Regional Anaesthesia, Stimulation, and Ultrasound Techniques

577 Pages·2014·9.91 MB·English

by  Paul Warman

OXFORD MEDICAL PUBLICATIONS
Regional Anaesthesia,
Stimulation, and
Ultrasound Techniques
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Regional Anaesthesia,
Stimulation, and
Ultrasound Techniques
Edited by
Dr Paul Warman Dr Barry Nicholls
Consultant Anaesthetist Consultant in Anaesthesia and
Leeds General Infirmary Pain Management
Leeds Teaching Hospitals Musgrove Park Hospital
NHS Trust Taunton and Somerset NHS
Leeds Foundation Trust
and Taunton
Honorary Senior Lecturer
University of Leeds Mr David Wilkinson
Leeds
Physicians’ Assistant
Dr David Conn (Anaesthesia)
Royal Devon and Exeter
Consultant Anaesthetist Hospital
Royal Devon and Exeter Hospital Royal Devon and Exeter NHS
Royal Devon and Exeter NHS Foundation Trust
Foundation Trust Exeter
Exeter
and
Honorary University Fellow
University of Exeter Medical
School
1
3
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v
Foreword
For a (large) pocket-sized handbook, this new addition to the Oxford
Handbook series contains an impressive range and depth of information
about regional anaesthesia, a sub-specialty of anaesthesia, which has truly
come of age in recent years.
The current popularity of regional anaesthesia can be attributed to three
main factors: advances in nerve location technology, especially the appli-
cation of ultrasound guidance; recognition of the central importance of
anatomy in achieving safe and successful results; and a better understanding
of the potential benefits and limitations of regional anaesthesia in the man-
agement of surgical anaesthesia, postoperative analgesia, and other causes
of acute pain. The very experienced editors of this practical and informative
book are well placed to attract an impressive array of authors and to ensure
that these three fundamental principles are used as a consistent framework
throughout the book. The result is a very readable approach to all the tech-
niques described, literally from head to toe. The expertise, enthusiasm, and
common sense of all the contributors are clearly communicated throughout
the text, enhanced by the excellent diagrams and ultrasound pictures.
It would be unusual to agree with the details of every technique, as
described, in an instructional textbook. While I might take a different view
on some of the nuances of practice, I can commend the book as a compre-
hensive and authoritative guide for the novice. It will also stimulate the more
experienced practitioners to question their own practice and encourage
debate to continue the evolution of regional anaesthesia for the benefit of
the next generation.
It is a privilege to be asked to write a foreword for such an instructive
book, if only because it has allowed me to update my knowledge base prior
to its general release. More importantly it allows me to pay tribute to the
many contributors who, during their working lifetimes, have worked hard
to ensure that regional anaesthesia has found its proper place in modern
anaesthetic practice.
Barrie Fischer
Dr H B J Fischer
Worcestershire, UK
vi
Preface
The purpose of this handbook is to provide clinicians with an easy access
to the art and science of regional anaesthetic techniques. We believe we
have provided the reader with a practical guide, in the familiar format of
the Oxford Handbook series, combined with aspects of a larger reference
text, in a handy pocket-sized book. We have deliberately included both
landmark or peripheral nerve stimulator-guided techniques and ultrasound
techniques to provide a complete clinical guide. Anatomy features strongly
throughout the chapters as it remains the cornerstone of good clinical
regional anaesthesia, whether using an ultrasound or a peripheral nerve
stimulator, and indeed the legendary Alon P. Winnie remarked ‘Regional
anesthesia is simply an exercise in applied anatomy’.
The first section covers a wide range of topics on the background of
regional anaesthesia. There is an amusing and enlightening chapter on the
history of regional anaesthesia. There are chapters covering the basic sci-
ence of physiology of pain, pharmacology of drugs, physics and use of
ultrasound, and peripheral nerve stimulators. Whilst maintaining a strong
science base, we have tried to make these chapters as clinically relevant as
possible and have useful clinical tips on the practice of regional anaesthesia
and frequent summaries of published evidence. There are also sections to
deal with risks and complications of regional anaesthesia. Included in this
section are some more advanced techniques of wound and nerve catheters
and paediatric regional anaesthesia.
The remainder of the book provides detailed descriptions of almost all
conceivable regional anaesthetic techniques over the whole of the body.
The obvious upper and lower limb blocks are there, with descriptions of
all common approaches. Unlike some pocket guides we have included head
and neck blocks and ophthalmic regional anaesthesia. We have also covered
trunk blocks, those of both the chest, including the increasingly popular
paravertebral blocks, and of the abdominal wall; such as TAP and rectus
sheath blocks. Each chapter provides a representation of the complexity of
the block, the indications, contraindications, and complications. There is an
overview of the anatomy with frequent diagrams to illustrate. The step-by-
step ‘hands on’ guides of the blocks are again complemented with diagrams
to aid understanding and to help the practice of block performance and of
course ultrasound images of the appropriate anatomy. There are frequent
helpful clinical tips and hints throughout.
Although familiar to many, we have included a section describing central
neuraxial techniques. Although the basics of the practical techniques are
covered, there is perhaps more of a focus on the use of these techniques in
certain situations and there is a chapter to describe and illustrate the emerg-
ing skill of spinal ultrasonography in regional anaesthesia.
There are many contributors to the text of the book; all are clinical
anaesthetists with an enthusiasm and passion for regional anaesthesia. Many
of them will be familiar names from the ‘aristocracy’ of regional anaesthesia
in this country, teaching and preaching on national and international stages
PREFACE vii
over many years of dedication. Our thanks to them all for their expert
contributions and their forbearance on bringing this book to publication.
The text and images have been checked, but we apologies in advance for
any errors (or differing points of view) and would welcome your feedback,
comments, and corrections. Whilst we hope that this handbook provides
an invaluable guide and reference, it is not a substitute for the proper study,
training, practice, and mentorship to attain proficiency in the safe and effec-
tive delivery of regional anaesthesia to your patients.
Paul Warman
David Conn
Barry Nicholls
David Wilkinson
Reference
. Winnie AP, Håkansson L (eds) (993). Plexus Anesthesia. Vol  (3rd edn). Philadelphia: WB
Saunders.
viii
Acknowledgements and
dedications
I would like to acknowledge the kind assistance of the Anatomy Department
at the University of Leeds. My thanks to Barry Nicholls and David Conn
for their teaching, guidance, and friendship. I dedicate this book to my
wife, Claire, who makes everything possible and to my children Harry and
Barnaby who make everything worthwhile. —PW
For the support and training shown to me by teachers and friends
Dr Edmund J Charlton and Dr Angus Pridie. —BN
To Sherdil Nath, Angus Pridie, and Barry Nicholls, who are the reason
I practise regional anaesthesia. Also to Clare, who keeps me sane. —DC
For IAW and AMR. —DW
ix
Contents
Contributors xii
Symbols and Abbreviations xv
Part  General Considerations
 A brief history of regional anaesthesia 3
2 The physiology of acute pain 
3 Local anaesthetics and additives 25
4 Local anaesthetic toxicity 37
5 Peripheral nerve location using nerve stimulators 49
6 Basic physics of ultrasound 6
7 Principles and practice of ultrasound-guided
regional anaesthesia 79
8 Risks, benefits, and controversies of
regional anaesthesia 97
9 Regional anaesthesia in patients taking
anticoagulant drugs 7
0 Preparation and care of the awake patient
during surgery 27
 Wound infiltration and catheter techniques 33
2 Dermatomes and myotomes 39
3 Paediatric regional anaesthetic techniques 49
4 Peripheral nerve catheters 69
5 Training and assessment in regional anaesthesia 77