Brief reports: paravertebral block for anesthesia: a systematic review.

BACKGROUND: The objective of this review was to assess the safety and efficacy of thoracic and lumbar paravertebral blocks (PVBs) for surgical anesthesia through a systematic review of the peer-reviewed literature. PVBs for surgical anesthesia were compared with general anesthesia (GA) or other regional anesthetic techniques. METHODS: We searched literature databases including MEDLINE, EMBASE, and The Cochrane Library up to May 2008. Included studies were limited to eligible randomized controlled trials. Eight randomized controlled trials were included in this review, 6 of which used PVBs for anesthesia during breast surgery, and 2 trials used PVB for anesthesia during herniorrhaphy. RESULTS: The ability to obtain firm conclusions was limited by the diversity of outcomes and how they were measured, which varied across studies. The PVB failure rate was not >13%, and patients were more satisfied with PVB than with GA. There was some indication that PVB could achieve shorter hospital stays than GA. PVB for anesthesia substantially reduces nausea and vomiting in comparison with GA (relative risk: 0.25, 95% CI: 0.13-0.50; P < 0.05), although it does carry a risk of pleural puncture and epidural spread of local anesthetic. CONCLUSIONS: In conclusion, based on the current evidence, PVBs for surgical anesthesia at the level of the thoracic and lumbar vertebrae are associated with less pain during the immediate postoperative period, as well as less postoperative nausea and vomiting, and greater patient satisfaction compared with GA.

Bilateral thoracic paravertebral block for abdominoplasty.

Thoracic bilateral paravertebral block is a technique commonly used in the ambulatory setting for numerous plastic surgery procedures. Paravertebral block has not been reported with abdominoplasty surgery. This case series explores this anesthetic technique in the inpatient and day patient setting.

Bilateral ankle blocks: a prospective audit.

BACKGROUND: There are significant advantages to the practice of bilateral ankle block. However, clinicians are reluctant to employ this technique due to concerns over reliability, local anaesthetic longevity and toxicity, surgical efficiency, and patient comfort. METHODS: Sixty-six patients undergoing bilateral ankle blocks during mid- and forefoot surgery were audited to determine success rate, local anaesthetic safety and efficacy, and patient acceptance. Intravenous sedation was administered both during insertion of ankle blocks and intraoperatively, as requested by the patient and as deemed necessary by the anaesthetist. The choice of local anaesthesia was either a 50/50 mixture of lignocaine 1.5% plain and ropivacaine 7.5 mg/mL, ropivacaine 7.5 mg/mL alone or ropivacaine 7.5 mg/mL and clonidine 1 microg/kg. RESULTS: A total of 89% of patients had a successful bilateral ankle block. Ropivacaine and clonidine combination, ropivacaine, and ropivacaine and lignocaine combination provided a mean length of action of 17 h, 14 h and 8 h, respectively. No adverse local anaesthetic events were reported. Sixty-one per cent of patients remembered intraoperative events; only one patient would choose not to have the procedure performed again under ankle blocks. CONCLUSIONS: The present audit demonstrates that bilateral ankle blocks are a safe and efficient technique. With appropriate doses of sedative drugs both during insertion of the ankle block and surgery, patients remain comfortable.

Acceptability of ankle tourniquet use in midfoot and forefoot surgery: audit of 1000 cases.

BACKGROUND: While use of a thigh tourniquet with general anesthesia is widely accepted, use of an ankle tourniquet in the awake patient is more controversial. In particular, it is not clear how long patients tolerate this device or what the consequences are of intraoperative tourniquet pain. METHOD: A prospective audit was done of 1000 patients undergoing midfoot and forefoot surgery using an ankle block. We examined the intraoperative problems associated with the use of an ankle tourniquet, particularly the role and consequences of intraoperative tourniquet pain. Risk factors for tourniquet pain were statistically examined, and patient acceptance was gauged through followup questions. RESULTS: With correct application and the option of sedation, 3.1% of patients complained of tourniquet pain. In 0.4% of patients tourniquet pain necessitated a conversion to general anesthesia. A significant association was found between tourniquet pain and both age and tourniquet time. We found that for patients younger than 70 years of age, the tourniquet can be applied comfortably for up to 30 minutes in over 97%. For each 11 minutes beyond this, another 1% of patients reported tourniquet pain. However, patients 70 years or older had an average 3.5 times increase in tourniquet pain. In this age group the tourniquet can be applied comfortably for up to 30 min in 91%. For each 3.2 minutes beyond this, another 1% reported tourniquet pain. When questioned, 97.2% of our patients reported that they would have surgery again with an ankle tourniquet. CONCLUSIONS: Our audit shows that with correct application and the option of sedation the ankle tourniquet is well tolerated by most patients. However, clinicians need to be mindful that patients 70 years of age or older are at greater risk of tourniquet pain and that in all patients the risk of tourniquet pain gradually increases when application times exceed 30 min.