching muscles, treatment of lymphedema, instruction in transfers or positioning, and the use of physical therapy for the alleviation of pain. OCCUPATIONAL THERAPIST

The occupational therapist’s role is to maintain autonomous functions such as control of self-care needs, including such activities as grooming, feeding, dressing, and moving about. The occupational therapist also assesses functions with which the patient needs assistance and those that the patient can still perform autonomously. The therapist should provide adaptive equipment or functional splints, and treatments should be changed in accordance with the patient’s status. In the inpatient setting, the focus of the occupational therapist on leisure can help to restore a sense of normal living through the introduction of corrective measures to help the patient adapt residual capacities to maintain the activities of daily life. VOLUNTEER

The volunteer’s roles vary according to the patient’s setting, although the focus is on improving the QOL, to provide a supportive presence that may facilitate communication, and to assist with the normal activities of daily living. Volunteers should be carefully selected and specifically trained by the pain and palliative care team.

Cancer Pain and Palliative Care: The Continuum Hospital-Hospice Model One of the most challenging tasks in care of patients with cancer pain is to ensure the delivery of specialized services throughout the different settings where the patient will be managed during the course of the disease. Most patients need specialized care in two or more settings because there is an increasing movement in industrialized countries to enable persons with advanced disease to live until death at their maximal potential, letting patients end their lives in the setting most appropriate to them and their families. Therefore, a major objective of care in cancer pain management is, whenever possible, to help patients to reach the limit of their physical and mental capacities with the highest level of autonomy in their own environments. The provision of continuity of care with such terms is conditioned by the availability of resources and, mainly, by an effective communication within the team, including the patient and family. The place of death and quality of care are among the most important concerns for the patient and family. Until the 19th century, people died where they had spent their lives or where they wished. During the 20th century, because of different conceptual assumptions, in Western societies, the place of dying has changed from the home to the hospital, which, in many cases, is not the preference of the patient. In 1965, in the United Kingdom, 63% of deaths occurred in the hospital compared with 73% in 1987. In the United States, in 1957, 70% of deaths occurred in the hospital. In Italy, 72% of the deaths occurred in the hospital in 1986 as opposed to 67% in 1990. In Israel, 29% of terminal patients currently die in hospital, 41% at home, and 31% at institutions for chronic diseases. The availability of home care services in Western Australia has allowed 70% of patients to die at home. If the patients are asked where they would like to spend the last days of their lives, the majority answer that they want to be at home.

HOSPITAL Since the 19th century, technology and industry have developed enormously, and life expectancy has doubled. In the 20th century, the hospital setting became a place designed to recover health and manage treatable diseases. Healing

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and prolongation of life have been assumed to be the hospital’s main objectives. There seems to be no time or space for patients who do not get well. On the other hand, society seems to be trying to eliminate death from its style of life, and dying persons are sent to the hospital to keep them far from the center of the family. Today, the hospital setting has to be considered as one important step for the multidisciplinary team in some circumstances. The hospital is the place where specific palliative therapies can be administered (e.g., radiation therapy, transfusions) and where difficult-to-control symptoms such as pain can be managed. In some cases, an admittance to the hospital is needed to perform a surgical procedure, such as nerve block, for the alleviation of pain. A patient with delirium sometimes requires hospital admission so that a quick and correct diagnosis of the cause of the delirium can be made and so that treatment can be provided if it is feasible. Severe dyspnea stemming from pleural effusion or other causes can require thoracocentesis in hospital. Difficult ulcers (paraneoplasic vasculitic syndromes), ischemic complications, or other miscellaneous conditions can be more effectively controlled in a hospital setting. In any case, the hospital stay should not be prolonged. Other causes of hospital admission can arise from the family situation, such as poor coping or extreme anxiety as well as distressing symptoms such as severe dyspnea, neoplasic ulcers, or agony. The patient who lives alone and has no means to acquire a caregiver sometimes requires hospital or hospice admission. Finally, the patient may make the decision to stay in the hospital. The best way to achieve good results, without the disadvantages of a hospital setting for a terminally ill cancer patient, is to create a palliative care unit (PCU) in a local hospital. Some hospitals have a PCU, which avoids many of the problems of the traditional hospital model. To resolve problems that appear during the disease, the team members must be trained in the treatment and control of the advanced disease and in the integral care of the patient and family. Communication skills are vital; loss of communication usually means that the patient becomes merely a care receiver instead of an active participant in the decision making. The team must have time to dedicate to the patient and family. The patient has to become familiar with the PCU team. The environment must be adequate to allow some degree of independence, and privacy must be maintained. Usually, the hospital is a hostile place for the patient who ignores hospital regulations. Also, privacy during family conferences is important, and a special room for this purpose is desirable to avoid discussions in the corridor. The PCU must have special equipment but not sophisticated technology. The concept of “nothing more can be done” must be abandoned, and inadequate therapeutic attempts or prolongation of agony should be avoided.

HOSPICE The first hospice where modern medicine was applied to terminal patients in a rational and scientific manner was St. Christopher’s Hospice in London ( Table 6-3 ). The human component was not forgotten, and pain management was fundamental. It was the beginning of palliative care as we know it today, and from this beginning the hospice movement expanded throughout the world. [35] [36]

The main purpose of the hospice is to take care of the human being who is ill with no possibility of healing. Its principal objective is to treat patients as whole

TABLE 6-3 -- LIST OF ELEMENTS BROUGHT TOGETHER AT ST. CHRISTOPHER’s HOSPICE Beds integrated in local community Development and monitoring of symptoms control Family support Bereavement service Home care Research and evaluation Education and training From Saunders C, Bains M: Living with Dying: The Management of Terminal Disease. Oxford, England, Oxford University Press, 1983.

persons, enabling them and their families to participate in decision making. The major principles of the hospice setting are symptom control; rehabilitation; attention to psychological and spiritual needs; allowing patients and families together to choose where patients will live during the final phase of their diseases and where they will die;

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maintaining good communication among team members, including patients and their families; and giving support during agony, providing accessibility to staff, and allotting enough time to comfort patients. Palliative care teams have developed skills that have enabled previously hospital-bound patients to return home, with use of techniques such as spinal analgesic delivery systems, pump-delivered subcutaneous medications, and continuous care of regular symptom management by doctors and nurses at the patients’ homes. Data on 3362 patients cared for by St. Christopher’;s Hospice between 1972 and 1977 showed that only 1% reported continuous pain, although more than three quarters of the patients had arrived at the hospice with pain. Cicely Saunders recognized that the achievement of such results, however, can provoke “staff pain,” resulting from prolonged exposure to the suffering of patients and families who are facing death. Although she acknowledged and described the need for formal staff support, she argued that, “The resilience of those who continue to work in this field is won by a full understanding of what is happening and not by a retreat behind a technique.” [31]

[32]

HOME The home setting offers several advantages for the patient. It helps patients to maintain their social and family roles, to use their time as they wish, and to develop personally satisfying eating and sleeping habits. Changing habits in the final days of life can lead to suffering and stress. Furthermore, patients at home can preserve privacy, can go on with occupational activities, and are in a familiar environment. Family members feel more satisfied because they can actively participate in giving care and in showing respect for the patient’;s wishes. Home care as a part of continuous care of the cancer patient benefits the health system by decreasing the number of hospital admissions, shortening hospital length of stay, and providing quality of care according to modern ethical principles. For a patient to be kept in the home, some conditions must be fulfilled ( Table 6-4 ): round-the-clock specialized care by the palliative care team must be available; the patient and relatives must be instructed on all issues related to the illness and its complications; information about home remedies for the appropriate management of pain and other symptoms must be provided; appropriate technical support for medical equipment must be given; and there must be written information about the use of medication. The patient and family must be assured that admittance to an institution is available if the clinical situation cannot be controlled at home. A bereavement program that provides care of the family after the patient’;s death is crucial. If a family has specific difficulties immediately after the patient’;s death, referral to community peer support groups or specialized counseling must be given.

Conclusions The importance of palliative medicine is expected to increase in upcoming years. For full coverage of the population, a rational approach is needed that stresses public health rather than institutionalized involvement. Gaining support for public health involvement should be a priority for the individuals, organizations, and countries in the worldwide network involved in implementing existing knowledge in palliative care. [37]

The implementation of the WHO recommendations in regard to palliative care could have a major impact on the QOL of cancer patients. However, strong political motivation and leadership are required to ensure a full involvement of healthcare systems without extreme expense (Appendix 6–1). Palliative care in Western societies is considered to be a human right when curative interventions are no longer indicated. For a large number of less developed

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Chapter 6 - Organization of Palliative Care Services TABLE 6-4 -- HOME CARE IN CANCER PAIN MANAGEMENT: CRITICAL ISSUES

24-hour specialized care available Patient and relatives taught about the disease Information about home remedies Appropriate technical support Written information on the use of medication

countries, palliation should be made available now, even before maturation of the country’;s economy can provide technical services. An important effort has to be made to encourage legislation that will at least make essential drugs—including opioids—available to the global population. Education of physicians and health workers in developing countries must be improved so that these countries can implement their own palliative care teams and training centers. REFERENCES 1. Aristotle:

Ethics. Harmondsworth, England, Penguin Books, 1976.

2. Aaronson

NK, Beckmann J (eds): The Quality of Life of Cancer Patients. New York, Raven Press, 1987.

3. Andrews

FM, Withey SB: Social Indicators of Well-Being. New York, Plenum Press, 1976.

4. Campbell 5. World

A, Converse PE, Rodgers WL: The Quality of American Life. New York, Sage, 1976.

Health Organization Constitution. Geneva, WHO.

6. Spitzer WO, Dobson AJ, Hall J, et al: Measuring the quality of life of cancer patients: A concise QL-index for use by physicians. J Chronic Dis 34:585–597, 1981. 7. Krupinsky

J: Health and the quality of life. Soc Sci Med 14a:203–211, 1980.

8. Calman KC: Definitions and dimensions of quality of life. In Aaronson NK, Beckman J (eds): The Quality of Life of Cancer Patients. New York, Raven Press, 1987, pp 1–9. 9. Calman

KC: The quality of life in cancer patients—an hypothesis. J Med Ethics 10:124–127, 1984.

10. Bonica

JJ, Ventafridda V, Twycross RG: Cancer pain. In Bonica JJ (ed): The Management of Pain, 2nd ed. Philadelphia, Lea & Febiger, 400– 460, 1990.

11. Bond 12. Daut

MR, Pearson IB: Psychosocial aspects of pain in women with advanced cancer of the cervix. J Psychosom Res 13:13–21, 1969. RL, Cleeland CS: The prevalence and severity of pain in cancer. Cancer 50:1913–1918, 1982.

13. Fishman

B: The treatment of suffering in patients with cancer pain: Cognitive behavioral approaches. Adv Pain Res Ther 16:301–316, 1990.

14. Feuz A, Rapin CH: An observational study of the role of pain control and food adaptation of elderly patients with terminal cancer. J Am Diet Assoc 94:767–770, 1994. 15. Massie MJ, Holland JC: The cancer patient with pain: Psychiatric complications and their management. Med Clin North Am 71:243–258, 1987. 16. Breitbart

W: Suicide in the cancer patient. Oncology 1:49–54, 1987.

17. Cleeland

CS: The impact of pain on the patient with cancer. Cancer 54:2635–2641, 1984.

18. World

Health Organization: Cancer pain relief and palliative care. Technical Report Series 804. Geneva, WHO, 1990.

19. Questions

and Answers About Pain Control: A Guide for People with Cancer and Their Families. Washington D.C., American Cancer Society and the National Cancer Institute, 1992.

20. Ferrell

BR, Rhiner M, Ferrell BA: Development and implementation of a pain education program. Cancer 72(Suppl 11):3426–3432, 1993.

21. The

Wisconsin Cancer Pain Initiative: Cancer Pain CAN Be Relieved: A Guide for Patients and Families. Madison, Wis, The Wisconsin Cancer Pain Initiative, 1989.

22. The

Wisconsin Cancer Pain Initiative: Jeff Asks About Cancer Pain: A Booklet for Teens About Cancer Pain. Madison, Wis, The Wisconsin

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Cancer Pain Initiative, 1990. 23. Dolore

da Cancro e Cure Palliative: Collana Rapporti Tecnici 804. Organizzazione Mondiale de la Sanità. Ginevra, 1990.

24. Manual

of Care for Terminally Ill Cancer Patients: Tokyo, Ministry of Health and Japan Medical Association, 1989.

25. Facing

Forward: A Guide for Cancer Survivors. Rockville, Md, U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute, 1990.

26. Teamwork: 27. Scott

The Cancer Patient’;s Guide to Talking with Your Doctor. Silver Spring, Md., National Coalition for Cancer Survivorship, 1991.

J: Canadian Brief on Palliative Care. Presented to Cancer 2000 on behalf of the Canadian Palliative Care Association, Silver Spring, Md.,

1990. 28. Bonica,

JJ: General clinical considerations (including organization and function of a pain clinic). In Bonica JJ, Procacci P, Pagni CA, et al (eds): Recent Advances on Pain: Pathophysiology and Clinical Aspects. Charles C. Thomas, Springfield, Ill, 1974, pp 274–298.

29. Saunders

C: Care of patients suffering of terminal illness at St. Joseph’;s Hospice, Hackney, London. Nurs Mirror February 14:vii–x, 1964.

30. Saunders

C: The challenge of terminal care. In Symington T, Cater R (eds): The Scientific Foundations of Oncology. London, Heineman,

1964. 31. Saunders

C: The philosophy of terminal care. In Saunders C (ed): The Management of Terminal Disease. London, Edward Arnold, 1979.

32. Saunders

C: Current views on pain relief and terminal care. In Swerdlow M (ed): The Therapy of Pain. Philadelphia, J.B. Lippincott, 1981.

33. Ventafridda 34. Parkes

V: Continuing care: A major issue in cancer pain management. Pain 36:137–143, 1989.

CM, Parkes J: Hospice versus hospital care: Reevaluation after ten years as seen by surviving spouses. Postgrad Med J 60:120–124,

1984. 35. Saunders

C, Baines M: Living with Dying: The Management of Terminal Disease. Oxford University Press. Oxford, England, 1983.

36. Saunders

CMS: Terminal care. In Weatherall DJ, Ledingham JGG, Warrell DA (eds): Oxford Textbook of Medicine. Oxford, England, Oxford University Press, 1983, p 288(1–28.13).

37. Stjernswärd J: Palliative Medicine—a global perspective. In Doyle D, DWC Hanks DWC, Macdonald N (eds): Oxford Textbook of Palliative Medicine. Oxford, England, Oxford Medical Publications, 1994.

Suggested Reading Brody BA (ed): Suicide and Euthanasia: History and Contemporary Themes. Dordrecht, The Netherlands, Kluwer, 1989. Cassell EJ: The Nature of Suffering and the Goals of Medicine. New York, Oxford University Press, 1991. Foucault M: The Birth of the Clinic: An Archaeology of Medical Perception. New York, Vintage Books, 1975. Numbers RL, Amudsen DW: Caring and Curing: Health and Medicine in the Western Religious Traditions. New York, Macmillan, 1986. APPENDIX 1: WHO Palliative Care Recommendations A WHO expert committee on the relief of cancer pain and palliative care has made the following recommendations to countries for achieving effective palliative care: 1. 2. 3. 4. 5.

Governments should establish national policies and programs for palliative care. Governments of member states should ensure that palliative care programs are incorporated into their existing healthcare systems; separate systems of care are neither necessary nor desirable. Governments should ensure that healthcare workers (physicians, nurses, pharmacists, or other categories appropriate to local needs) are adequately trained in palliative care. Governments should review their national health policies to ensure that equitable support is provided for programs of palliative care in the home. In the light of the financial, emotional, physical, and social burdens carried by family members who are willing to care for cancer patients in the home, governments should consider establishing formal systems of recompense for the principal family caregivers.

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Governments should recognize the singular importance of home care for patients with advanced cancer and should ensure that hospitals are able to offer appropriate backup and support for home care. Governments should ensure the availability of both nonopioid and opioid analgesics, particularly morphine for oral administration. Further, they should make realistic determinations of their opioid requirements and ensure that annual estimates submitted to the INCB reflect actual needs. Governments should ensure that their drug legislation makes full provision for the following: • Regular review, with the aim of permitting importation, manufacture, prescribing, stocking, dispensing, and administration of opioids for medical reasons • Legally empowering physician, nurses, pharmacists, and, where necessary, other categories of healthcare workers to prescribe, stock, dispense, and administer opioids • Review of the controls governing opioid use, with a view to simplification, so that drugs are available in the necessary quantities for legitimate use

9.

With pressure for the legalization of euthanasia likely to increase, governments should make strenuous efforts to keep fully informed of all developments in the fields of cancer pain relief, palliative care, and management of terminal cancer.

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Chapter 7 - The Practice of Regional Anesthesia in Developing Countries

Chapter 7 - The Practice of Regional Anesthesia in Developing Countries RAMANI VIJAYAN

About three quarters of the countries of the world fall into the category of “developing countries,” and four fifths of the world’s population lives in them. How does one categorize these countries? What is the politically correct definition of a developing country? The concept of the Third World emerged after World War II as a category to identify political neutrality in the context of the Cold War, with the distinction originally based on ideologic commitment rather than conditions of economic development. However, the term quickly became associated with economic status and degree of richness or poverty. Hence, the industrial market economy of Western Europe, North America, Australia, New Zealand, Israel, and Japan made up the First World. The centrally planned economies of Eastern Europe made up the Second World. Finally, the remaining countries of the world, such as those in Africa, Asia, the Middle East, the Pacific, Latin America, and the Caribbean, made up the nonaligned Third World. [1]

[2]

In the last two decades, the term developing countries has been used largely to identify those countries that have not yet reached the sophisticated status of industrialized nations such as those of Western Europe and North America. It also denotes that these countries, in particular the low-income countries, have not achieved an advanced level of infrastructure development with regard to the provision of clean water, electricity, housing, healthcare, and education for the large majority of their population. Typically, they have been plagued by poverty, high rates of population growth, low growth rates of gross domestic product (GDP) and industrialization, high dependence on agriculture, high rate of unemployment, and uneven income distribution. There is, of course, a very wide range in the GDP and per capita income in developing countries. The Overseas Development Administration of the United Nations divides them into two lists. Part I covers countries such as Bangladesh and Ethiopia that are characterized as low income (per capita gross national product [GNP] less than U.S. $675 in 1992); low- to middle-income countries such as Papua New Guinea and Armenia; and upper- to middle-income countries that are relatively rich such as Greece, Malaysia, and Argentina. Part II covers countries in transition, such as the countries of Central and Eastern Europe. [3]

Any discussion of the practice of regional anesthesia in developing countries must also take into account the vast differences in healthcare budgets in developing countries. The main differences between anesthesia in the prosperous, developed countries and the less affluent developing countries are related to manpower, training, facilities, equipment, drug availability, and cost of drugs. This difference can be seen even in different parts of the same developing country. In some middle-income countries, more favorable national statistics disguise wide disparities between the conditions of the rural/urban poor and the more affluent urban dwellers who are better educated and have better access to health services that closely resemble those of industrialized countries. [4] [5]

[4] [6]

Anesthesia cannot be separated from the framework of the healthcare system in any given country. It is also linked to the percentage of the population that lives in rural areas, and the degree of rural development. It is not uncommon in many rural areas for a pregnant mother to be transported to a health center 100 to 150 km away, crossing a river or two without bridges. However, the cities and towns in that same country may have excellent facilities typical of large, thriving communities. When rural facilities and other amenities are scarce, doctors generally congregate in urban areas, and anesthetic services tend to be provided primarily by trained nurses or other paramedical staff, who may or may not be taught regional anesthetic techniques. [6]

There are more than 200 developing countries in which the overall population had surpassed 4 billion by the end of the 20th century. It is estimated to pass 5 billion by 2010. There is marked cultural, economic, and political diversity among these countries, and it is difficult to generalize or attempt to categorize the practice of regional anesthesia without running the risk of being either too superficial or too pedantic. This chapter is a review of some of the salient and interesting work that has been undertaken in developing countries and published in indexed journals. It also includes the results of a survey that was conducted in Asian countries in 1999 as well as comments and personal communications garnered from it. [7]

Regional anesthesia, particularly spinal and nerve blocks, have been practiced for many years in developing countries. International anesthetic literature, however, does not quite reflect this practice. The reasons for this could be multifactorial. Papers are often published in local journals, which may not be indexed, and often in languages other than English. Research and writing require time, sufficient staff, and facilities, all or some of which may not

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be easily available in many parts of the developing world. The acute shortage of anesthesiologists and the heavy workload are also not usually conducive to undertaking much research work. Since 1990, however, many of the countries of East Asia and Latin America have seen phenomenal economic growth. In tandem with this growth, there have been vast improvements in healthcare allocation and increased sophistication in healthcare delivery systems. The recent increase in the number of publications from these countries could reflect their growing affluence. Regional anesthesia covers a large number of different techniques. It ranges from simple procedures such as local infiltration with local anesthetic agents practiced by surgeons to those that are more complex, such as the combined-spinal epidural technique.

Regional Anesthesia Administered by Surgeons Surgeons all over the world use local infiltration anesthesia for minor and intermediate surgery. In many parts of the developing world, about 30% to 40% of all surgery is performed under local or local-regional anesthesia. The majority of dental extractions and ophthalmic surgeries are performed under regional anesthesia. Surgeons routinely use retrobulbar or peribulbar blocks for cataract extraction, which may or may not be supplemented by sedation. Peribulbar injection, which avoids the serious complications of retrobulbar injection, is widely used for intraocular surgery and lens implantation. All commonly available local anesthetic drugs, such as lignocaine, bupivacaine, and the newer drug, ropivacaine, have been used with or without the addition of hyaluronidase for ophthalmic surgery. [8] [9]

[10]

[11]

[12]

[13] [14]

Groin surgery accounts for nearly 15% of all general surgery procedures in developing countries and forms a considerable proportion of the surgical workload. Local-regional anesthesia administered by surgeons is used extensively for inguinal hernia repair. When anesthetic services were not available, Nicholls from the Seychelles continued to perform inguinal herniorrhaphy using regional anesthesia only. He found the technique was well tolerated by patients and economical, and he continued using it even after anesthesia became available. Other reports Soukup and have also shown that there is widespread use of regional anesthesia for inguinal hernia repair. Vomacka successfully used local infiltration anesthesia supplemented by sedation in 203 patients undergoing percutaneous nephrolithotomy in Czechoslovakia. [15]

[16]

[17] [18] [19]

[20]

Limiting explosive population growth is a national priority in many developing countries, and female sterilization is one of the more popular methods of family planning. Minilaparotomy to perform tubal ligation under local anesthesia has been found to be a safe, simple, low-cost, and widely applicable technique suitable for even rural areas. It has been used extensively in many developing countries, such as Thailand, India, and the Philippines. Apelo and coworkers from the Philippines reported using local anesthesia in a majority of 2488 women undergoing tubal ligation. Local anesthesia was supplemented with sedation initially in the first 650 women but was omitted in later patients because it was not needed. Of 1546 patients undergoing voluntary sterilization in Nigeria, local anesthesia was used in 996 patients (64.4%). Occasionally, entire teams of healthcare personnel set up mobile hospitals in remote areas to cater to certain specific needs of the rural population. Reichart and coworkers were able to successfully perform outpatient laparoscopic tubal ligation on women under local anesthesia in a remote part of Nicaragua. [21]

[22]

[23]

The administration of local anesthetic drugs into the subarachnoid space is technically easy because most doctors are familiar with lumbar puncture. Spinal anesthesia is therefore the regional anesthetic technique that is most often used by nonspecialists. In many countries, surgeons, medical officers, and nurse anesthetists administer spinal anesthesia because of the general shortage of trained anesthetists. More than 20 years ago (1977), Ajao and Adeloye from Nigeria reported their series of 95 patients in whom major abdominal surgery was accomplished with minimum complications under spinal anesthesia administered by surgeons. They suggested at that time that all surgeons working in “peripheral” hospitals should learn to give spinal anesthesia and deal with its side effects! Inadequate specialist anesthesia service continues up to the present with surgeons providing spinal and epidural anesthesia for surgery in several parts of the developing world. [24]

[25] [26] [27]

Spinal Anesthesia For several decades, spinal anesthesia has enjoyed great popularity in developing countries. In 1966, El-Shirbiny and coworkers from Cairo University reported a large series of 20,000 patients who had surgery under spinal anesthesia with mepivacaine (carbocaine). The list included all types of general surgical (upper and lower abdominal), gynecologic, urologic, and orthopedic procedures. High spinal blocks were performed using 2 mL (80 mg) of mepivacaine with the patient placed in a 10-degree to 15-degree Trendelenburg position. Vasopressors were required only for midlevel and high spinal blocks. A 1976 report from Hungary cites the use of spinal anesthesia with bupivacaine in 240 patients who required surgery after trauma. There were no serious complications, even though one third of the patients were elderly and a quarter were in poor general condition. Kosumian from Russia [28]

[29]

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(1985) reported successful use of spinal anesthesia in 2402 patients in a central regional hospital. Gueguen from Senegal reported that 86% of all surgery is performed under spinal anesthesia in his hospital because it has been found to be a simple and inexpensive technique. [30]

[31]

SPINAL ANESTHESIA AND HYPOTENSION (NONOBSTETRIC) Hypotension is a well-recognized problem associated with spinal anesthesia, and a couple of studies have addressed this issue. Kafle and colleagues from Nepal investigated the efficacy of oral ephedrine in reducing the incidence of hypotension. Two hundred patients undergoing lower abdominal surgery were randomized to receive either oral ephedrine (30 mg) or placebo half an hour before spinal anesthesia with 3.2 to 3.6 mL of 0.5% heavy bupivacaine. Both groups had a volume preload with 10 mL/kg of crystalloid solution. The total dose of intraoperative intravenous (IV) ephedrine supplement was significantly less (P < 0.01) and the number of patients requiring the supplement was significantly less in the group given oral ephedrine (P < 0.01). None of the patients in the treated group exhibited any signs of excitation. Prophylactic oral ephedrine appears to be a simple method of curtailing hypotensive episodes in patients undergoing spinal anesthesia who are classified by the American Society of Anesthesiologists (ASA) at levels I and II. [32]

Baraka and coworkers from Lebanon compared the influence of prehydration with either hypertonic saline (3% NaCl solution, 7 mL/kg) or normal saline (7 mL/kg) on hemodynamic changes and serum sodium concentration in 33 patients undergoing transurethral resection of the prostate under spinal anesthesia. The incidence of hypotension was less with hypertonic saline, but the difference was not significant. The central venous pressure was significantly elevated before spinal anesthesia in the hypertonic group, but there was no difference in the serum sodium levels between the two groups. Although hypertonic saline can be used to prevent the dilutional hyponatremia associated with surgery for transurethral resection of the prostate, caution should be exercised in the presence of left ventricular dysfunction. [33]

VOLUME AND BARICITY OF LOCAL ANESTHETIC DRUGS There appears to be considerable debate about the optimal volume and baricity of local anesthetic solutions that are needed to provide spinal anesthesia. Several studies have been published to determine the most effective volume and type of local anesthetic drugs that can ensure adequate spinal anesthesia for various types of surgery. Table 7-1 shows a summary of studies that have investigated the extent of sensory and motor blocks with different volumes and types of local anesthetic agents. Attygalle and Rodrigo used the sitting position to administer hyperbaric cinchocaine (2 mL), diluted to either 6 or 8 mL, to two groups of patients who were taller than 150 cm. A significantly higher level of sensory block was noted with the 8 mL volume (P < 0.001), but there was no correlation with the height of the patient. In a subgroup of patients shorter than 150 cm who were given 6 mL of diluted cinchocaine, there was a significant correlation between the patient’s height and the upper level of sensory block achieved. The study showed that the height of a patient should be taken into consideration for short patients when deciding the volume of anesthetic solution in spinal anesthesia. Tay and coworkers investigated three different volumes of dilute bupivacaine 0.125% (obtained by diluting 0.5% bupivacaine with normal saline) in 30 patients undergoing postpartum tubal ligation. The bupivacaine was administered with the patients in a lateral position. A sensory level up to T10 was reliably obtained with 8 and 10 mL for the duration of the surgery, but not with 6 mL. The incidence of high sensory blockade was higher with 10 mL. The optimal volume of bupivacaine 0.125% was found to be 8 mL, and this volume could be recommended as a test dose for epidural analgesia for labor. [34]

[34]

[35]

Amponsah studied the effect of different volumes of lignocaine 2% for spinal anesthesia in 70 patients undergoing lower abdominal and lower limb surgery. The volumes used were 3.0, 3.5, and 4 mL. The levels of sensory blockade were adequate for the intended surgery, and there was no significant difference in the mean levels of analgesia and duration of sensory and motor blockade among the three groups. In another study using plain lignocaine 2%, Imbelloni and Carneiro from Brazil investigated the effect of posture on the extent of sensory blockade. One hundred patients were divided into two groups to receive a fixed dose [36]

[37]

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TABLE 7-1 -- SPINAL ANESTHESIA: THE EFFECT OF DIFFERENT VOLUMES AND CONCENTRATION OF LOCAL ANESTHETIC DRUGS ON THE EXTENT OF BLOCK Local Anesthetic Investigated

Type of Surgery Number of Patients

Investigation

Result

Cinchocaine hyperbaric 2 mL Diluted with CSF 3 groups: up to 8 mL, 6 mL, 6 mL (<150 cm, ht)

Lower abdominal surgery No. = 83

Effect of varying volumes Correlation with height

Significantly higher sensory block with 8 mL Significant correlation between height and sensory levels in patients <150 cm

Tay et al.,[35] 1992/Singapore

Bupivacaine 0.125% 3 groups—6, 8, 10 mL

Postpartum tubal ligation No. = 30

Optimum volume for surgery

Optimum volume = 8 mL

Amponsah,[36] 1993/ Nigeria

Lignocaine 2% Lower abdominal/ lower 3 groups—3.0, 3.5, 4.0 mL limb No. = 70

Effect of different volumes No significant difference on extent of block

Cherng et al.,[38] 1998/Taipei

Bupivacaine 0.5% Diluted with CSF 3 groups—none, 1 mL, 2 mL

Urologic and orthopedic surgery No. = 60

Effect of CSF dilution on extent or block

No significant difference

Imbelloni et al.,[37] 1998 Brazil

Lignocaine 2% 2 groups—sitting, lateral

General and orthopedic No. = 100

Effect of posture at induction

Significantly greater spread with sitting position

Researchers/Country Attygalle & Rodrigo, 1985/Sri Lanka

[34]

of 4 mL of lignocaine 2% either in the sitting or lateral position. The spread of sensory block and analgesia was significantly greater for those in the sitting posture than for those in the lateral position. Lignocaine 2% was found to be effective for spinal anesthesia in both studies, indicating that it is a useful alternative to lignocaine 5%, which has come under suspicion for neurotoxicity. In another prospective study, Cherng and coworkers from Taipei studied the effect of diluting bupivacaine plain 0.5% with cerebrospinal fluid in 60 patients undergoing urologic and orthopedic surgery. Patients were divided into three groups and received either 3 mL of bupivacaine 0.5% or the same volume diluted with 1 or 2 mL of cerebrospinal fluid in the lateral decubitus position. There was no significant difference among the three groups with regard to onset time, maximum cephalic spread, duration, and two-segment regression of the sensory block. The only difference was the time to reach maximal motor block, which was significantly shorter in the undiluted group but had no clinical relevance. [38]

Outpatient surgery has become increasingly popular owing to lower costs and more efficient use of hospital beds. Spinal anesthesia is not usually considered an appropriate technique for day surgery because the residual motor block associated with it precludes early ambulation and discharge. Postdural puncture headache (PDPH) may be another reason. Liew and his colleagues from Singapore studied the efficacy of lignocaine 0.5% in day case surgery. Thirty women undergoing minor gynecologic procedures were allocated to two groups and received 5 mL of lignocaine 0.5% (total dose of 25 mg) with either a 26-gauge (G) Atraucan (pencil point) or 29-G Spinocan (cutting bevel) needle. A sensory block up to T10 was obtained in 93% of patients. The mean time for the onset and duration of sensory block was 8 minutes and 32 minutes, respectively. Motor power returned within 1 hour, and all patients were discharged on the same day. There was no incidence of postoperative headache. Lignocaine 0.5% provided reliable analgesia with fairly rapid onset and early return of motor power and was found to be suitable for minor gynecologic outpatient surgery. [39]

The distribution of a hypobaric solution in the spinal canal depends on posture. Patient position can be used to restrict the spread of local anesthetic solution and provide selective sensory block. Maroof and colleagues from Riyadh studied the effect of hypobaric bupivacaine 0.1% for anorectal surgery. Twenty adult male patients were positioned prone in a jackknife position, with an operating table break angulation of 30 degrees and head down tilt of 20 degrees. Dural puncture was performed with the patient in this position, and 5 mL of bupivacaine 0.1% were injected into the subarachnoid space at the L3 to L4 interspace. Surgery was performed without changing the patient’s position. All patients enjoyed excellent operative analgesia. The onset of sensory block took a mean of 5.3 minutes, with the highest sensory level at T10. There was no motor block, cardiovascular stability was well maintained throughout surgery, and the time to first postoperative analgesia was a mean of 339 minutes. [40]

SPINAL ANESTHESIA AND SEDATION Benzodiazepines are commonly used for sedation and anxiolysis during regional anesthesia. Ketamine is widely used in many developing countries, either as a sole anesthetic agent or to provide additional analgesia for procedures done under local anesthesia. Tripathi and Saxena (India) compared the effects of a combination of diazepam and [41]

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ketamine with diazepam and placebo in providing comfort to patients undergoing spinal anesthesia. One hundred patients were randomly divided into two groups. The first group was given diazepam 0.1 mg/kg bolus followed by a bolus of ketamine 0.5 mg/kg and an infusion of 0.5 mg/kg/hour of ketamine. The second group was given the same dose of diazepam followed by a placebo. The addition of ketamine significantly improved the quality of anesthesia and the patients’ acceptance of the technique, without any increase in side effects. Akinyemi and coworkers conducted a survey among 200 Nigerian patients in the postoperative period to determine whether patients preferred general or regional anesthesia. There was an equal distribution between men and women, and all the patients were interviewed between 2 and 7 days after surgery. Most of the patients (59.5%) preferred general anesthesia because they were afraid to be awake during surgery, although many of them were not really given a choice. Fear of being awake and feeling pain appears to be a universal feeling and is not really related to any degree of sophistication in a population. Assurance of intraoperative sedation in addition to adequate preoperative explanation should also allay patient anxiety, reduce apprehension, and possibly improve the rate of acceptance of regional anesthesia among patients. [42]

Benzodiazepines, however, should be used with caution in elderly patients, because sedation during regional anesthesia can lead to episodes of life-threatening hypoxemia. In a prospective, double-blind, randomized study, Munoz and colleagues from Chile investigated the effect of benzodiazepines in 80 elderly patients having surgery under spinal anesthesia. Patients were divided into four groups, with one serving as a control and the others given 1 mg flunitrazepam, 1 mg lorazepam, and 7.5 mg midazolam, respectively. Patients who were alert and had a sensory block below T7 had a significantly lower incidence of hypoxemic episodes than patients who were drowsy and had an anesthetic level above T7. Episodes of hypoxemia did not correlate with any other factors, such as age, weight, ASA physical status, or position of the patient. All episodes of desaturation were easily corrected by supplemental oxygen. Oral premedication with benzodiazepines should be used with caution in elderly patients. Monitoring during surgery should include pulse oximetry, and supplemental oxygen should be provided for all patients, especially if they are sedated. [43]

In an interesting study, Vale and coworkers (Brazil) investigated circadian variations in the cephalic spread of a fixed dose of lignocaine and bupivacaine in 55 patients undergoing spinal anesthesia. Patients who were given a spinal anesthetic in the morning had a longer latency and a significantly lower level of sensory block compared with patients who had the spinal anesthetic in the afternoon. The afternoon group also required more pharmacologic support for hypotension. There was no obvious explanation for these results. Further studies need to be done to decide whether circadian variation has any significant implications in clinical practice. [44]

COMPLICATIONS OF SPINAL ANESTHESIA Haleem and colleagues from India studied audiometric changes after spinal anesthesia using different sizes of needles. One hundred and twenty-five patients were randomly divided into five groups to receive spinal anesthesia with five different sizes of spinal needle: 20-G, 22-G, 23-G, 24-G, and 25-G. All patients had baseline audiometric values recorded at 250 Hz to 500 Hz before surgery. Patients who received spinal anesthesia with 20-G and 22-G needles had a significant decrease (12% and 8%) in audiometric values on the first postoperative day (P < 0.001). These alterations returned to normal values by the fifth postoperative day. A significant alteration (8% decrease) was also noted in the group with 23-G needle (P < 0.05). There was no significant decrease in audiometric values after spinal anesthesia with the smaller 24-G and 25-G needles. Besides reducing the incidence of PDPH, smallgauge needles can also minimize audiometric alterations associated with spinal anesthesia. [45]

In a similar study from Turkey, Oncel and coworkers used pure tone audiometry to investigate vestibulocochlear dysfunction after central neural blockade. Forty-five patients (age range 23 to 84 years) undergoing urologic surgery were divided into three groups and received either epidural anesthesia or spinal anesthesia with a 22-G or 25-G spinal needle. Pure tone audiometry was performed before surgery and repeated on the third and fourth postoperative days. No statistically significant hearing loss was noted in the epidural group, but the hearing loss in the 25-G group was significantly less than in the 22-G group (P < 0.01). None of the patients suffered from either headache or cranial nerve lesions. Audiometry was found to be a more sensitive indicator of cerebrospinal fluid leakage than headache. Elderly patients often have preexisting hearing impairment, and the use of the 22-G needle for spinal anesthesia may temporarily make it worse. Every effort should, therefore, be made to use smaller needles, even in this group. [46]

PDPH continues to be reported with an incidence between 2.8% and 13.9% in different series, indicating the Epidural blood patches have been considered as the treatment of extensive use of spinal anesthesia for surgery. choice for the headache after dural puncture. Pedrosa and coworkers from Brazil successfully treated 60 patients [47] [48] [49]

[50]

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suffering from PDPH, aged 18 to 42 years, with epidural blood patches, using 10 mL of autologous blood. All patients could be discharged within 24 hours of receiving the patch. An alternative method for treating headache after spinal anesthesia was described by Tsenov from Bulgaria. The author used acupuncture to treat PDPH in 35 women after spinal anesthesia for cesarean section. Thirty out of 35 (85%) of the patients needed only one treatment, and it was effective in all after three treatments. [51]

Epidural Anesthesia The incidence of PDPH after spinal anesthesia led to the popularity of epidural anesthesia. Long-acting local anesthetic drugs, epidural catheters, and the ability to extend anesthesia for prolonged surgery have resulted in a Epidural and spinal anesthesia are less widespread use of epidural anesthesia for surgery. expensive than general anesthesia. This could be an added incentive for their widespread use in developing countries (see survey discussed later in this chapter). [52] [53] [54] [55] [56] [57] [58] [59] [60] [61]

Xie and Liu conducted a survey of the practice of epidural anesthesia in China. Questionnaires were sent to 237 hospitals over six geographic areas, including some military hospitals. The response rate was 38% (90 hospitals). There were 1,304,214 documented epidural blocks in these hospitals. The percentage of blocks performed at different levels of the spine is shown in Table 7-2 . This survey revealed that epidural anesthesia was used extensively in China for various types of surgery, ranging from the neck to the lower extremities. The success rate was 98%, and the incidence of accidental dural puncture was 0.32%. The incidence of total spinal anesthesia as a complication was reported to be only 0.013%, and about half of these cases required intubation and ventilation. [59]

In a retrospective study, Liu and coworkers reviewed patients undergoing surgery for primary hyperparathyroidism [61]

TABLE 7-2 -- SURVEY OF THE USE OF EPIDURAL ANALGESIA IN CHINA Type of Epidural Anesthesia

Percentage

Lumbar epidural

38.8

Lower thoracic

32.0

Middle thoracic

23.0

Upper thoracic

4.6

Cervical

1.6

Accidental dural puncture

0.32

Incidence of total spinal anesthesia

0.013

Incidence of respiratory depression

0.54

Modified from Xie R and Liu YP: Survey of the use of epidural analgesia in China. Chin Med J (Engl) 104(6):510–515, 1991.

in Beijing from 1980 to 1989. They noted that nearly two thirds of the operations were performed under continuous cervical epidural anesthesia, with satisfactory results in 90% of them. General anesthesia was reserved for complicated cases and patients who had undergone cervical spine surgery. In another 10-year retrospective study, Guo reviewed 763 patients who had received continuous cervical epidural block for surgery. The technique provided satisfactory analgesia at low cost with no air pollution in the operating theatre. They found, however, that the conduct of cervical epidural anesthesia required a high degree of skill, both in insertion of the catheter and in intraoperative management. [60]

Surgery of the anal canal for fistulas and fissures in ano is quite common. Maintenance of anal sphincter tone during surgery is important, as it helps the surgeon delineate the extent of surgery that is required without risk to the sphincter. A spinal anesthetic provides excellent analgesia but is not suitable owing to complete loss of sphincter tone. Although it is possible to maintain tone with a light general anesthetic, laryngospasm can be a problem. Kausalya and Jacob from India investigated the efficacy of low-dose epidural anesthesia in surgery of the anal canal and compared it with the efficacy of general anesthesia. Fifty adult patients were randomized to receive either lumbar epidural bupivacaine 0.375% (12 to 16 mL) or a general anesthetic without the use of neuromuscular blocking drugs. More patients in the epidural group had normal sphincter tone (80%) as assessed by the surgeon. The incidence of intra- and postoperative complications was significantly higher in the general anesthesia group, and the epidural group spent a significantly shorter period in the recovery room because they were less drowsy. Lowdose epidural anesthesia was found to be an excellent analgesic with minimal motor block for anal surgery. Patients in the epidural group were given diazepam for intraoperative anxiolysis. [62]

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Orthopedic surgery of the lower limbs is eminently suitable for central neuraxial blockade, and both total hip and total knee replacements are commonly done under epidural anesthesia. The ability to provide epidural analgesia in the postoperative period has encouraged the trend toward bilateral total knee arthroplasty (TKA) at the same time. Lu and coworkers from Beijing studied the results of one-stage bilateral TKA under epidural anesthesia in patients with rheumatoid arthritis. Over a 5-year period, from 1987 to 1992, bilateral simultaneous TKA was performed on 45 patients who were followed over a mean period of 63 months. Improved function and pain relief were noted in all patients. Revision was needed in five knees owing to aseptic loosening, and the late infection rate was only 5.6%. Bilateral TKA under epidural anesthesia was found to facilitate early rehabilitation in addition to reducing blood loss and shortening the period of hospitalization. [63]

The position of the patient during epidural administration of local anesthetic drugs was found to make a significant difference in two studies. Strnad and coworkers (Czech Republic) investigated the effect of posture (10-degree Trendelenburg position) in patients undergoing upper abdominal surgery under epidural anesthesia. Epidural anesthesia was established in 60 patients, with a mean age of 71 years, with bupivacaine 0.5% administered at the upper lumbar level. Patients were positioned in a Trendelenburg position with a 10-degree head-down tilt and maintained in that position until the sensory level reached T3. Half the patients were then straightened to the horizontal position, and the other half were kept in the same head-down position for surgery. There was no significant difference in the ephedrine requirements between the two groups. The head-down group required significantly less intraoperative sedation and showed fewer cardiovascular variations with visceral traction than the other group. This study showed that posture could be used to enhance the quality of the block. [64] [65]

[64]

Epidural anesthesia for cesarean section can be less satisfactory than spinal anesthesia. One of the reasons cited is that local anesthetic solutions may not reach the sacral segments, resulting in an inadequate block. Chan and coworkers from Malaysia investigated the effect of maintaining a 10-degree head-up tilt position when establishing epidural anesthesia for elective cesarean section. One hundred patients were randomized to receive epidural bupivacaine 0.5% with 50 µg of fentanyl in either the horizontal or 10-degree head-up position. The patients were maintained in that position until epidural anesthesia was established up to T6, with additional doses of bupivacaine 0.5%, if necessary. The incidence of intraoperative pain and discomfort was significantly less in the head-up group (P < 0.05). There was no difference on the effect of blood pressure or motor block. [65]

Regional Anesthesia and Obstetric Practice Spinal anesthesia is perhaps the commonest anesthetic technique for cesarean section in most developing countries.

[66]

[67] [68] [69] [70] [71] [72] [73]

SPINAL ANESTHESIA AND HYPOTENSION Hypotension is the commonest problem following spinal anesthesia for cesarean section. It results from a decrease in arteriolar and venous tone secondary to sympathetic block, with a resulting reduction in systemic vascular resistance and venous return. The prevention of aortocaval compression by left uterine displacement and the prophylactic administration of IV crystalloid solutions have been widely advocated for years and are considered mandatory. These measures may not be adequate and ephedrine is often required to treat hypotension. Table 7-3 is a summary of several studies that have addressed this problem in different ways. Mathru and coworkers used 5% albumin in Ringer’s lactate with 5% dextrose solution at 15 mL/kg as a preload and compared it with the same volume of solution without albumin in 87 patients undergoing [74]

TABLE 7-3 -- TECHNIQUES TO REDUCE THE INCIDENCE OF HYPOTENSION AFTER SPINAL ANESTHESIA FOR ELECTIVE CESAREAN SECTION Researcher/Country [74]

Mathru et al.,

India

No. Patients/Local Anesthetic

Investigation

Results

5% albumin in D5RL No. = 87 vs. D5RL

S—better neonatal outcome with albumin, P< 0.02

Bhagwanjee et al.,[77] 1990/S. Africa *

Legs wrapped after spinal vs. control

No. = 24 Bupivacaine 0.5%, 1.5 mL, sitting

S—incidence of hypotension less with leg wrapping, P < 0.0033

Rout et al.,[78] 1993/S. Africa *

Legs wrapped vs. leg elevation vs. control

No. = 97 Bupivacaine 0.5%, 1.5 mL

S—leg wrapped vs. control, P< 0.004 S—leg wrapped vs. leg elevation NS—leg elevation vs. control

Chan et al.,[75] 1997/Hong Kong *

Ephedrine infusion vs. volume preload

No. = 46 Bupivacaine 0.5%

S—incidence of hypotension, less with ephedrine P < 0.04 S—umbilical pH higher with ephedrine, P<

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TABLE 7-3 -- TECHNIQUES TO REDUCE THE INCIDENCE OF HYPOTENSION AFTER SPINAL ANESTHESIA FOR ELECTIVE CESAREAN SECTION Researcher/Country

No. Patients/Local Anesthetic

Investigation

Results 0.02

[76]

Webb & Shipton,

1998/S. Africa

*

Prophylactic IM No. = 24 ephedrine 37.5 mg vs. Bupivacaine 0.5% placebo hyperbaric, 2.5 mL/sitting

NS—ephedrine supplement and SBP soon after spinal anesthesia, Apgar scores S—lower incidence of delayed hypotension

S = significant; NS = not significant; No. = number of patients; SBP = systolic blood pressure; intravenous ephedrine supplement, Apgar scores in all patients. *Umbilical arteriovenous pH also recorded.

cesarean section under spinal anesthesia. The incidence of hypotension in the albumin group was significantly less than in the crystalloid group and could be attributed to the longer intravascular half-life of the colloid. Neonatal outcome was also significantly better in the albumin group (P < 0.01). Chan and coworkers compared the efficacy The place of prophylactic ephedrine was reevaluated in two studies. of prophylactic IV ephedrine infusion (0.25 mg/kg) with fluid preloading using Ringer’s lactate solution (20 mL/kg) in preventing maternal hypotension during spinal anesthesia in 46 women undergoing cesarean section. The incidence of severe hypotension was significantly less in the group given ephedrine (P = 0.04), and the mean umbilical venous pH was also significantly higher in the ephedrine group (P = 0.02). Doppler ultrasound scans showed no difference between pre- and postspinal uterine blood flow. In a double-blind randomized controlled study of 40 patients, Webb and Shipton gave either 37.5 mg of ephedrine or placebo, intramuscularly, before spinal anesthesia for cesarean section. All patients were also given a volume preload of 500 mL of Ringer’s lactate over 15 to 20 minutes. The group given intramuscular (IM) ephedrine was found to have a significant reduction in the incidence of delayed hypotension (>30 minutes) compared with the control group. Umbilical vein pH was within the normal range in both groups, and IM ephedrine was not associated with any reactive hypertension. They suggested that IM ephedrine may provide more sustained cardiovascular support than IV ephedrine, and this action may be an advantage in the postoperative period. [75] [76]

[75]

[76]

Two studies investigated leg wrapping with Esmarch bandages in an effort to reduce the incidence of hypotension. Bhagwanjee and coworkers randomly allocated 24 women to either have their legs wrapped immediately after the induction of spinal anesthesia or to serve as control subjects. Both groups were given a prophylactic volume preload with 20 mL/kg of crystalloid solution. Leg-wrapped patients had a significantly lower incidence of hypotension (P < 0.0033) than control subjects. They also required significantly less ephedrine, and no patient experienced hypotension when the legs were unwrapped after surgery. In a follow-up study in the same institution, 97 women undergoing elective cesarean section under spinal anesthesia were allocated randomly to have their legs elevated to 30 degrees on pillows, legs elevated and wrapped with elasticized Esmarch bandages, or neither of the two (control) after induction of the block. All patients received intravenous crystalloid solution before the block. Leg wrapping significantly reduced the incidence of postspinal hypotension (18%) compared with the control group (53%) (P < 0.004). Leg elevation alone did not significantly reduce the incidence of hypotension (39%). Both studies showed that wrapping the legs can provide a simple means of reducing the accompanying hypotension and is a technique that should be used more widely. [77]

[78]

[77]

[78]

PETHIDINE AS A LOCAL ANESTHETIC AGENT Pethidine is the only opioid that is known to have local anesthetic properties in addition to analgesia. Kafle investigated the efficacy and safety of intrathecal pethidine as the sole anesthetic for cesarean section and compared it with lignocaine. Fifty full-term women who were scheduled for elective sections were randomly assigned to receive either preservative-free 5% pethidine, 1 mg/kg, or 5% hyperbaric lignocaine, 1.2 to 1.4 mL for spinal anesthesia. The sensory and motor block was adequate for surgery in all but two patients who required sedation at skin incision. The incidence of hypotension was significantly higher in the lignocaine group (P< 0.05). Pruritus and drowsiness were significantly higher in the patients given pethidine, but their occurrence was not clinically significant. All patients could be aroused easily, and there were no problems with the neonates. Postoperative analgesic requirements were significantly less in the pethidine group, with the average duration of pain relief being 6 hours compared with 1 hour in patients given lignocaine (P< 0.01). Pethidine was shown to be an effective alternative to lignocaine, with a significantly longer duration of postoperative analgesia and less hypotension. [79]

ANALGESIA IN LABOR

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Regional anesthesia (mainly epidural analgesia) with its selective central sensory blockade is an established technique for the relief of pain in labor. The conduct of safe epidural analgesia for labor requires anesthetists who are trained in this technique, skilled midwives, and facilities to monitor patients and staff to deal with any untoward effects. The provision of an obstetric epidural service in developing countries is often limited to the large teaching hospitals in urban centers. Shortage of personnel and facilities for monitoring often make it difficult for a majority of hospitals to offer such a service routinely. [80] [81]

A nationwide survey conducted by Takacs and colleagues from Hungary in 1993 sums up the situation that is found in most developing countries. In their survey, information was available for 104,137 deliveries from 98 obstetric units. They found that 81% (71,744 patients) who had had vaginal deliveries did not have any type of pain relief. Of the others who had some form of analgesia, 8.3% were given systemic opioids, and 5% had inhalational (nitrous oxide/oxygen) analgesia. Only 5.2% received epidural analgesia. Sixty-two of the 98 units surveyed did not routinely offer epidural analgesia to their patients. Regional anesthesia (spinal/epidural) was used in only 37% of all cesarean sections. The authors concluded that pain relief in labor was given a low priority in Hungary. The main reasons cited were shortage of anesthetic staff and the traditional attitudes of obstetricians. [80]

A 1-week survey of analgesic services in the labor ward of a large hospital in South Africa in 1993 reported a similar situation. Of 249 patients who had normal vaginal deliveries, 113 (45%) received no analgesia whatsoever. Intramuscular pethidine was the commonest form of analgesia and was used in 97 patients (39%). Only 36 patients (14%) received epidural analgesia, and the remaining patients (4%) received Entonox. About 76% of mothers who had an obstetric indication for epidural analgesia were not given it because of lack of medical staff. Periodic surveys such as these are necessary to create awareness among obstetricians, anesthetists, and administrators about the need to improve analgesic services in labor wards. It may not be possible to improve the staffing situation quickly, but it serves to focus on these important issues when planning future personnel needs for the healthcare in the country. [81]

[81]

Single-shot intrathecal opioids can provide analgesia in labor, but the onset is slower than that for local anesthetic drugs. The duration of pain relief with a single dose of opioid is also variable, and, thus, it may not be able to provide adequate analgesia for the entire duration of labor. Wu and coworkers, from Taiwan, retrospectively studied 55 primiparas who were given a combination of morphine 0.5 mg and 2.5 mg of 0.1% bupivacaine for the relief of pain in the active first stage of labor. They compared these patients with 88 similar patients who did not receive any analgesia for their labor. The mean onset of analgesia was 2.6 plus or minus 0.5 minutes and the duration was between 4 and 12 hours. Ninety-three percent of the women did not request any additional analgesia. The duration of first and second stages was significantly longer, and the frequency of instrument-assisted vaginal deliveries was higher than in the control group. There was, however, no difference in the rate of cesarean section and Apgar scores in the neonates. Most of the side effects, such as pruritus and nausea, were mild and alleviated by naloxone. A combination of a single dose of morphine and bupivacaine appears to be an effective and safe alternative when epidural analgesia is not available. [82]

Peripheral Neural Blockade Regional anesthesia is suitable for surgery of arms and legs. It has been extensively used for microsurgery on both upper and lower limbs in Shanghai, People’s Republic of China. Fang reviewed the anesthetic technique used in 1185 microsurgical procedures carried out in Number 6 Municipal Hospital, Shanghai, over an 18-year period from 1968 to 1985. The review included 500 reimplantations of amputated fingers and toes, 271 free transfers of toes, 96 free transfers of fibulas, 63 free transfers of muscle, 34 reconstruction of hands, and 88 ear-nose-throat procedures. Brachial plexus block was used in 33.8% (401 patients), cervical epidural block in 19.6% (232 patients), and general anesthesia in 16.3% (193 patients) of surgical procedures. A combined lumbar and cervical epidural block was used in 12.6% (149 patients), brachial plexus with lumbar epidural block in 10.4% (123 patients), lumbar epidural block alone in 5.4%, and acupuncture in 1.9% of patients. Neural blockade provided excellent operating conditions for prolonged surgery and was used to reduce or avoid vasospasm and facilitate vascular anastomosis. [83]

BRACHIAL PLEXUS BLOCK In a series of 126 patients undergoing hand surgery, Koh and Lim from Singapore used interscalene brachial plexus blockade. They used a Contiplex plexus cannula (B. Braun) and a nerve stimulator to establish the block with 40 mL (20 mL of bupivacaine 0.5% and 20 mL of 1.5% lignocaine with adrenaline) of local anesthetic solution. The analgesia was extended into the postoperative period with a continuous infusion of bupivacaine 0.25% via a disposable infusion device for a mean period of 3 days. Most of the patients (93.7%) obtained excellent pain relief and were able to participate in active physiotherapy. Catheter complications, which occurred in 18 patients (14.3%), were minor, such as dislodgment and pain at the site of insertion. Early physiotherapy was vital for a successful [84]

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outcome, and a low-dose continuous block of the brachial plexus was able to provide excellent analgesia without the side effects of systemic opioids. The level of block achieved by an interscalene brachial plexus block is usually inadequate for shoulder and proximal upper extremity surgery. Ho and Wong described a technique called “Ho’s method” to block C3 and C4 nerve roots separately and to combine these blocks with an interscalene block. In their series of 65 patients, 62 were operated on satisfactorily by this technique for shoulder surgery. This can be a useful alternative to general anesthesia when one wants to avoid manipulating the airway. Regional anesthetic techniques are also preferable to general anesthesia in patients with renal failure. Yeboah and coworkers from Ghana reviewed 92 patients with renal failure who required vascular access for hemodialysis. One hundred and seven arteriovenous shunts (98 in the arm, 7 around the ankle, 1 in the groin) were created under local or regional anesthesia. Ultrasonography was found to be a useful aid in accurately placing a catheter into a neurovascular sheath. It was used as an imaging aid to enhance the success of brachial plexus blockade by the axillary and infraclavicular approaches. [85]

[86]

[87] [88]

INTRAPLEURAL BLOCKS Intrapleural blocks have been advocated as an alternative to thoracic epidural analgesia for pain relief after thoracic surgery. Mehta and coworkers from New Delhi compared the efficacy of thoracic epidural analgesia and intrapleural analgesia after minimally invasive direct coronary artery bypass surgery with regard to quality of analgesia and complications in 50 patients undergoing elective surgery. The thoracic epidural was inserted (T4-5) before induction of general anesthesia, whereas the intrapleural catheters were inserted under direct vision by the surgeon at T6-7 intercostal space. Bupivacaine 0.25% was administered via the catheters for analgesia. The pain scores in the intrapleural group were significantly lower, with no difference in the hemodynamic or respiratory parameters or postoperative requirements for supplementary analgesia between the groups. Three patients in the epidural group had catheter migration, and four patients complained of severe back pain. The investigators concluded that intrapleural catheters were easy to insert, had fewer complications, and were a safe alternative to thoracic epidural analgesia, provided they were positioned carefully and the chest tube clamped at administration of the local anesthetic. [89]

LOWER LIMB PERIPHERAL NERVE BLOCKS Spinal or epidural anesthesia is usually chosen when regional anesthesia is being considered for lower limb surgery. An alternative to central neural blockade is the combined femoral and sciatic nerve block. The sciatic nerve block component is technically more difficult, and, therefore, it is not widely used. In a study of 40 patients undergoing unilateral total knee replacement, Lau and coworkers (Taiwan) compared spinal anesthesia with combined femoral (3-in-1) and sciatic nerve block. The two techniques were comparable for surgery, intraoperative blood loss, and time to first postoperative analgesia. Ten of the 20 patients in the spinal group developed postoperative urinary retention, whereas none had this complaint in the femoral/sciatic group. Urinary retention and subsequent bladder catheterization can be a potential source of infection in patients with an implant. Combined femoral/sciatic nerve block was shown to be a good alternative to central neuraxial blockade. It can be used in patients with abnormal spine pathology or previous back surgery. As an extension of the technique, continuous femoral nerve sheath infusion with dilute local anesthetic solution can provide postoperative analgesia. [90]

INTRAVENOUS REGIONAL ANESTHESIA Intravenous regional anesthesia (IVRA) is a technique that is simple to perform and readily lends itself to minor and outpatient surgery, particularly of the upper limb. It is useful in the emergency department for the reduction of fractures. The volume of local anesthetic solution necessary for adequate analgesia can be a cause of some concern when there is an inadvertent leak of the applied tourniquet. Several modifications to the classical IVRA technique have been reported to increase the safety margin in the event of a leak. Acalovschi and Cristea from Romania investigated meperidine as the sole anesthetic agent for IVRA in 45 volunteers (medical students in ASA I physical status). They were divided into three groups of 15 each and were given either 40 mL of meperidine 0.25%, lignocaine 0.5%, or 0.9% saline. The time to complete motor block and onset of sensory block at six sites on the forearm and hand was documented. The recovery characteristics after cuff deflation were also noted along with the incidence of any side effects. The onset of sensory and motor block was significantly faster in the meperidine group compared with normal saline (P< 0.001) but significantly slower than the lignocaine group (P< 0.001). The sensory and motor characteristics in the meperidine group indicated that meperidine had local anesthetic properties but was definitely inferior to lignocaine. The high incidence of nausea and dizziness along with pain on injection with meperidine also made it unsuitable as a sole agent for IVRA. They suggested that it should perhaps be reserved for patients who are allergic to local anesthetic drugs. [91]

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In another modification, Abdulla and Fadhil (Iraq) investigated the effect of adding fentanyl and pancuronium to a small dose of lignocaine for IVRA. In a randomized, double-blind study, 80 patients undergoing surgery of the forearm and hand were assigned to four groups. Each group received one of the following four solutions: 100 mg of lignocaine in 40 mL of saline alone, lignocaine combined with 0.05 mg of fentanyl or with 0.5 mg of pancuronium, or lignocaine combined with both. All three drugs were also administered to 20 volunteers and the cuff released immediately to evaluate the safety of the solutions studied. Analgesia was most profound in the group containing all three drugs (100%). The number of patients who had successful analgesia in each of the other groups was less than 27%. Volunteers complained only of minor and transient side effects such as dizziness. The authors suggested that the dose of lignocaine required for IVRA can be significantly reduced with the addition of low-dose fentanyl and pancuronium, without any serious side effects. [92]

OTHER PERIPHERAL NERVE BLOCKS Ahuja and coworkers studied the effect of infraorbital nerve blocks for postoperative pain relief. Twenty infants were randomized to receive bilateral infraorbital nerve blocks or sham blocks following cleft lip repair under general anesthesia. Excellent postoperative pain relief was seen in all 10 infants who received the block. It was found to be a simple and effective technique that can be administered by the surgeon to provide postoperative analgesia in children. One report from Djibouti describes a local-regional anesthesia technique for outpatient cleft lip repair that uses block of the superior maxillary nerve, because nearly 50% of patients who need the repair are adults. Blocks of the inferior alveolar, auriculotemporal, lingual, buccal, and superficial cervical plexus have also been used to successfully drain and treat submandibular abscesses. [93]

[94]

[95]

Transphenoidal surgical excision of the pituitary gland often elicits severe cardiovascular responses despite an adequate depth of anesthesia. Chadha and coworkers from India investigated the effect of bilateral maxillary nerve block in suppressing these responses. Thirty-nine patients undergoing transphenoidal excision of the pituitary gland were randomly assigned to two groups. Group 1 patients did not receive nerve blocks and served as controls, and Group 2 received 5 to 10 mL of bupivacaine 0.5% and lignocaine 2% (1:1) after induction of general anesthesia. The local anesthetic was injected into the pterygopalatine fossa via the zygomatic approach on each side to block the maxillary and sphenopalatine ganglion. The cardiovascular responses to surgery were monitored and recorded in both groups. The control group in the study was stopped at only seven patients for ethical reasons, because all the patients assigned to this group developed sudden and sometimes uncontrollable hypertension during manipulation of the nasal speculum. In the rest of the 32 patients, the block significantly reduced the hypertensive response to nasal infiltration with adrenaline solution, nasal dissection, and application of the speculum. All patients in the control group required additional halothane and sodium nitroprusside to control blood pressure. Bilateral maxillary and sphenopalatine ganglion blocks were shown to be useful adjuncts to transphenoidal surgery. [96]

Regional Anesthesia in Children Caudal epidural anesthesia and analgesia in children has been popular for many years. It has been extensively used In along with general anesthesia for lower abdominal and lower limb surgery in most developing countries. a retrospective study to evaluate regional anesthetic techniques in developing countries, Aguemon and coworkers from Benin reported using spinal and caudal anesthesia in 1875 children undergoing lower abdominal and lower limb surgery. There were 1145 children, between 14 days and 17 years of age, who had caudal anesthesia with a mixture of 1% lignocaine and 0.25% bupivacaine with 1:200,000 adrenaline, whereas 730 neonates and infants younger than 3 years of age had spinal anesthesia with isobaric bupivacaine 0.5%. The failure rate was less than 1%, and all the children had stable cardiovascular and respiratory parameters during surgery. [97] [98] [99] [100]

[101]

Sadraoui and coworkers from Morocco reported their experience of spinal anesthesia in infants for lower abdominal surgery. Hyperbaric 5% lignocaine, 3 mg/kg, was administered at L4-5 in 18 infants, with a mean age of 15 months and a mean weight of 10 kg, to induce spinal anesthesia. Motor block was obtained 2 minutes after the injection, and the duration of the sensory block was 40 plus or minus 9.7 minutes (mean ± SD). Blood pressure and heart rate throughout surgery showed only minor variation, and the anesthesia was satisfactory in 16 of 18 cases. Spinal anesthesia has been suggested as the anesthetic technique of choice for surgery in ex-preterm infants, because postoperative apnea is associated with general anesthesia. It should be considered as a reasonable option for infants requiring elective lower abdominal and lower limb surgery lasting less than 45 minutes. [102]

Epidural anesthetic techniques in children have recently gained popularity. There has also been an increasing appreciation that children should benefit from the excellent pain relief obtained with continuous epidural analgesia in the postoperative period. The drawbacks to the use of lumbar epidural anesthesia in the past have probably been the uncertainty of the skin-epidural distance in a child, the fear of accidental dural puncture, and the difficulty in obtaining small needles and catheters. Bosenberg from South Africa measured the skin-epidural distance in [103]

[104]

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children who received lumbar epidural analgesia and correlated it with the weight of the child. The skin-epidural distance was measured at the L3–4 interspace in 274 children who had lumbar epidural anesthesia. Their pages ranged from 2 days to 16 years and their weight was between 2 and 43 kg. All lumbar epidurals were performed under general anesthesia with 19-G Tuohy needles, using a midline approach. A good correlation between weight and skin-epidural distance (1.00 mm per kg body weight) was found between the ages of 6 months and 10 years of age, whereas this correlation was not true outside this age range. All the children had an epidural catheter inserted and had a successful block, with no incidence of either dural puncture or bloody tap. This useful guide should help popularize the practice of lumbar epidural anesthesia in children. Central neural blockade is an excellent method of providing analgesia, even in neonates and infants. Although caudal epidural anesthesia can be readily used for lower abdominal surgery, adequate analgesia for upper abdominal and thoracic surgery via the caudal route requires large volumes of local anesthetic agents with potential toxicity and morbidity. Direct lumbar or thoracic epidural administration is an option. However, these procedures can be technically difficult in a neonate or infant. Bosenberg and colleagues from Durban investigated an alternative route of threading catheters up to the thoracic level via the caudal route. They initially investigated the feasibility of threading the catheters in 14 human cadavers (premature to 11 years) and animals (piglets). Epidural catheters could be threaded up to the required level in all infant cadavers younger than 9 months of age and in all animals. They subsequently studied 20 neonates and older infants who were to undergo biliary surgery. Under general anesthesia, epidural catheters were threaded up via the sacral hiatus to the thoracic level and their position confirmed by radiographic contrast medium injection. Bupivacaine 0.5%, 0.5 mL/kg, was administered to provide epidural analgesia in these infants. Analgesia was considered excellent in all cases, and there were no untoward incidents of hypotension, bradycardia, or arrhythmias. The authors demonstrated a technically simple alternative method of providing lumbar and thoracic epidural analgesia in small infants. [105]

Peripheral nerve blocks are not commonly attempted in children, because eliciting paresthesia to locate nerves can be painful. Eliciting paresthesia is not necessary when a peripheral nerve stimulator is used as an aid to locate and block nerves under general anesthesia. Bosenberg reported the successful use of a peripheral nerve stimulator to block femoral and sciatic nerves in 411 children undergoing lower limb surgery over an 8-year period from 1986 to 1994. The mean age was 4.25 (SD 3.8) years and mean weight was 16.8 (SD 9.4) kg, with 120 children younger than 1 year of age. The blocks were performed using unsheathed or noninsulated needles, which were easily available and not as expensive as the sheathed needles. The current required to stimulate the more superficial femoral nerve was 0.5 to 1 mA, and the deeper sciatic nerve required 1.2 to 2 mA. The overall success rate was 98% with excellent postoperative analgesia. Junior staff under supervision performed nearly 50% of the blocks. The simplicity of the techniques and the excellent surgical outcomes obtained indicate that peripheral nerve blockade in children should be used more widely. [106]

Regional Anesthesia for Postoperative Pain Relief In the last decade, acute pain services (APSs) have been established in many parts of the world for more effective Many hospitals in developing countries, particularly in Asia, have management of postoperative pain. Most of these are anesthesiology-based services enthusiastically followed this trend by establishing APSs. that provide specialized techniques, including patient-controlled analgesia (PCA) and epidural analgesia. Epidural analgesia is either by epidural opioid administration or by continuous infusion of a mixture of low-dose local anesthetic solution and opioids. [107] [108]

[109] [110] [111]

Tsui and coworkers from Hong Kong compared the efficacy of epidural infusion of bupivacaine and fentanyl with IV PCA morphine in patients undergoing gynecologic surgery. One hundred and twenty patients undergoing gynecologic surgery under general anesthesia were randomized to receive either an epidural infusion of bupivacaine 0.0625% and fentanyl 3.3 µg/mL (10 mL/hour) or IV PCA morphine (PCA bolus of 1 mg and a lockout interval of 5 minutes). Patients were monitored for the degree of pain relief and the incidence of side effects. The epidural group had a significantly lower score on the verbal rating scale (VRS) for pain both at rest and on cough in the first 40 hours after surgery. There was no incidence of hypotension or respiratory depression in both groups and no difference in the incidence of nausea. All patients were nursed in the general wards, with continuous pulse oximetry (SpO2 ) in addition to routine ward monitoring, indicating that the nurses on the general wards are capable of managing sophisticated postoperative analgesic techniques. [112]

[112]

In an audit of their APS, Tsui and coworkers reviewed the adverse effects and safety of postoperative pain management in 2509 consecutive patients at a tertiary referral teaching hospital over a 32-month period. All the patients were managed on the general wards using the APS standard monitoring protocols. Of these patients, 590 (23.5%) received a continuous infusion of either epidural bupivacaine/fentanyl or epidural morphine. Hypotension due to the analgesic technique was noted in only four patients, and this was promptly detected in the wards and [110]

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managed with no untoward effects. They demonstrated that patients receiving bupivacaine/fentanyl infusions can be safely nursed in general wards provided monitoring protocols are in place and ward staff undergo training with regard to the use of sophisticated techniques. Ketamine, an N-methyl-D-aspartate (NMDA) antagonist has been investigated to determine its role in reducing central Chia and coworkers from Taipei studied the sensitization of nociceptors and reducing postoperative pain. effect of adding a small dose of ketamine (0.4 mg/mL) to the epidural infusion in patients receiving multimodal patient-controlled epidural analgesia (PCEA) after major abdominal surgery. Ninety-one patients were divided into two groups to receive PCEA with bupivacaine 0.08%, morphine 0.02 mg/mL, epinephrine 4 µg/mL with or without the addition of ketamine. The group given ketamine had significantly better pain relief, particularly during coughing, and used less analgesic solution than the other group, demonstrating that low-dose epidural ketamine can provide an additive analgesic effect when added to a multimodal analgesic regime. [113] [114]

[113]

In a randomized, placebo-controlled study, Abdel-Ghaffar and colleagues from Saudi Arabia also investigated the effect of low-dose epidural ketamine on postoperative analgesic consumption. Sixty-one patients undergoing total abdominal hysterectomy were assigned to three groups to receive either 30 mg of epidural ketamine before induction or 20 minutes after skin incision or epidural normal saline. In the postoperative period, all patients received PCEA with low-dose bupivacaine 0.1% and fentanyl 1 µg/mL after a bolus dose of bupivacaine and fentanyl given at first request for analgesia. The time to request of first analgesic dose was significantly less in the control group (P< 0.05) compared with the other two groups. The total amount of analgesia consumed by the control group was also significantly greater (P< 0.01). There was no difference in the analgesic requirements whether the ketamine was given before or after skin incision. [114]

Ngan Kee and coworkers from Hong Kong compared a portable disposable device with a standard electronic PCEA pump in two groups of patients using PCEA after cesarean section. The disposable device was found to be just as effective as the more expensive device and allowed the patient greater mobility. The preceding studies on postoperative pain indicate that many institutions in developing countries are currently trying to improve pain management using regional analgesic strategies. [115]

Combined use of general and caudal epidural anesthesia is also widely used in children as can be seen by the several studies that have compared caudal bupivacaine plain with bupivacaine/pethidine or buprenorphine or bupivacaine/morphine or bupivacaine/midazolam. Kumar and Jacob, in a randomized controlled study of 50 children, found that although the addition of pethidine provided a significantly longer period of postoperative analgesia, there was a high incidence of vomiting and urinary retention, which would preclude the routine addition of pethidine to bupivacaine. Girotra and coworkers compared caudal buprenorphine 4 µg/kg with caudal bupivacaine 0.25% in 40 children undergoing genitourinary surgery. Both groups had excellent analgesia in the immediate postoperative period, but the buprenorphine group had analgesia for 20 to 24 hours. Gulec and colleagues from Turkey compared the effect of caudal bupivacaine with bupivacaine/morphine and bupivacaine/midazolam mixtures in 60 children undergoing inguinal or urogenital surgery. The bupivacaine/midazolam mixture resulted in a significantly longer duration of analgesia when compared with bupivacaine plain (P < 0.001) or bupivacaine/morphine (P < 0.01), but was associated with more sedation. [116]

[118]

[117]

[116]

[117]

[118]

Regional Anesthesia for Battlefield Surgery Field hospitals play an important role in managing military and civilian casualties, which result from ethnic conflicts, political strife, and warfare in many developing countries. Surgery is often performed under less than ideal conditions, on patients who need urgent procedures to prevent loss of life or limb. Anesthesia for these patients can be challenging owing to difficult circumstances such as shortage of personnel, inadequate equipment, and lack of drugs. Lenz and coworkers documented their experience of working in Red Cross missions in surgical field hospitals on the Thai-Cambodian border, in Lebanon, at the Afghan-Pakistan border, and in Indonesia. Between the years 1979 and 1984, a total of 3665 civilian emergency patients received anesthesia; 17.5% of the patients were operated on under local anesthesia, and another 17% received regional anesthesia, in most cases spinal anesthesia. The remaining patients were managed under general anesthesia, either with halothane or ketamine. Despite the primitive working conditions, there were no anesthesia-related deaths. [119]

Basic Research Several studies have concentrated on research that was not directly concerned with the effects of various drugs or techniques in patients. Bahk and coworkers from Korea conducted a study to identify a method of predicting epidural depth in adults using a patient’s readily available physical measurements. Computed tomography was used to accurately measure the epidural depth at L3–4 in 51 Korean male volunteers between the ages of 20 and 25 years. [120]

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The skin-epidural, skin-supraspinous, and supraspinous-epidural distances were measured and correlated with height, weight, shoe size, body mass index (BMI), neck circumference, waist circumference, and the ratios of weight/height, waist/neck, waist/height, and weight/neck of these volunteers. The value of the supraspinous-epidural distance was found to be independent of any physical measurement. A significant correlation was found between the skin-supraspinous distance and physical measurements that were related to obesity. The waist circumference/neck circumference ratio and BMI resulted in a higher predictive value of epidural depth than the traditional weight or weight/height ratio. Enhanced neutrophil activity constitutes an important early defense strategy against bacterial infection during and after surgery. Erskine and colleagues from Cape Town compared neutrophil biocidal activity during general and spinal anesthesia in patients undergoing hip arthroplasty. Twenty-five patients were randomized into three groups to receive either general anesthesia with halothane or isoflurane or spinal anesthesia. Assays were performed on neutrophils extracted from blood drawn 1 hour after start of surgery. Neutrophils from patients under spinal anesthesia exhibited significantly greater bactericidal activity when incubated with Staphylococcus aureus than those taken from the general anesthesia group. They suggested the possibility that either general anesthesia per se or the stress response of surgery could be responsible for inhibition of normal neutrophil activity generated by surgery. Regional blockade, which blunts the stress response, could contribute to a reduction in perioperative sepsis, but further research in this area is indicated. [121]

The precise mechanism of action of local anesthetic solutions injected into the interpleural space remains conjectural. McKenzie and Mathe from Harare studied the distribution of India ink, which was injected into the interpleural space in six cadavers. Following injection of 20 mL of the dye, autopsy revealed that the spread of the ink was uniformly wide, with a tendency to pool in the paravertebral gutter. Histologic slides of transverse sections showed normal bone, skeletal muscle, and nerve tissue with black pigment on the pleural surface and in the subpleural space. They suggest that local anesthetic solutions probably diffuse through the parietal pleural membrane, perhaps by bulk flow, into the subpleural space and access intercostal nerves. [122]

Severe bronchospasm has been reported during epidural and spinal anesthesia. This has been attributed to the sympathetic blockade associated with central neural blockade. Yuan and coworkers from Taipei investigated the effects of high thoracic epidural anesthesia on peripheral airway reactivity in an animal model. Peripheral airway resistance was recorded under steady state conditions in seven mongrel dogs under thiopentone anesthesia. The animals were then challenged with acetylcholine 8 µg/kg, and histamine, 3 µg/kg, consecutively before and after establishing thoracic epidural anesthesia with bupivacaine. Thoracic epidural anesthesia did not alter the baseline peripheral airway resistance and did not affect peak airway resistance induced with acetylcholine and histamine. They noted, however, that the recovery time of airway resistance was significantly prolonged with epidural anesthesia, and this was inversely related to the change in cardiac output. They suggested that decrease in cardiac output might be an important factor in the recovery of airways from any stimulus that produces bronchoconstriction. [123]

Patients with diabetes mellitus often require surgery of the lower limbs because of complications such as nonhealing ulcers and ischemic gangrene. Regional anesthesia is often the anesthetic of choice. Long-term diabetic patients have incipient multiorgan dysfunction that may alter the way in which they metabolize local anesthetic drugs. Peeyush and coworkers from India studied the pharmacokinetic profile of lignocaine administered by the epidural route in eight well-controlled patients with type 2 diabetes mellitus and compared it with a similar group of patients without diabetes. Epidural lignocaine 8 mg/kg was administered by the lumbar route, and plasma drug concentration in serial blood samples was measured by the HPLC technique. The plasma level of lignocaine was lower in diabetic patients, although the peak level was obtained at 20 minutes in both groups. The clearance of the drug was significantly higher (39.9 mL/kg/min vs. 16.7 mL/kg/min) and was associated with a decreased elimination half-life. This suggested that the rate of absorption of the drug was not altered but that hepatic metabolism was increased in diabetic patients compared with nondiabetic patients. This may have implications when setting infusion rates for long-term infusion of lignocaine in patients with diabetes mellitus. [124]

Regional Anesthesia for Chronic Pain Management Patients with reflex sympathetic dystrophy (RSD) are generally resistant to a variety of conventional pain management regimens and often suffer from severe pain, allodynia, hyperesthesia, swelling, and loss of function of the extremity involved. Lin and coworkers from Taipei report two cases in which they used a combination of epidural ketamine, morphine, and bupivacaine. Two patients failed to obtain satisfactory pain relief from nonsteroidal anti-inflammatory drugs, steroids, anticonvulsants, antidepressants, epidural lignocaine sympathectomy, and rehabilitation. Both suffered from severe pain in their right leg due to RSD. Ketamine 7.5 mg, morphine 0.75 mg, and 6 mL of bupivacaine 0.1% were injected three times a day via a lumbar epidural catheter for a period of 1 week. Rehabilitation was initiated with the onset of some pain relief. Several courses of treatment over [125]

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3 and 6 months achieved satisfactory pain relief in both patients. At the end of 6 months, both patients were able to manage slight weight bearing in walking with the help of a crutch.

Acupuncture and Analgesia Acupuncture analgesia is not really classified as a regional anesthetic technique. In some countries, however, acupuncture analgesia is practiced as a substitute or to enhance the effect of local anesthesia in certain surgical procedures. Chen and Chen from Shanghai reviewed the records of 1622 patients undergoing appendectomy under acupuncture analgesia from 1970 to 1982. The success rate for acupuncture was noted to be 96.6%, and it was possible to achieve this result by following a set of strict guidelines for its use. These guidelines included stringent selection of cases, acupuncture point selection based on symptoms and maintenance of needling sensation, relatively fixed group of surgeons and assistants, improvement of operative technique, and a reasonable use of adjuvant drugs. No mention was made of the extent of adjuvant drugs used. [126]

[127]

Sun and coworkers from Inner Mongolia compared acupuncture analgesia with epidural anesthesia in 80 patients who required appendectomy. Patients were randomly assigned to receive either lumbar epidural anesthesia with local anesthesia or acupuncture using Zusanli points (ST-36) as the main stimulating points and Hegu points (LI-4) as auxiliaries. The patients who had been given acupuncture had less hypotension and fewer cardiac arrhythmias and required less IV infusion than those in the epidural group. They also required less analgesia and antibiotics in the postoperative period. [128]

The mechanism of action of acupuncture analgesia is not known, although it has been extensively practiced in China for many years. For success with this technique, patient and surgeon must cooperate fully. Acupuncture imposes considerable limitations on the surgeon and requires careful surgical technique. It may have only a limited role in contemporary anesthetic practice. [126]

Survey of the Practice of Regional Anesthesia in Asian Countries A survey was undertaken to assess the role of regional anesthetic techniques in current anesthetic practice in Asian countries and to identify any factors that may influence their use. The survey included anesthetic departments of various hospitals in the East and South Asian region. They were chosen from the mailing list of members of the Asia Oceanic Society of Regional Anesthesia, from addresses of authors in recent publications, and from personal contact with anesthetic colleagues in the region. Questionnaires were mailed or sent by e-mail (when available) in the beginning of November 1998. Japan was excluded, as it is not considered a developing country. The questionnaire included items that sought to identify the type of institution, different regional anesthetic techniques used in these institutions, the percentage of patients who were operated on under regional anesthesia alone, obstetric anesthetic practice, and the comparative costs of regional and general anesthesia. Other questions were on the use of epidural analgesia in the postoperative period, availability of acute pain services, the type of local anesthetic drugs available, and the type of spinal needles used. Four questions focused on postgraduate training in anesthesia for doctors and the training of nurse anesthetists. Checkoff options were provided for each item to facilitate response. In addition, they were invited to make general comments on the practice of regional anesthesia in their countries. The project was discontinued in the middle of January 1999.

RESULTS Questionnaires were posted to 61 institutions. Twenty-six were returned by the second week of January 1999, giving a response rate of 42.6%. One letter sent to Iraq was returned with the word “service suspended” (presumably, the postal service). Eighteen university teaching hospitals, six state general hospitals, one provincial hospital, and one urban private hospital responded from India, China, Malaysia, Sri Lanka, Myanmar, Taiwan, Korea, Thailand, Papua New Guinea, Hong Kong, Singapore, and Bangladesh. There was no response from the Philippines, Indonesia, Pakistan, Nepal, Iran, and Saudi Arabia. The annual number of surgeries performed annually was a mean of 16,300 (range, 5000 to 47,000). The number of specialist staff in these institutions ranged from one (Papua New Guinea) to 54 (Thailand), with a mean of 16 specialists. The number of trainee anesthetists ranged from none (urban private center) to 65 (Sri Lanka), with a mean of 22 trainees. Figure 7-1 shows the percentage of surgical procedures performed under regional anesthesia alone in the different institutions surveyed. In the majority of hospitals, it was between 20% and 30%. Central Women’s Hospital from Yangon, Myanmar, had the highest rate (>80%). Both hospitals that responded from the People’s Republic of China (Shanghai and Beijing) reported a rate between 59% and 60%, and the lowest rate (<10%) was from Hong Kong.

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In 21 of 26 (80.7%) hospitals, spinal and epidural anesthesia constituted 80% of all regional anesthetic practice, with peripheral nerve blockade (PNB) making up the other 20%. Only 4 of 26 reported that PNB was used in 40% of their practice (Boroka, Papua New Guinea; Galle, Sri Lanka; Shanghai, China; and Vellore, India). Only three institutions (11.5%) reported using peripheral nerve stimulators regularly ( Table 7-4 ). PNBs appear to be underutilized. Figures 7-2 A and 7-2B show the extent to which the various regional anesthetic techniques are used in the institutions surveyed. Central neuraxial blockade (spinal and epidural anesthesia) was used in all hospitals, and most hospitals routinely used catheters for epidural anesthesia. Fifty percent of the hospitals were also familiar with combined spinal epidural anesthesia, whereas only 4 of 26 (15.3%) used continuous spinal anesthesia. Lower limb blocks were also less frequently used than upper limb blocks, which may be expected, because spinal and epidural anesthesia is commonly used for lower limb surgery. IV regional anesthesia had a surprisingly low rate of usage (50%) for such a simple technique. It may be due to the lack of availability of prilocaine in many countries. Interpleural block was also used infrequently (26.9%). Other blocks performed occasionally were ankle block, paravertebral block, and block of the dorsal nerve of the penis. Regional anesthesia, either spinal (18 of 26) or epidural (3 of 26) was used for cesarean section in the majority of hospitals. Twelve of the institutions responded that spinal anesthesia had been used for many years (range, 10 to 45 years), whereas the remaining hospitals reported that the use of regional anesthesia was a recent trend (1 to 5 years). Three hospitals reported using general anesthesia routinely, and two hospitals did not have an obstetric unit. The commonest gauge of spinal needle in use was 25-G, with some hospitals also using 27-G needles. The cutting bevel Quincke needle continues to be popular, although the pencil point and Sprotte needles were also available in 50% and 23% of those surveyed. Only seven institutions routinely offered epidural analgesia for labor pain (see Table 7-4 ). The common reasons cited for not offering an epidural analgesia service was shortage of staff, inadequate monitoring facilities in the labor ward, and preference of the obstetrician (23.0%). The majority of hospitals combined regional anesthesia and general anesthesia for major abdominal, major orthopedic, thoracic, and pediatric surgery (see Table 7-4 ). Postoperative epidural analgesia was available in 23 of 26 (88.0%) of the hospitals surveyed; 60% of them nursed these patients on the general wards, and the rest sent them to high-dependency units. Table 7-4 also shows that an APS was available in 61.5% of the hospitals surveyed. Spinal opioids were routinely used for postoperative pain relief in 15 of 26 (57.7%) institutions. Lignocaine and bupivacaine were reported to be freely available in all countries, but three countries reported the availability of the newer local anesthetic drug, ropivacaine. Prilocaine was available in three countries. Hyperbaric bupivacaine 0.5% was the most frequently used local anesthetic agent for spinal anesthesia in all institutions. Bupivacaine 0.5% plain and lignocaine 5% heavy was also routinely used in 23% and 31% of hospitals, respectively. All but one hospital reported that the cost of regional anesthesia was definitely less (range, 30%–70%) than the cost of general anesthesia for a similar procedure. Most of the difference TABLE 7-4 -- SURVEY OF THE PRACTICE OF REGIONAL ANESTHESIA IN 26 HOSPITALS Selected Questionnaire Items

Yes

No

Occasionally

Do you combine general anesthesia with regional anesthesia?

22

3

1

Do you use peripheral nerve stimulators?

3

11

12

Are catheters used routinely for epidural anesthesia?

26

-

-

If yes, are they used for postoperative pain relief?

22

3

1

14

8

-

Do you use spinal opioids for postoperative pain relief? *

If yes, do you use them in general wards?

15

5

-

Does your hospital have an acute pain service?

16

10

If regional anesthesia is used for cesarean section, is this a recent trend?

9

12

Is epidural analgesia offered for labor routinely?

7

8

*Six hospitals did not respond to this question. †Not a recent trend. Regional anesthesia has been used for the last 10 to 45 years.

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†

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Figure 7-2 Percentage of hospitals using the different techniques of regional anesthesia. A, Central neuraxial block. B, Peripheral nerve blocks. CSE, combined spinal-epidural analgesia; Cont, continuous; Epi-cath, epidural catheter; Epi-SS, epidural—single shot.

lay in the cost of expensive general anesthetic agents. In China, the cost of 5 mL of bupivacaine 0.75% was noted as less than $1.00 (U.S. currency), whereas the cost of 100 mL of isoflurane was $110 (U.S. currency). Similarly, in Malaysia, the cost of 4 mL of heavy bupivacaine 0.5% was $2.50 (U.S. currency), and isoflurane (100-mL bottle) costs $100 (U.S. currency). All institutions reported that postgraduate diplomas and degrees in anesthesia were available in their countries and that training in regional anesthesia was considered important. Nurses were trained to administer anesthesia in Thailand, Korea, Taiwan, and Papua New Guinea. In Malaysia, medical assistants (a category similar to that of male nurse) were trained to provide anesthesia only in East Malaysia, to serve the remote rural hospitals of Sabah and Sarawak. In the last 2 years, they have been taught to provide spinal anesthesia. In West Malaysia, doctors provided anesthesia even in the small district hospitals. Nurses in Taiwan and Papua New Guinea were also taught regional anesthetic techniques such as spinal and epidural anesthesia. Once accredited, these nurses and medical assistants serve rural hospitals and work under the supervision of the surgeon.

DISCUSSION The limitation of this survey is that it reflects only the practice of regional anesthesia in the institutions that responded. The sample size was small, mainly because of the difficulty in obtaining the names and addresses of hospitals in different countries. There is no Asian directory or list of hospitals available that one could choose from. The Asia Oceanic Society of Regional Anesthesia mailing list was chosen because it was the most up-to-date list available, but many of the members had to be ruled out because they were from Australia and Japan. Internet search for Web sites yielded a few addresses. Another limitation was that of time. Two months was rather short, and it was not possible to send a round of reminders to those who did not respond. The lack of response from the Philippine Islands and Indonesia was disappointing because both of them together have a population of 260 million people. Nevertheless, the 40% response rate was reasonable given the short period of time. There was at least one response from 12 of the 19 countries that were sent questionnaires. The comments made by some of the senior staff of these institutions were the most interesting part of the survey. Regional anesthesia alone was used in 20% to 29% of surgical procedures in the majority of hospitals. It was interesting to note that there was a marked difference between anesthetic practice in Shanghai/Beijing in Mainland China and Hong Kong. This difference could reflect the difference in the facilities available in the two regions, which have been two regions in the same country only since July 1997. Regional anesthesia was usually combined with general anesthesia except for obstetrics in Hong Kong, and this practice could be attributed to a greater degree of affluence in Hong Kong than exists in Shanghai or Beijing. With regard to the type of regional anesthetic techniques practiced, central neuraxial blockade was a major component of the practice of regional anesthesia in most hospitals. PNBs appear to be underutilized, particularly lower limb blocks. This practice could be due to lower success rates with blocks, which again is probably due to not using peripheral nerve stimulators routinely. Peripheral nerve stimulators may not be available in the hospitals that did not use them. Underutilization of PNB has been reported in a recently published survey of the use of PNB in anesthetic practice in the United States. [129]

Professor Zheng Liping from Beijing wrote as follows: Prior to 1980, about 80% of all surgery was performed under regional anesthesia, which included continuous epidural anesthesia, spinal, and plexus blockade. With increase in anesthetic staff and better facilities available since the 1980s, general anesthesia has become popular. Continuous epidural anesthesia is the most widely used technique. Thyroid, breast, and, often, upper limb surgery is performed under continuous cervical epidural anesthesia. The combined spinal and epidural anesthesia technique has recently increased the use of spinal anesthesia. However, the cost of the needles prevents more widespread use. In the larger metropolitan hospitals of China, the ratio of general to regional anesthesia is now 1:1; however, in district hospitals, regional anesthesia is widely practiced. The reasons for its popularity are (1) anesthetists generally feel it is safer and prefer it; (2) regional anesthesia is a lot cheaper than general anesthesia; (3) facilities for general anesthesia are limited or not available; hence, there is no choice but to use regional anesthesia. Professor Zheng also quoted a recent survey of 413 hospitals in China where 50% of the hospitals were large urban hospitals and the remainder were regional hospitals. The best facilities for anesthesia were concentrated in large hospitals associated with universities, whereas regional hospitals were poorly equipped, with some not having even a simple general anesthetic machine (unpublished data).

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Dr. N. Rodrigo from Sri Lanka wrote: We are all for regional anesthesia! The most popular is spinal for cesarean section. It has been used in Sri Lanka for many years and its popularity did not wane even when it disappeared from the United Kigdom after the Woolley and Roe case. The pencil point and 25-G needles, now available, have cut down the incidence of headache considerably. In the large teaching hospitals, epidural analgesia is routinely offered to primiparas in labor; whereas, spinal morphine or fentanyl is offered to multiparas. Obstetricians prefer general anesthesia due to the slightly longer time taken to establish regional anesthesia! Plexus blocks are less popular because of a higher failure rate and delay in onset. With regards to cost, a spinal needle and bupivacaine costs Rs.500; whereas, the cost of general anesthesia for 3 hours is approximately Rs. 3000. Dr. Chia (Taiwan) commented that the reimbursement for general anesthesia is higher than that for regional anesthesia from the health insurance scheme; hence, a majority of surgical procedures were performed under general anesthesia. Major thoracic and abdominal surgery was performed under combined general and regional anesthesia, and postoperative epidural analgesia was offered routinely in their hospital. However, health insurance did not cover postoperative analgesia and patients had to pay for this service. There was a shortage of anesthesiologists in rural Taiwan; therefore, nurses or surgeons conducted most of the anesthesia in those areas, with a resulting increase in morbidity rate. Professor T. T. Khing from Myanmar noted: If a survey of the whole of Myanmar were done, then regional anesthetic techniques will constitute 80% of anesthesia for all surgical procedures. Lignocaine is the commonest local anesthetic used both for spinal and epidural anesthesia. General anesthesia in rural areas consists of ether supplemented by oxygen via oxygen concentrators. Centers in India sent the following comments: Regional anesthetic techniques such as spinal and epidurals are widely used. Spinal anesthesia is a common technique even in remote areas of the country and local anesthetic drugs are freely available. Regional anesthesia is definitely less expensive than general anesthesia. A large number of local anesthetic blocks are used by ophthalmic and ENT surgeons. From Papua New Guinea comes: Bupivacaine has been used for regional anesthesia only in the last 2 years. Siriraj Hospital, Bangkok, Thailand noted: The information in this questionnaire does not truly reflect the practice of regional anesthesia in the whole of Thailand, as Siriraj Hospital is the largest training hospital in Thailand. The problem of shortage of anesthetists in rural areas persists. Nurse anesthetists provide anesthetic services in these areas, and they are not taught regional anesthetic techniques. Spinal anesthesia is occasionally performed by surgeons and the patients monitored by nurse anesthetists.

Summary Regional anesthesia is practiced in most developing countries. The extent of practice varies enormously between countries and depends largely on the economic situation and the type of healthcare system in place in individual countries. In countries where there is a larger pool of physician anesthetists, regional anesthesia is more extensively practiced than in countries that are less developed and depend largely on nurse anesthetists. Professor Paul Fenton from Malawi commented: The general trend all over Africa is for general anesthesia. Nurse anesthetists provide anesthesia in a large number of hospitals. With regard to regional block there is only one block and that is spinal. Nerve blocks, Bier blocks, and epidurals are used only occasionally (personal communication).

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Spinal and epidural anesthesia are the most commonly used of all the regional anesthetic techniques. Regional anesthesia is also extensively used for cesarean sections in keeping with worldwide trends. Caudal epidural anesthesia is also widely used, along with general anesthesia in children, to provide intra- and postoperative analgesia. With increased understanding of the stress response to surgery and the need to provide better postoperative analgesia, there appears to be an increasing trend toward combining regional anesthesia with general anesthesia for major surgery. The increasing popularity of regional anesthesia in developing countries of Asia, Eastern Europe, and South America could also be due to the role of the European, Asian and Oceanic, and Latin American societies of regional anesthesia. The cost of providing regional anesthesia is less, sometimes substantially less, than the cost of an equivalent general anesthetic. The last two decades have seen a rapid escalation of healthcare costs all over the world, and developing countries have not been spared. The current economic crisis engulfing Asia and many other developing countries has brought about a greater awareness of providing more cost-effective methods of management, and this could lead to a greater use of regional anesthesia.

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Chapter 8 - Training and Education of a Physician for Regional Anesthesia COLIN J. L. McCARTNEY VINCENT W. S. CHAN

To achieve consistently successful outcomes with regional anesthesia, practitioners must have adequate knowledge and experience. Increasing pressure on both trainers and trainees, combined with the complexity of modern general anesthetic agents, has caused anesthetic trainees to become less familiar and thus less confident in the practice of many regional anesthetic techniques. Often, it is easier to give a general anesthetic, especially when faced with a tight operating room schedule, or a surgeon or patient who does not appreciate the benefits of regional anesthesia. As a result, a lack of familiarity with regional anesthetic techniques among trainers can lead to a consequent decrease in exposure for trainees. However, regional anesthesia offers many advantages over general anesthesia, including reduction in postoperative pain, nausea, and sedation. The results of a large meta-analysis published in 2000 showed that regional anesthesia was superior to general anesthesia, with a decrease in morbidity and mortality rates. The reasons for teaching residents to use regional anesthesia are, therefore, becoming clearer to anesthesiologists. In addition, because regional anesthesia is an important option for so many surgical procedures, there is a responsibility for training centers to ensure that all trainees are familiar with the most common regional anesthesia techniques by the time they have completed their training. [1]

[2]

This chapter examines the teaching of regional anesthesia techniques to both physicians in training and those who have completed their training. The parameters that are currently regarded as acceptable for adequate training are presented as well as the best time frame to provide this training. Finally, current assessment methods for regional anesthesia skills are discussed.

Why Teach Anesthesiologists Regional Anesthesia? Regional anesthesia is an important part of the anesthesiologist’s armamentarium. It provides an alternative to general anesthesia and is customarily performed in “difficult” surgical patients whose severe or unstable disease processes make general anesthesia undesirable. These patients include those in whom airway manipulation could precipitate bronchospasm, those for whom general anesthesia might compromise an unstable cervical spine, or those in whom disturbance of respiratory function could result in decompensation. Regional anesthesia may be beneficial if the patient’s sympathetic response to tracheal intubation may aggravate myocardial ischemia or if general anesthesia is likely to cause cognitive dysfunction. Regional anesthesia is particularly indicated for patients undergoing peripheral limb surgery, because it provides effective intraoperative anesthesia and postoperative pain control. However, regional anesthesia should not be reserved for only the most challenging anesthetic cases. Regional anesthesia also offers some unique perioperative advantages over general anesthesia. Administration of local anesthetics or other analgesic adjuncts into the subarachnoid or epidural space during and after surgery can attenuate surgical stress response and therefore lessen the degree of perioperative catabolism and hypermetabolism commonly seen when general anesthesia is performed alone. Regional anesthesia also provides effective pain control after surgery, especially when a continuous catheter technique is combined with a constant analgesic infusion. Reduction of postoperative pain at rest and with movement can further reduce postoperative morbidity and hasten convalescence, which is especially beneficial for patients after thoracic surgery. Increased use of regional analgesic techniques significantly reduces dependence on systemic opioids, thus lowering the incidence of opioid-related side effects such as nausea, vomiting, and sedation in outpatients and of postoperative paralytic ileus in patients who have had bowel surgery. Studies in the literature support the application of regional anesthesia in high-risk surgical patients, particularly with respect to modifying cardiac and respiratory morbidity rates. Some studies confirm the beneficial effects of regional anesthesia in patients undergoing major vascular surgery, showing a reduction in the incidence of graft occlusion and myocardial ischemia. Several meta-analyses confirm a reduction of pulmonary morbidity rates for patients after thoracotomy and major abdominal surgery when thoracic epidural analgesia is applied. Data concerning patients undergoing bowel surgery also advocate the use of thoracic epidural analgesia with local [3] [4]

[5]

[6]

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anesthetic, with or without opioid, to speed up recovery from paralytic ileus. The beneficial effects of regional anesthesia on blood loss and thromboembolic complications are well documented. [7] [8]

[2]

There are, therefore, many clinical advantages associated with use of regional anesthesia. The success of regional anesthesia is heavily dependent on the technical skill of the anesthesiologist; hence, educating anesthesiologists in regional anesthesia remains a vital part of any anesthesia training program.

Methods for Teaching Regional Anesthesia The ability to perform any regional technique adequately is based on the anesthesiologist’s sound knowledge of anatomy combined with sufficient clinical experience to achieve consistently good results. Traditionally, the theoretical knowledge required to perform any regional anesthetic technique has been found in textbooks such as this. Other methods for teaching include lectures and tutorials, video demonstrations, and workshops with hands-on experience. In addition, more recently, a number of CD-ROMs that provide instruction in regional anesthesia have become available. However, the technology has to date fallen short of the ability to provide simulation of blocks in a virtual reality environment. Other modern media have made available many resources for learning. In particular, there are many excellent resources on the Internet. The best of these resources, along with summaries of the information presented, are listed in Table 8–1 . These resources provide instruction, often with video accompaniment and anatomic drawings, as well as tests of knowledge with the opportunity to complete on-line continuing medical education exercises.

When Is the Ideal Time to Learn Regional Anesthesia Techniques? It seems logical that the best time to begin learning about regional anesthesia is as early in training as possible. The principles of good knowledge of anatomy and block technique that ensure success apply to many regional anesthesia techniques. If these principles are learned early, trainees become confident of their technical ability. This confidence facilitates learning new anesthesia techniques later in their medical careers. In most training programs, obstetric and orthopedic experience tends to occur earlier, and these are the areas in which the majority of clinical experience with regional anesthesia takes place. Later in the training program, more emphasis is placed on the major subspecialties, which potentially offer fewer opportunities for experience in regional anesthesia. Thus, for trainees who have no specialized interest in regional anesthesia, optimal training would reasonably include an early overall experience of regional techniques, followed by regular updates as the trainees progress through the program. For those who would like to pursue regional anesthesia as a subspecialty, it would seem logical that they should complete a fellowship year after training.

What Constitutes Adequate Training in Regional Anesthesia? What constitutes adequate training in regional anesthesia has not been defined. In the past, regional anesthesia TABLE 8-1 -- REGIONAL ANESTHESIA RESOURCES ON THE INTERNET Site

URL

Features

American Society of Regional Anesthesia

www.asra.com

Details of meetings and review courses, CME for members

Pain.com (regional anesthesia section)

www.pain.com/regional/default.cfm

Instructional videos, library, CME, RA forum

Virtual Anaesthesia Textbook

www.virtual-anaesthesia-textbook.com/vat/ anatomy.html

Anatomy demonstrations and video of nerve stimulation

Global Textbook of Anesthesiology

www.gasnet.org/gta/#regional

Cervical block for carotid endarterectomy, techniques of orbital RA

St. Luke’s Roosevelt Hospital Center, NY

www.nysora.com/

RA techniques as practiced at St. Luke’s Hospital Center, NY

Cleveland Clinic Manual of Orthopedic Anesthesia

www.anes.ccf.org:8080/pilot/ortho/ orthintr.htm

Manual of orthopedic anesthesia for residents

Illustrated notes in regional anesthesia

www.depts.washington.edu/anesth/regional/ welcome.html

Brachial plexus, femoral, sciatic and stellate blocks with images

CME, continuing medical education; RA, regional anesthesia.

was taught in many institutions in a haphazard manner, and trainees were often left to pursue experience in regional anesthesia on their own. A common complaint among many anesthetists after completion of training is their lack of

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experience in performing regional techniques. However, the benefits of good training in regional anesthesia are evident. Trainees who complete their programs with confidence in their regional anesthesia skills are often more willing to continue regional anesthesia practice afterward. [9]

What constitutes a core knowledge of regional anesthesia by completion of training is a controversial topic, but it would seem reasonable to expect a competent practicing anesthesiologist to be able, if necessary, to perform regional anesthesia on any part of the body below the neck level. Thus, it would seem essential that all anesthetists should be competent to perform thoracic or lumbar epidural and spinal anesthesia as well as at least one regional method of anesthetizing the upper limb, such as axillary brachial plexus block. Journal articles have shown that in North America a large variation exists in trainees’ performance of regional anesthesia techniques ( Fig. 8–1 ). The majority of their experience is derived from performing central neuraxial blocks, particularly for obstetric cases, and they have less experience with peripheral nerve block techniques. Peripheral nerve blocks provide excellent anesthesia and postoperative analgesia for upper and lower limb surgery. Many anesthetists are unfamiliar with the practice of peripheral nerve blocks, especially of lower limb blocks. Lower limb regional anesthesia may become increasingly important for lower limb surgery owing to the increased use of potent antithrombolytic drugs and the potential complications from those drugs that may stem from use of central neuraxial techniques. [10]

[11]

It has been estimated that residents in the United States may finish training having performed no more than 3 spinal, 27 epidural, and 7 peripheral nerve blocks. Moreover, instruction in administering nerve blocks may occur several years before the training period is complete. This level of experience does not constitute adequate training in regional anesthesia.

Assessing Adequate Training in Regional Anesthesia Attempts have been made in the past few years to determine what constitutes adequate training in several anesthesia-related practical procedures, including regional anesthesia techniques. Most investigators have concentrated on quantitative methods.

QUANTITATIVE ASSESSMENT METHODS Several investigators have made efforts to determine the number of blocks that have to be performed to achieve a consistent level of success. Kopacz and coworkers examined epidural and spinal anesthesia and found that to consistently achieve more than an 80% success rate, 60 attempts and 41 to 45 attempts, respectively, were required. In a similar study, Konrad and coworkers found results similar to those of Kopacz and coworkers for epidural and spinal anesthesia and noted that 60 attempts were required to learn axillary brachial plexus block using a nerve stimulator technique ( Fig. 8–2 ). Other investigators in other areas of anesthesia practice and medicine have found similar results for learning new technical skills as diverse as upper and lower gastrointestinal endoscopy and All reports noted that about 20 attempts were required to achieve a marked managing cardiac anesthesia patients. improvement. However, this number was followed by a plateau or a decrease in success that was [12]

[13]

[14] [15]

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Figure 8-1 Disparities in the amount of regional anesthesia used in training programs in the United States.(From Kopacz DJ, Bridenbaugh LD: Are anesthesia residency programs failing regional anesthesia? The past, present, and future. Reg Anesth 18:84–87, 1993.)

Figure 8-2 Illustration of typical learning curve for a regional anesthesia procedure using quantitative teaching methods (axillary brachial plexus block).(From Konrad C, Schupfer G, Wietlisbach M, et al: Learning manual skills in anesthesiology: Is there a recommended number of cases for anesthetic procedures? Anesth Analg 86:635–639, 1998.)

only reversed after 45 to 60 attempts, when the expected level of skill was eventually acquired. For most teaching programs, providing trainees with this level of experience would require restructuring of departmental staff to successfully increase trainee exposure. Training based on quantitative assessment methods alone would probably mean that during the short period of time that any trainee spends in the anesthesia apprenticeship (between 4 and 7 years, depending on the training scheme), it would be necessary to concentrate on a number of essential core regional anesthesia techniques, with the goal of achieving a satisfactory level of experience in these techniques before completion of training. The volume of experience required to achieve necessary skills (as assessed by quantitative methods) is not available in many training programs. This has led to an appraisal of qualitative methods of training and assessment. [11]

QUALITATIVE ASSESSMENT METHODS Qualitative training and assessment have been developed in the last few years, primarily in surgical training programs that have had less clinical material available for training. In common with regional anesthesia, the surgical

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specialties must also certify competency in technical tasks, and mos