ABSTRACT
BACKGROUND: The incorporation into the routine operating procedure of patients with small but acute hand and forearm injuries requiring surgery who present in the emergency admission department, represents a challenge due to limited resources. The prompt treatment in the emergency admission department represents an alternative. This article retrospectively reports the authors' experiences with a treatment algorithm in which emergency patients were treated by ultrasound-guided axillary brachial plexus blocks (ABPB) and surgery carried out in the emergency department without further anesthesia attendance. METHODS: Patients were preselected by the surgeon if they were suitable for a standardized treatment without anesthesia attendance during surgery. If there were no anesthesiological or surgical contraindications patients received an ABPB in the holding area of the operating room (OR) under standard monitoring. Blocks were performed as a multi-injection, ultrasound-guided technique which is anatomically described in detail. Patients >60â¯kg received a total volume of 30â¯ml of a mixture of 10â¯ml 1% ropivacaine (100â¯mg) and 20â¯ml 2% prilocaine (400â¯mg). Patients <60â¯kg received the same mixture with a reduced volume of 25â¯ml corresponding to 82.5â¯mg ropivacaine and 332.5â¯mg prilocaine. After controlling for block success patients were admitted to the emergency department and the surgical procedure was carried out under supervision by the surgeon without further anesthesia attendance. At discharge patients were explicitly instructed that in the case of any complications or a continuation of the block for more than 24â¯h they should contact the emergency department. RESULTS: Between January 2013 and November 2017 a total of 566 patients (46.4 years, range 11-88 years, 174.9â¯cm, range 140-211cm, 80.8â¯kg, range 42-178kg, ASA 1/2/3, 190/338/38, respectively) were treated according to a standardized protocol. The ABPBs were performed by 74 anesthetists. In 5% of the patients the initial block was incomplete and rescue blocks were performed with a maximum of 23ml 1% prilocaine per corresponding nerve. After completion the block was ensured and all patients underwent surgery without further analgesics or local anesthetic infiltration by the surgeon. Complications related to the ABPB and readmissions were not observed. CONCLUSION: It could be demonstrated that minor surgery could be carried out safely and effectively with a defined algorithm using ABPB in selected patients outside the OR without permanent anesthesia attendance: however, indispensable prerequisites for such procedures are careful patient selection, patient compliance, the safe and effective performance of the ABPB and reliable agreement with the surgeon.
Subject(s)
Anesthetics, Local/administration & dosage , Brachial Plexus Block/methods , Upper Extremity/injuries , Upper Extremity/surgery , Adolescent , Adult , Aged , Aged, 80 and over , Child , Emergency Service, Hospital , Female , Humans , Male , Middle Aged , Prilocaine , Retrospective Studies , Ropivacaine , Ultrasonography, Interventional/methodsABSTRACT
This is the first report of a schwannoma of the inferior gluteal nerve (IGN) as a cause of chronic low back pain in a 43-year-old man. The patient suffered from severe pain radiating to the gluteal region. He was treated for months without pain relief and was on long-term disability. Only a targeted sonographic exam revealed a hypoechoic intrapelvic mass along the course of the IGN. By tumor resection, a schwannoma was histologically confirmed. After tumor removal the patient is free of pain with all medication discontinued. He has been fully reintegrated into his professional life.