Describe the regional
analgesic techniques available for postoperative pain relief. Which are
applicable to this patient?
Regional analgesic techniques with local
anesthetics are invaluable, underutilized techniques for the treatment of
postoperative pain. The simple infiltration of a wound with a long-acting local
anesthetic can greatly decrease pain in the postoperative period. Blockage of
peripheral nerves to the hands and arms (brachial plexus analgesia), legs
(femoral or popliteal blocks), and chest and upper abdomen (intercostal blocks)
can reliably provide up to 12 hours of analgesia postoperatively, as can
blockade of the ilioinguinal and iliohypogastric nerves after inguinal her-nia
surgery. The recent resurgence of the use of indwelling catheters for
peripheral nerve anesthesia and analgesia has greatly expanded the utility of
these procedures. Analgesia obtained by these methods is free from the
sympathectomy and its attendant hypotension seen with local anesthetic blockade
of the neuraxis.
Interpleural catheters were utilized in the
1990s for uni-lateral thoracic or upper abdominal surgery. Local anes-thetics
may be administered into the interpleural space by placing a catheter between
the parietal and visceral pleura of the lung. In this location, local
anesthetics bathe the intercostal nerves and, to a lesser extent, the thoracic
sym-pathetic nerves. Analgesia is obtained in the distribution of these nerves.
Their use fell into disfavor for many reasons including difficulty of
placement, risk of pneumothorax, high local anesthetic blood levels, and the
inability to use them effectively with a chest tube in place.
Neuraxial opioids, by the spinal or epidural
route, can provide profound analgesia, with a lower incidence of side-effects
compared with the use of parenteral opioids, including those administered via
PCA. Adding a dilute concentration of a local anesthetic (i.e., bupivacaine
0.1%) can enhance the analgesia, allow the use of lower doses of opioids (with
a lower incidence of side-effects), and still avoid the motor blockade and
hypotension seen with higher concentrations of epidural local anesthetics.
Appropriate choices for this patient include
wound infiltration and the use of neuraxial opioids. Although intercostal
blocks could be performed, the need to perform bilateral blocks at multiple
levels makes this an impractical option.
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