Essentials of Regional Anesthesia Alan David Kaye Richard D. Urman ● Nalini Vadivelu Editors Essentials of Regional Anesthesia Editors Alan David Kaye, MD, PhD Richard D. Urman, MD, MBA Director of Interventional Pain Management Assistant Professor of Anesthesia University Hospital and Ochsner Kenner Harvard Medical School Hospital Director Professor and Chairman Hospital Procedural Sedation Management Department of Anesthesiology and Safety Professor Co-Director Department of Pharmacology Center for Perioperative Management Louisiana State University School and Medical Informatics of Medicine Brigham and Women’s Hospital New Orleans, LA 70112, USA Boston, MA 02115, USA Nalini Vadivelu, MD Associate Professor of Anesthesiology Yale University School of Medicine New Haven, CT 06510, USA ISBN 978-1-4614-1012-6 e-ISBN 978-1-4614-1013-3 DOI 10.1007/978-1-4614-1013-3 Springer New York Dordrecht Heidelberg London Library of Congress Control Number: 2011943562 © Springer Science+Business Media, LLC 2012 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identifi ed as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) For my wife of over 20 years, Kim Kaye, MD, for her patience, love, and wisdom in raising our two wonderful children, Aaron and Rachel. Alan David Kaye To my mentors, students, and trainees for their inspiration, and to my parents, Dennis and Tanya, and my wife, Zina Matlyuk-Urman, MD. Richard D. Urman I dedicate this book to my parents, my husband Muthu, my sons Gopal and Vijay, and all my colleagues and friends for their constant encouragement. Nalini Vadivelu Foreword The editors of E ssentials of Regional Anesthesia have asked me to write a Foreword for the book. Their request is most likely due to my involvement in regional anes- thesia and its growth in the last 40 years. I have written and published on regional anesthesia extensively during this period, and this opportunity allows me to refl ect on the progress regional anesthesia has made since its inception in 1884. Regional anesthesia came to the European medical scene with a bang, when Carl Koller experimented with cocaine for its use in eye surgery and presented the data of his experiments to the Ophthalmological Congress in Heidelberg in September, 1884. His fi ndings were accepted readily by the surgeons, since they were having signifi cant morbidity and mortality with Ether and Chloroform. During the ensuing years up to 1930, regional anesthesia was commonly practiced safely, both in Europe and North America. New techniques such as spinal block, epidural block and peripheral nerve block were developed during this period. The limitation of per- forming regional anesthesia was that there was no training program for any physi- cian who wished to learn this practice. It was done on an ad hoc basis by the assistants to the surgeons and the nurses. As the specialty of anesthesia started in 1933, the anesthesiologists preferred general anesthesia to regional anesthesia because general anesthesia was easier to learn. The scientifi c growth in monitoring and safety in anesthesia practice was the main reason for popularization of anesthesia techniques. All the same, Mayo Clinic in 1930s and 1940s still did their major surgeries with spinal anesthesia or peripheral nerve blocks with intravenous sedation by a barbitu- rate. Gaston Labat worked at this institution and became very accomplished in regional anesthesia. He wrote the fi rst book on the subject – R egional Anesthesia: Its Technique and Clinical Application – which even today is a seminal book for practitioners of regional anesthesia. He was uniquely responsible for forming a society called the “American Society of Regional Anesthesia” (ASRA) for inter- ested regional anesthesia physicians. The society’s deliberations and activities are well documented in the Wood Library Museum. ASRA started to wither with future scientifi c growth in general anesthesia, such as the introduction of Halothane, intra- venous induction of anesthesia with a barbiturate, and the discovery of muscle vii viii Foreword relaxants like Curare. This allowed the anesthesiologist to easily monitor the level of anesthesia necessary for surgery and not have the patient kept awake. Surgeons loved this change in anesthesia practice. During the 1970s, anesthesia training was overwhelmingly for general anesthe- sia practice, and the instances in which physicians used regional anesthesia tech- niques were few and far between. In spite of this state of affairs, giant fi gures like John Bonica, Philip Bromage, Alon Winnie, Daniel Moore, and Donald Bridenbaugh fought hard to advocate for the practice of regional anesthesia for surgical, obstetric, or cancer pain patients. They were the teachers of regional anesthesia and started the training programs in their departments. This culminated in the revival of the American Society of Regional Anesthesia. The residents going into the anesthesia specialty loved to learn about regional anesthesia, and with their support, regional anesthesia practice fl ourished. ASRA created practical workshops and educational programs, and with their infl uence the society was able to spread its wings in Europe, Asia, and Latin America. During the period 1975–2010, remarkable scientifi c advances were made in the techniques, local anesthetics, and devices that assist in the success of regional anes- thesia. In the 1980s, the peripheral nerve stimulator was an advance in locating nerves, and in the last few years, assistance by ultrasound techniques was intro- duced. Both of these techniques have been well received by the practitioners of regional anesthesia. Many books and documentaries are now available for training the physician in regional anesthesia. Alan David Kaye has provided me with the reason why this book was conceived. He explains it is for the clinicians, students, residents, fellows, and attendees to learn and train in the new technology of regional anesthesia practice. He has mostly chosen authors who are Directors of the Regional Anesthesia Fellowship programs; this provides a sound basis on which the trainee can get the most up-to-date infor- mation on the state of practice of regional anesthesia. The book is divided into six sections, including general considerations, basic science and clinical practice, equipment, and the modern practice of regional anes- thesia. There are 31 chapters most of the chapters are formatted consistently, such as (a) anatomy of the block (b) indications for the block (c) types of techniques available (d) clinical pearls (e) complications. The chapters commonly end with multiple-choice questions. I fi nd E ssentials of Regional Anesthesia very well organized and timely and that it fi lls the void created by rapidly changing regional anesthesia practices. Even though there are many books available on regional anesthesia, the incorporation of ultrasound for each block is a unique feature of this book and will be well received by the trainees. I recommend this book for all libraries of anesthesia departments, including for training of residents and medical students. Lubbock, TX, USA P. Prithvi Raj Preface The practice of regional anesthesia has undergone tremendous evolution in the past few decades. Until recently, older blind techniques were taught, and successful regional anesthetics were typically limited to a few extraordinary clinicians in each department of anesthesia worldwide. Ultrasound, electrical stimulation, fl uoros- copy, and continuous catheters have contributed to a revolution in the fi elds of regional anesthesia and pain management. Advances in technology have changed these fi elds signifi cantly, resulting in the development of formal regional anesthesia and pain fellowships. The present fi eld of regional anesthesia has challenged not only new residents and fellows but also older practicing anesthesiologists to learn these new techniques and technologies in their clinical practices. Excellence and versatility in regional anesthesia can provide the means by which we better manage acute and chronic pain. Modern regional anesthesia provides hope and optimism for the comfort of future generations of patients affl icted with a wide array of medical conditions. One of the strategies in creating a book on E ssentials of Regional Anesthesia was to make it practical for the clinician. To that end, we have recruited regional anes- thesia fellowship directors and their fellows as authors for most of the chapters in this book. We also requested that authors identify clinical pearls and help us create a databank of questions for trainees to facilitate learning of the subject material. The editors of the book agree that this has been a challenging but rewarding project. Since this is a fi rst edition, we have endeavored to present the material with clarity and conciseness. Our goal has been a book of practical applicability for the anesthe- sia provider. Best of luck to each of you as you develop your clinical practices in regional anesthesia. New Orleans, LA, USA Alan David Kaye Boston, MA, USA Richard D. Urman New Haven, CT, USA Nalini Vadivelu ix Contents Part I General Principles of Regional Anesthesia Practice 1 General Considerations for Regional Anesthesia Practice ................. 3 Edward R. Mariano and Karley J. Mariano 2 Monitoring for Regional Anesthesia ..................................................... 21 Jeff Gadsden 3 Regional Anesthesia in the Community Practice Setting .................... 37 Joseph Marino and Brian E. Harrington Part II Basic Science and Clinical Practice 4 The Anatomy of Pain .............................................................................. 83 Harry J. Gould III and Alan David Kaye 5 Practical Pharmacology in Regional Anesthesia .................................. 121 Jose A. Aguirre, Gina Votta-Velis, and Alain Borgeat 6 Anticoagulation and Regional Anesthesia Concerns ........................... 157 Rinoo Shah, Alan David Kaye, Adam Kaye, and Jeffrey Y. Tsai Part III Equipment for Regional Anesthesia 7 Equipment and Clinical Practice: Aids to Localization of Peripheral Nerves ............................................................................... 177 Beverly Pearce-Smith and Johnny K. Lee 8 Principles of Sonography ....................................................................... 191 Paul E. Bigeleisen and Steven Orebaugh xi xii Contents 9 Ultrasound-Guided Peripheral Nerve Blockade .................................. 199 David M. Polaner and Alan Bielsky 10 Sonopathology ......................................................................................... 239 Jonathan T. Weed and Brian D. Sites Part IV Techniques for Regional Anesthesia 11 Neuraxial Blockade: Subarachnoid Anesthesia ................................... 261 Maria Teresa Gudin, Ramón López, Jesus Estrada, and Esperanza Ortigosa 12 Neuraxial Blockade: Epidural Anesthesia ............................................ 293 Sreekumar Kunnumpurath, S. Ramessur, A. Fendius, and Nalini Vadivelu 13 Upper Extremity Nerve Blocks .............................................................. 339 De Q.H. Tran, Shubada Dugani, and Juan Francisco Asenjo 14 Peripheral Nerve Blocks for the Lower Extremity .............................. 385 Sylvia Wilson and Anna Uskova 15 Regional Anesthetic Techniques for Foot Surgery ............................... 407 Rick Chien-An Chen and Peter A. Blume 16 Regional Anesthesia of Thorax and Abdomen ..................................... 423 Rita Merman and Vlad Shick 17 Head and Neck: Scalp, Ophthalmic, and Cervical Blocks .................. 463 Desiree Persaud and Sébastian Garneau 18 Local Anesthesia of the Masticatory Region ........................................ 483 Henry A. Gremillion, Christopher J. Spencer, and Alex D. Ehrlich 19 Topical and Regional Anesthesia of the Airway ................................... 505 Ryan P. Ellender, Paul L. Samm, and Richard H. Whitworth, Jr. 20 Selective Regional Anesthesia Options in Surgical Subspecialties........................................................................................... 525 Henry Liu, Charles James Fox, Michael J. Yarborough, and Alan David Kaye 21 Regional Anesthesia for Chronic Disease States .................................. 541 Siamak Rahman and Parisa Partownavid 22 Intravenous Regional Anesthesia .......................................................... 557 Lindsey Vokach-Brodsky 23 Regional Anesthesia and Trauma .......................................................... 565 Daniela Elena Francesca Ghisi, Andrea Fanelli, and Carl Rest