What are the recommendations for using regional anesthesia in surgical procedures?

Recommendations for Regional Anesthesia in Surgical Procedures

Regional anesthesia should be considered the first-line anesthetic approach for appropriate surgical procedures due to its benefits in reducing postoperative delirium, improving pain control, and avoiding airway manipulation.

Benefits of Regional Anesthesia

Regional anesthesia offers several advantages over general anesthesia:

• Reduced postoperative delirium: Low-quality evidence suggests regional anesthesia reduces the incidence of postoperative delirium in older adults 1
• Improved pain control: Regional techniques provide superior analgesia, especially for pain provoked by movement 2
• Avoidance of airway manipulation: Eliminates risks associated with intubation and extubation 1
• Reduced resource utilization: Less need for sedatives and hypnotics compared to general anesthesia 1
• Earlier mobilization: Facilitates early postoperative mobilization, potentially reducing morbidity and mortality 2

Appropriate Surgical Applications

Regional anesthesia can be applied in various surgical settings:

• Orthopedic procedures: Particularly effective for upper and lower extremity surgeries 3
  • Interscalene blocks for shoulder surgery 4
  • Saphenous nerve blocks (motor-sparing) preferred over femoral nerve blocks for knee surgery 4
• Vascular procedures: Can be used for carotid endarterectomy, lower extremity bypass, and AV fistula formation 5
• Day surgery: Particularly beneficial for ambulatory procedures 1, 6
• Obstetric procedures: Indicated for vaginal procedures and cesarean sections 7, 8

Types of Regional Anesthesia

Neuraxial Techniques

• Spinal anesthesia: Suitable for day surgery with low-dose techniques and shorter-acting agents like hyperbaric prilocaine 2% and 2-chloroprocaine 1
• Epidural anesthesia: Provides longer duration of analgesia
• Combined spinal-epidural: Offers benefits of both techniques

Peripheral Nerve Blocks

• Upper extremity: Interscalene, supraclavicular, infraclavicular, and axillary blocks 3
• Lower extremity: Femoral, saphenous, sciatic, iPACK, ankle, and lumbar plexus blocks 3
• Truncal blocks: Intercostal, ilioinguinal/iliohypogastric nerve blocks 4

Implementation Considerations

Patient Selection

• Assess for contraindications:
  • Coagulopathy or anticoagulant therapy (risk of hematoma)
  • Infection at injection site
  • Patient refusal or inability to cooperate
  • Significant anatomical abnormalities

Technical Considerations

• Use ultrasound guidance to improve efficacy and minimize complications 3
• Consider block room utilization to improve efficiency and confirm adequate nerve blockade before surgery 1
• Have LAST (Local Anesthetic Systemic Toxicity) treatment guidelines and rescue medications (intralipid) readily available 3

Special Populations

Older Adults

• Regional anesthesia may help prevent delirium in older adults undergoing surgery 1
• Consider reduced dosing requirements in elderly patients

Day Surgery Patients

• Patients may be safely discharged home with residual motor or sensory blockade, provided:
  • The limb is protected
  • Appropriate support is available at home
  • Written instructions are provided regarding expected duration of blockade 1

Potential Complications and Management

Regional anesthesia is generally safe but carries some risks:

• Local anesthetic systemic toxicity (LAST): Ensure proper dosing and have lipid emulsion available
• Nerve injury: Use ultrasound guidance and proper technique
• Falls: Particularly with lower extremity blocks affecting motor function
• Hematoma: Follow appropriate guidelines for patients on anticoagulants
• Infection: Maintain strict aseptic technique
• Allergic reactions: Be prepared to treat if they occur 3

Multimodal Approach

Regional anesthesia should be part of a multimodal approach:

• Combine with non-opioid analgesics (NSAIDs, acetaminophen) when not contraindicated 1
• Consider dexamethasone to decrease postoperative opioid requirements and reduce nausea/vomiting 1
• Develop an analgesic plan for when the block wears off, including premedication with oral analgesics 1

Conclusion

Regional anesthesia offers significant benefits for appropriate surgical procedures. The choice of technique should be based on the surgical site, expected duration of surgery, and patient factors. Proper implementation requires skilled practitioners, appropriate equipment, and protocols for managing potential complications.