James R. Hebl

ASRA Practice Advisory on Neurologic Complications in Regional Anesthesia and Pain Medicine

Neurologic complications associated with regional anesthesia and pain medicine practice are extremely rare. The ASRA Practice Advisory on Neurologic Complications in Regional Anesthesia and Pain Medicine addresses the etiology, differential diagnosis, prevention, and treatment of these complications. This Advisory does not focus on hemorrhagic and infectious complications, because they have been addressed by other recent ASRA Practice Advisories. The current Practice Advisory offers recommendations to aid in the understanding and potential limitation of neurologic complications that may arise during the practice of regional anesthesia and pain medicine.

Use of Lean and Six Sigma Methodology to Improve Operating Room Efficiency in a High-Volume Tertiary-Care Academic Medical Center

BACKGROUND Operating rooms (ORs) are resource-intense and costly hospital units. Maximizing OR efficiency is essential to maintaining an economically viable institution. OR efficiency projects often focus on a limited number of ORs or cases. Efforts across an entire OR suite have not been reported. Lean and Six Sigma methodologies were developed in the manufacturing industry to increase efficiency by eliminating non-value-added steps. We applied Lean and Six Sigma methodologies across an entire surgical suite to improve efficiency. STUDY DESIGN A multidisciplinary surgical process improvement team constructed a value stream map of the entire surgical process from the decision for surgery to discharge. Each process step was analyzed in 3 domains, ie, personnel, information processed, and time. Multidisciplinary teams addressed 5 work streams to increase value at each step: minimizing volume variation; streamlining the preoperative process; reducing nonoperative time; eliminating redundant information; and promoting employee engagement. Process improvements were implemented sequentially in surgical specialties. Key performance metrics were collected before and after implementation. RESULTS Across 3 surgical specialties, process redesign resulted in substantial improvements in on-time starts and reduction in number of cases past 5 pm. Substantial gains were achieved in nonoperative time, staff overtime, and ORs saved. These changes resulted in substantial increases in margin/OR/day. CONCLUSIONS Use of Lean and Six Sigma methodologies increased OR efficiency and financial performance across an entire operating suite. Process mapping, leadership support, staff engagement, and sharing performance metrics are keys to enhancing OR efficiency. The performance gains were substantial, sustainable, positive financially, and transferrable to other specialties.

Upper extremity regional anesthesia. Essentials of our current understanding, 2008

Brachial plexus blockade is the cornerstone of the peripheral nerve regional anesthesia practice of most anesthesiologists. As part of the American Society of Regional Anesthesia and Pain Medicines commitment to providing intensive evidence-based education related to regional anesthesia and analgesia, this article is a complete update of our 2002 comprehensive review of upper extremity anesthesia. The text of the review focuses on (1) pertinent anatomy, (2) approaches to the brachial plexus and techniques that optimize block quality, (4) local anesthetic and adjuvant pharmacology, (5) complications, (6) perioperative issues, and (6) challenges for future research.

The Importance and Implications of Aseptic Techniques During Regional Anesthesia

nfectious complications may occur with any re-gional anesthetic technique. However, those as-sociated with neuraxial anesthesia and analgesiaare of greatest concern because of their potentiallydevastating sequelae including meningitis, paraly-sis, and even death. Fortunately, the frequency ofsuch complications appears to be relatively low.Aromaa et al.

Brachial plexus anesthesia: Essentials of our current understanding☆

Brachial plexus regional anesthesia has been a mainstay of the anesthesiologist’s armamentarium since Hall1 first reported the use of cocaine to block upper extremity nerves in 1884. The American Society of Regional Anesthesia and Pain Medicine (ASRA) has sponsored a unique educational endeavor to provide practitioners and academicians alike with a comprehensive resource pertaining to brachial plexus anesthesia. Initially presented as an all-inclusive workshop at its May 2001 meeting, the material is available in its entirety on the ASRA Web site (www.asra.com). This review is a summary that presents the essential scholarly work resulting from this effort. It strives to (1) serve as a review of pertinent brachial plexus anatomy, (2) compare the efficacy of brachial plexus approaches and techniques, (3) describe the complications inherent to brachial plexus anesthesia, and (4) present available evidence to guide selection of drugs. Because evidence-based data pertaining to brachial plexus anesthesia is incomplete, we acknowledge informational gaps and emphasize areas in which we believe further study is needed. Readers desiring a more in-depth discussion of specific topics will find it in the Web site source documents, which also include additional anatomic photographs. Brachial Plexus Anatomy

Neurologic Complications of 405 Consecutive Continuous Axillary Catheters

Continuous axillary brachial plexus block may theoretically increase the risk of neurologic complications because of catheter-induced mechanical trauma or local anesthetic toxicity. In this study, we retrospectively reviewed the frequency of complications using current techniques and applications. There were 405 continuous axillary catheters in 368 patients. A preexisting neurologic condition was present in 41 (10.1%) patients, including 30 patients with a preoperative ulnar neuropathy. In 305 (75.3%) cases, the axillary catheter was placed to facilitate rehabilitation after major elbow surgery. Catheters were typically placed postoperatively, after documentation of the patient’s normal neurologic examination. The local anesthetic infusion contained bupivacaine in 355 (88.7%) patients and mepivacaine in 45 (11.1%) patients. The mean infusion rate was 10 ± 2 mL/h. Catheters remained indwelling for 55 ± 32 h. In 31 patients, the axillary catheter was replaced because of technical problems or inadequate analgesia. There were 9 complications in 8 patients for an overall frequency of 2.2%. Complications included one each of the following: localized infection (treated with catheter removal and antibiotics), axillary hematoma, and retained catheter fragment requiring surgical excision. In addition, two patients reported signs and symptoms of systemic (preseizure) local anesthetic toxicity. Four (1.0%) patients reported new neurologic deficits postoperatively. In two patients, the neural dysfunction was non-anesthesia related. All four had continuous catheters placed after major elbow surgery. We conclude that the risk of neurologic complications associated with continuous axillary blockade is similar to that of single-dose techniques.

Analgesia for Total Hip and Knee Arthroplasty: A Multimodal Pathway Featuring Peripheral Nerve Block

Patients undergoing total hip and knee arthroplasty experience substantial and sustained postoperative pain. Inadequate analgesia may impede physical therapy and rehabilitative efforts and delay hospital dismissal. Traditionally, postoperative analgesia after total joint replacement was provided by either intravenous patient-controlled analgesia or epidural analgesia. Each, however, had disadvantages as well as advantages. Peripheral nerve blockade of the lumbosacral plexus has emerged as an alternative analgesic approach. In several studies, unilateral peripheral block provided a quality of analgesia and functional outcomes similar to those of continuous epidural analgesia and superior to those of systemic analgesia, but with fewer side effects because of their opioid-sparing properties. Peripheral nerve block techniques may be the optimal analgesic method following total joint arthroplasty.

Anesthetic, patient, and surgical risk factors for neurologic complications after prolonged total tourniquet time during total knee arthroplasty

Nerve injury after prolonged tourniquet inflation results from the combined effects of ischemia and mechanical trauma. Tourniquet release, allowing a reperfusion interval of 10–30 min followed by re-inflation, has been recommended to extend the duration of total tourniquet time. However, this practice has not been confirmed clinically. We retrospectively reviewed the medical records of 1001 patients undergoing 1166 primary or revision knee replacements with tourniquet time more than 120 min during a 5-yr interval. Mean total tourniquet time was 145 ± 25 min (range, 120–308 min). In 759 patients, the tourniquet inflation was uninterrupted. Two tourniquet inflations, interrupted by a single deflation, were noted in 371 patients, and 3 tourniquet inflations interrupted by 2 deflation intervals were noted in 23 patients. A total of 129 neurologic complications (peroneal and/or tibial nerve palsies) were noted in 90 patients for an overall incidence of 7.7%. Eighty-five cases involved the peroneal nerve and 44 cases involved the tibial nerve. In 39 cases, both peroneal and tibial deficits were noted. Complete neurologic recovery occurred in 76 (89%) peroneal and 44 (100%) tibial palsies. Postoperative neurologic dysfunction was associated with younger age (P < 0.001; odds ratio = 0.7 per 10-yr increase), longer tourniquet time (P < 0.001; odds ratio = 2.8 per 30-min increase), and preoperative flexion contracture >20° (P = 0.002; odds ratio = 3.9). In a subset of 116 patients with tourniquet times ≥180 min, longer duration of deflation was associated with a decreased frequency of neurologic complications (P = 0.048). We conclude that the likelihood of neurologic dysfunction increases with total tourniquet time and that a reperfusion interval only modestly decreases the risk of nerve injury.

A Comprehensive Anesthesia Protocol That Emphasizes Peripheral Nerve Blockade for Total Knee and Total Hip Arthroplasty

R ecently, advances in radiographic imaging and surgical instrumentation have allowed experienced orthopaedic surgeons to perform total hip and total knee replacement surgery with surgical exposures that are less extensive than those associated with traditional techniques1,2. Commonly referred to as “minimally invasive total hip and total knee arthroplasty,” these techniques are now being touted as important surgical advancements. The introduction of minimally invasive total hip and total knee techniques has been accompanied by substantial concomitant changes in perioperative anesthetic techniques, rapid rehabilitation protocols, and changes in patient education and expectations. However, the specific contribution of each of these changes to observed improvements after contemporary total hip and total knee arthroplasty remains unclear. Tremendous strides in anesthesiology and perioperative pain management have been made with regard to the understanding of pain mechanisms and the importance of perioperative analgesia. The consequences of uncontrolled pain and medication-related side effects include the inability to actively participate in rehabilitation, delayed recovery, poor or suboptimal surgical outcome, prolonged hospitalization, and greater use of health-care resources3. Traditionally, the administration of intravenous opioids has been the mainstay for postoperative analgesia following total hip or total knee arthroplasty. However, parenteral opioids are commonly associated with inadequate pain relief, generalized sedation, and adverse side effects such as nausea, vomiting, gastrointestinal ileus, and pruritus. In response, some anesthesiologists have embraced the concept of “preemptive multimodal perioperative analgesia.” Preemptive analgesia involves the administration of analgesics prior to painful stimuli in order to prevent central sensitization and thus the amplification of pain4. Multimodal analgesia refers to the use of combined analgesic regimens for the treatment of postoperative pain. For example, low-dose opioids, local anesthetic infiltration, peripheral nerve blockade, nonsteroidal anti-inflammatory drugs, corticosteroids, clonidine, and cryotherapy all have been used in various combinations to manage postoperative …

Neuraxial anesthesia and analgesia in patients with preexisting central nervous system disorders.

Historically, the use of regional anesthetic techniques in patients with preexisting central nervous system (CNS) disorders has been considered relatively contraindicated. The fear of worsening neurologic outcome secondary to mechanical trauma, local anesthetic toxicity, or neural ischemia is commonly reported. We examined the frequency of new or progressive neurologic complications in patients with preexisting CNS disorders who subsequently underwent neuraxial blockade. The medical records of all patients at the Mayo Clinic from the period 1988 to 2000 with a history of a CNS disorder who subsequently received neuraxial anesthesia or analgesia were retrospectively reviewed. One-hundred-thirty-nine (n = 139) patients were identified for study inclusion. Mean patient age was 60 ± 17 yr. Gender distribution was 86 (62%) males and 53 (38%) females. An established CNS disorder diagnosis was present a mean of 23 ± 23 yr at the time of surgical anesthesia, with 74 (53%) patients reporting active neurologic symptoms. Spinal anesthesia was performed in 75 (54%) patients, epidural anesthesia or analgesia in 58 (42%) patients, continuous spinal anesthesia in 4 (3%) patients, and a combined spinal-epidural technique in 2 (1%) patients. Bupivacaine was the local anesthetic most commonly used in all techniques. Epinephrine was added to the injectate in 72 (52%) patients. There were 15 (11%) technical complications, with the unintentional elicitation of a paresthesia and traumatic needle placement occurring most frequently. A satisfactory block was reported in 136 (98%) patients. No new or worsening postoperative neurologic deficits occurred when compared to preoperative findings (0.0%; 95% confidence interval, 0.0%–0.3%). We conclude that the risks commonly associated with neuraxial anesthesia and analgesia in patients with preexisting CNS disorders may not be as frequent as once thought and that neuraxial blockade should not be considered an absolute contraindication within this patient population.