Regional Analgesia and Acute Pain Management: Major Leaps in Small Steps?

Abstract

Vincent Chan, MD, FRCPC, Guest EditorView Large Image Figure ViewerDownload Hi-res image Download (PPT)Management of pain has evolved steadily over the past few years thanks to the knowledge derived from a large number of basic science and clinical research studies. While the management of chronic pain has utilized a significant amount of information from this research, acute pain management has benefited to a lesser extent. Our mainstay of therapy for acute pain remains opioid based, but we have realized that opioid drugs do a less-than-optimal job of relieving activity-associated pain in many acute scenarios. We have also realized the downside to using opioids as we see more and more patients with opioid tolerance, opioid-induced hyperalgesia, and immunosupression. While brachial plexus block was performed through an open dissection almost a century ago, it is only in the last three decades that we have started the practice of regional nerve blockade for managing acute pain. Regional anesthesia provides excellent pain relief particularly for orthopedic surgery, and can significantly improve activity-associated pain and functional rehabilitation outcomes. The benefits of regional anesthesia are for patients, patients' families, as well as hospitals. For example, in the face of increasing economic restraints, regional anesthesia allows painful surgeries to be performed in outpatients by providing good quality pain relief at home. This can save hospital cost and utilization. The use of continuous peripheral nerve block at home is a relatively new concept. With any such innovation, we inherit unique problems associated with adapting it into clinical practice. We have to make sure the block catheters are in perfect position in order to send patients home with them. The use of ultrasonograpy for regional anesthesia is gaining popularity, and there is growing evidence that ultrasound can improve nerve block accuracy. Drs Antonakakis, Ting, and Sites have provided an evidence-based comprehensive review of this topic for us in this issue of Anesthesiology Clinics. Dr Ilfeld tells us how to provide effective continuous perineural blockade in the hospital and at home, and outlines the practical considerations for organizing a home care program. Drs Phillips, Knizner, and Williams provide an objective analysis of cost benefits and cost utility of regional anesthesia for acute pain management as compared to general anesthesia. The economic and practice management issues associated with acute pain management are discussed in detail. One of the major advances in local anesthetic toxicity research is the use of intralipid to counter local anesthetic-induced cardiovascular collapse. In this issue of Anesthesiology Clinics, Drs Mercado and Weinberg teach us how to prevent and manage local anesthetic systemic toxicity, and describe the scientific basis of using lipid emulsion. Getting close to the nerves has potential for neurological injury. The pathophysiology and mechanism of injury is often difficult to define in the face of a postblock neurological deficit. Anesthesiologists are often ill prepared to defend or too ready to take the blame. In this issue we have Drs Borgeat and Aguirre, leading experts in this area, share with us their vast knowledge of evaluating postblock neurological deficits and effective treatment options. Dr Horlocker further reviews in detail the incidence and mechanisms of central and peripheral nerve injuries associated with regional anesthesia and acute pain management and provides recommendations to avoid them. Unintentional subdural injection, a complication of neuraxial anesthesia and analgesia, is thoroughly addressed by Dr Hoftman. Yet not all postsurgical pain is amenable to some of these regional techniques. We also have patients with extraordinary requirements for pain management such as those with renal dysfunction and those receiving chronic opioid therapy, to mention but a few. In this issue Drs Gandhi, Heitz, and Viscusi give us pearls on how to manage such patients with multimodal analgesia. While the regional blocks provide excellent analgesia for upper limb surgery, lower limb weakness and risk of fall associated with regional blocks are problematic. The development of local infiltration analgesia is a possible solution and the art of wound infusion of local anesthetics is described by Drs Ganapathy, Brookes, and Bourne. Above all, we have come to realize the entity of chronic postsurgical pain. Can poorly managed acute pain result in chronic postsurgical pain? Dr de Kock tells us about prevention of such debilitating chronic pain following surgery. This issue devoted to acute pain management aims to provide you with information that promotes high-caliber pain relief for your patients, both adults and children. We hope you enjoy reading this issue of Anesthesiology Clinics.