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On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.55 no.6 Campinas Nov./Dec. 2005
The art of peripheral regional anesthesia
In the last six years (from 2000 to September 2005), our journal has published 26 articles on peripheral blocks (Table I). Among them, only six have included the improvement of postoperative analgesia as primary outcome (Table II).
The absolute majority of these studies on peripheral blocks have compared techniques, evaluated the performance of new local anesthetic agents and shown regional anesthetic alternatives for specific procedures.
Only six (23.08%) publications have included postoperative analgesia and patients wellbeing as primary outcome. Although we dedicate a lot to regional anesthesia for peripheral surgeries (perineal or limb procedures) we indicate plexus or central blocks, and postoperative analgesia restricted to continuous and central techniques. Yes, such alternatives assure long-lasting analgesia, but are still questioned in terms of patients wellbeing: pruritus, increased nausea and vomiting and unpleasant prolongation of extensive paresis/paresthesia are disadvantages impairing total satisfaction of patients.
In this edition of the Brazilian Journal of Anesthesiology, Imbelloni et al. have presented their experience with postoperative analgesia after orificial surgery in outpatient regimen, performed with short-lasting spinal anesthesia (2% lidocaine - 50 mg), complemented with bilateral pudendum nerve block with 0.25% R-25-S75 bupivacaine. Pudendum nerves block was oriented with neurostimulator. The method allowed for early ambulation and hospital discharge 6 hours after surgery with distant follow-up by telephone calls. Postoperative analgesia lasted 23.77 ± 4.49 h with high level of patients' satisfaction 1.
Recently, we have followed in international publications and scientific meetings, an increase in the indication of peripheral regional techniques, simple or continuous 2-6, with the primary goal to prolong residual anesthesia in the immediate postoperative period, improving patients' wellbeing and recovery 7. Peripheral blocks, even mere infiltrations, have been included in multimodal planning of postoperative analgesia for outpatient procedures 6. Undoubtedly, such objectives are reached with: neurostimulator for technical enhancement; mastering of different alternative for peripheral conduction blocks; and the intention to promote postoperative wellbeing and total and prolonged analgesia. All of these were achieved by this proposal of Imbelloni et al.
The trend toward total General Anesthesia (GA) automation is confirmed by programmable equipment which, soon, may become self-programmable as from the feedback of analgesia/anesthesia depth monitors (BIS) and neuromuscular conduction. The possibility of further GA automation tends to minimize the requirement of specific skills, and to transform, in a near future, what was challenge and art into routine programming of equipment.
Certainly, art, skills, anatomy understanding and, especially quality of attention to patients, will continue to distinguish us professionally. The mastering of Anesthesia and Analgesia Peripheral Regional Techniques to promote a painless postoperative period, limiting anesthetized area to what is needed, will help to make the difference!
Leite Oliva Filho, TSA, M.D.
Member of the Editorial Board
01 - Imbelloni LE, Beato L, Beato C et al - Analgesia pós-operatória com bloqueio bilateral do nervo pudendo com bupivacaína S75:R25 a 0,25%. Estudo piloto em hemorroidectomia sob regime ambulatorial. Rev Bras Anestesiol, 2005;55:614-621.
02. Liu, SS - Why Should We Use Regional Analgesia for Postoperative Pain Relief? Texts and Abstracts of the 13th World Congress of Anesthesiologists. Paris. 2004: L06.
03. Steele, SM - Peripheral nerve blocks for ambulatory surgery. Texts and Abstracts of the 13th World Congress of Anesthesiologists. Paris. 2004: CO3a.
04. Borgeat A - Advantages of continuous perineural catheter. Actas del 34º Congreso Argentino de Anestesiología. Buenos Aires, 2005:30-1.
05. Borgeat A - Peripheral nerve blocks for the lower extremity. Actas del 34º Congreso Argentino de Anestesiología. Buenos Aires, 2005;340-342.
06. White PF - Role of Non-Opioid Analgesics in the management of acute perioperative pain. Actas del 34º Congreso Argentino de Anestesiología. Buenos Aires, 2005;375-385.
07. Capdevila X, Barthelet Y, Biboulet P et al - Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery. Anesthesiology 1999;91: 8-15.