Ankle Block Research Articles

Ankle block success rate: A prospective analysis of 1,000 patients

Ankle block success rate: A prospective analysis of 1,000 patients

Bilateral ankle blocks: A prospective audit

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. 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. 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. 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

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. 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. 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. 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.

Combined popliteal and saphenous nerve blocks at the knee: an underused alternative to general or spinal anesthesia for foot and ankle surgery.

Peripheral nerve blocks at the ankle have long been used for foot surgery. However, when local foot and ankle blocks are inappropriate or contraindicated, general and spinal anesthesia are the common alternatives. Both have disadvantages and require added equipment and monitors. Combined popliteal and saphenous nerve blocks at the knee can offer a desirable alternative to general and spinal anesthesia for foot and ankle surgery. In addition, popliteal and saphenous nerve blocks provide anesthesia of the entire lower leg, thus permitting a greater variety of procedures to be performed. This article reviews the anatomical considerations, various block techniques, and surgical applications of this useful approach to lower-leg anesthesia.

Impediments to the use of ankle block in Australia.

Anaesthetic trainees and consultants who enrolled in a regional anaesthetic workshop completed a questionnaire regarding their own ankle block practice. The questionnaire focused on frequency of use, barriers to use, technique and perceived success rate. One hundred and twelve respondents participated, with 73% performing less than 10 ankle blocks per year. Forty-eight per cent believed that they did not have an appropriate operating list or a suitable patient, whilst 27% believed time constraints were the major barrier. Of those performing less than 10 ankle blocks peryear, 22% cited lack of anatomical knowledge or technique as their major barrier and 71% perceived their success rate as medium to low. Eighty per cent performed their ankle block with the patient fully awake or sedated. Sixty-five per cent did not know the length of action of their ankle block. This survey supports recent suggestions that the practice of ankle block is under-utilized. Teaching workshops and clinical training for peripheral nerve blocks should receive high priority for the future.

The efficacy and tolerance of local anaesthesia without sedation for foot surgery

Peripheral nerve blockade has become a popular technique for ambulatory surgery, usually in conjunction with peri-operative sedation. The main purpose of this study was to investigate the use of LA as anaesthesia for foot surgery without sedation. 270 adult patients undergoing foot surgery who had previously agreed to surgery under LA, were included consecutively over a period of 6 months on the day of surgery. Data were collected to determine the reliability and safety of respective nerve blockade techniques, the level of pain associated with the injection and satisfaction with the method of anaesthesia used. A questionnaire was used on the day of surgery to elicit opinion regarding anaesthetic preference if a theoretical choice was given. Local anesthesia was achieved in all cases without the need for sedation. 22.6% of blocks required additional anaesthesia following the initial block with the ankle block being significantly less reliable than the digital block (P<0.01). There was no correlation with anaesthetic volume. Mean satisfaction and willingness to repeat the procedure under LA was 94.4% and 89.3% respectively. A pre-operative preference for GA (as a theoretical option) was the most powerful predictor of lower acceptability, but an age below 45 also predicted lower satisfaction levels. In conclusion, foot surgery can be safely and acceptably performed under LA without sedation although a pre-operative preference for GA indicated that surgery would be better-tolerated with sedation or under GA.

Single-injection applications for foot and ankle surgery

Foot or ankle surgery is often performed in an ambulatory care setting. The post-operative pain that follows can be moderate to severe in intensity and difficult to control with oral analgesics. Regional anaesthetic techniques have been advocated for such procedures.Wound infiltration with long-acting local anaesthetic provides post-operative pain relief which, though efficient, lasts for too short a time. Intravenous regional anaesthesia (IVRA) is a safe anaesthetic technique for minor surgery of short duration. It is not indicated for painful and/or complex procedures. Ankle block is convenient for most procedures but is somewhat less reliable than popliteal sciatic nerve block. Associated with a saphenous or femoral nerve block, posterior popliteal sciatic nerve block is the technique of choice. Patients can be safely discharged even when long-acting local anaesthetics are used. In major surgery a continuous technique can be proposed. When the prone position is impossible the lateral approach is an efficient alternative.

Distal tarsal tunnel release with partial plantar fasciotomy for chronic heel pain: an outcome analysis.

This study evaluated the effectiveness of distal tarsal tunnel release with a partial plantar fasciotomy for chronic subcalcaneal pain syndrome in patients who failed nonoperative management through a retrospective review of all patients undergoing this procedure between 1994 and 1999. Distal tarsal tunnel release and a partial plantar fasciotomy were offered only to those patients with disabling heel pain and were performed under general anesthesia or ankle block. Seventy-five patients (80 heels), averaging 20 months of nonoperative treatment, were identified (group I). Postoperative outcome questionnaires (SF-36 and Foot Function Index [FFI]) were sent to these patients and 44 (46 heels) responded (group II). In group I, 88% of patients had a good to excellent result. Many continued with mild to moderate residual symptoms, which typically did not limit their activity. In group II, 91% of patients were somewhat to very satisfied with their outcome. Visual analogue scale scores for pain were reduced by a mean of 55. SF-36 scores, matched against a control group of patients receiving just nonoperative treatment, showed a statistically significant improvement in all pain and functioning subcategories. We conclude that a distal tarsal tunnel release with a partial plantar fasciotomy may successfully increase function and decrease pain in patients who fail nonoperative treatment.

Peripheral Nerve Blockade with Long-Acting Local Anesthetics: A Survey of The Society for Ambulatory Anesthesia

Despite the growth of ambulatory anesthesia and the renewed popularity of regional techniques, there is little current information concerning outpatient regional anesthesia practices or attitudes about discharge with an insensate extremity. We present results from a survey sent to all members of the Society for Ambulatory Anesthesia (SAMBA). The survey was mailed in January 2001 to 2373 SAMBA members, along with a self-addressed stamped return envelope. After 3 mo, 1078 surveys were returned (response rate 45%). Respondents indicated that they were most likely to perform axillary (77%), interscalene (67%), and ankle blocks (68%) on ambulatory patients. They were less likely to perform lower extremity conduction blocks in ambulatory patients (femoral blocks, 40%; all other types of blocks, <23%]. Eighty-five percent of respondents discharged patients with long-acting blocks, but this was mainly limited to three types. Of the 16% who never or rarely discharged patients with long-acting blocks, the primary reasons were concern about patient injury (49%) and the inability for patients to care for themselves (28%). Only 22% of office-based anesthesiologists would perform upper extremity blocks and only 28% would perform lower extremity blocks (P < 0.001). This survey demonstrates that use of regional anesthesia in outpatients is common but restricted to a few techniques. Discharge with an insensate upper extremity is prevalent but discharge with an insensate lower extremity is not common and remains controversial. Despite the reasoning for the reported practices, randomized data are necessary to confirm the validity of these concerns. This survey demonstrates that use of regional anesthesia in outpatients is common but restricted to a few techniques. Discharge with an insensate upper extremity is common but discharge with an insensate lower extremity is not prevalent and remains controversial.

Group II muscle afferents probably contribute to the medium latency soleus stretch reflex during walking in humans.

1. The objective of this study was to determine which afferents contribute to the medium latency response of the soleus stretch reflex resulting from an unexpected perturbation during human walking. 2. Fourteen healthy subjects walked on a treadmill at approximately 3.5 km h(-1) with the left ankle attached to a portable stretching device. The soleus stretch reflex was elicited by applying small amplitude (approximately 8 deg) dorsiflexion perturbations 200 ms after heel contact. 3. Short and medium latency responses were observed with latencies of 55 +/- 5 and 78 +/- 6 ms, respectively. The short latency response was velocity sensitive (P < 0.001), while the medium latency response was not (P = 0.725). 4. Nerve cooling increased the delay of the medium latency component to a greater extent than that of the short latency component (P < 0.005). 5. Ischaemia strongly decreased the short latency component (P = 0.004), whereas the medium latency component was unchanged (P = 0.437). 6. Two hours after the ingestion of tizanidine, an alpha(2)-adrenergic receptor agonist known to selectively depress the transmission in the group II afferent pathway, the medium latency reflex was strongly depressed (P = 0.007), whereas the short latency component was unchanged (P = 0.653). 7. An ankle block with lidocaine hydrochloride was performed to suppress the cutaneous afferents of the foot and ankle. Neither the short (P = 0.453) nor medium (P = 0.310) latency reflexes were changed. 8. Our results support the hypothesis that, during walking the medium latency component of the stretch reflex resulting from an unexpected perturbation is contributed to by group II muscle afferents.

Complete vs. selective ankle block anaesthesia for forefoot surgery with ankle tourniquet

s and Programme: European Society of Anaesthesiologists; 9th Annual Meeting with the Swedish Society of Anaesthesiology; Gothenburg, Sweden, 7-10 April 2001: Local and Regional Anaesthesia

Postoperative analgesia after peripheral nerve block for podiatric surgery: Clinical efficacy and chemical stability of lidocaine alone versus lidocaine plus ketorolac

Background and Objectives: The purpose of this study was to determine whether the addition of ketorolac tromethamine to local anesthesia for ankle block alters the quality or duration of analgesia after podiatric surgery. The second aim was to determine the chemical stability of ketorolac tromethamine when added to local anesthetic solutions. Methods: The study design was double-blinded, placebo-controlled, and randomized. Seventy-nine American Society of Anesthesiologists (ASA) class I or II patients scheduled for bunionectomy or hammer toe repair, or both were randomized to 1 of 4 groups. Group L received plain 1.73% lidocaine for their ankle block. Group K received 1.73% lidocaine with ketorolac (4 mg/mL) added to the local solution. Group Kiv received 1.73% plain lidocaine for ankle block and 20 mg of ketorolac intravenously. Group E received 1.73% lidocaine with .67% ethanol added. The final concentration of lidocaine for all groups was 1.73%. The block performed in each patient was a 5-point ankle block. Beginning at 1 hour after the completion of the block and every 30 minutes thereafter, visual analogue scale (VAS) and verbal pain scores were recorded. The time from performance of the block to the initial pain and time to the first oral pain medication intake were also recorded. The time and amount of postoperative oral analgesics in the first 9 hours after the block were recorded. Adverse events were also recorded for each group. Results: There were significantly lower overall VAS and verbal pain scores for group K compared with groups E and L and group Kiv compared with group E. Group K also had a significantly longer time to the first reported pain and first oral pain medications than groups E and L, but not with Group Kiv. The same group had significantly fewer average doses of pain medications postoperatively than Groups E and L. Group E had significantly shorter times to first report of pain and first pain medications and higher mean dose of postoperative oral analgesics than group K and Group Kiv. There were no untoward side effects reported from any group. Chemical analysis by gas chromatography (GC) and capillary electrophoresis (CE) showed no significant change in composition of the solutions when ketorolac was mixed with lidocaine and/or bupivacaine and stored at 37°C for 1 week. Conclusions: The addition of ketorolac to lidocaine for ankle block contributed to longer duration and better quality analgesia after foot surgery compared with plain 1.73% lidocaine or 1.73% lidocaine plus intravenous ketorolac. The ethanol vehicle is unlikely responsible for the analgesic effects of ketorolac. Ketorolac retains its chemical stability when placed in local solutions of lidocaine or bupivacaine. Reg Anesth Pain Med 2000;25:506-513.

Peripheral Nerve Blocks. A Colour Atlas

J. E. Chelly (Ed.) Lippincott Williams & Wilkins, 1999. 240 pp. This beautiful book reflects the growing interest in peripheral, as opposed to central, nerve blockade, and therefore makes no mention of spinal or epidural injections. The book is divided into four sections: General Concepts; Single Injection; Peripheral Blocks: Continuous Peripheral Blocks; and Paediatric Peripheral Blocks. Section One deals briefly with preparation, well with the use of a nerve stimulator and very briefly with local anaesthetic solutions. It does not set out to be a pharmacology textbook, but makes sensible suggestions as to the choice of local anaesthetic, additives and the avoidance of toxicity. The bulk of the book is made up of a beautifully illustrated practice guide to nerve blockade with over 200 of the 240 pages being dedicated to sections 2, 3 and 4. Each section is logically laid out, dealing with upper limb, lower limb and other blocks, in that order. Where there are several methods, these are given in the author's choice of order. Despite being a multi-author publication, the style is uniform throughout, and most descriptions are clear and understandable even by the inexperienced. As you read you feel that the authors are describing what they practice. Having said that, some blocks, the anterior approach to the sciatic nerve for instance, are much more easily described than performed, and I am unsure of the value of the author's variation on Beck's original approach. The sections on catheter techniques and paediatric blocks are a joy and a delight even for those who, like me, no longer practice paediatric anaesthetics. To have catheter techniques together in one section is valuable, and children definitely are different. References are limited in number with between two and eight being cited at the end of each description, but are sufficient to give depth to each section if required. Predominantly drawn on American publications, there is also a reasonable number from British and other European sources, especially French. Many of the English language references will be familiar to those interested in peripheral blocks but those in French may be less well known. The index is more than adequate, despite my best efforts to catch it out. There are, of course, oddities and niggles. It is surprising to find that Raj's supine approach to the sciatic nerve, which has the ischeal tuberosity, and the greater trochanter as landmarks, merits only three lines under ‘Anterior Approaches’. Metatarsal block is referred to as a successful alternative to ankle block, but not described. One manufacturer of insulated needles is named 60 times in the text, which eventually I found very annoying; I realised I was scanning each page for the offending name before I could read it. Other companies are also acknowledged but in what appeared to be a rather haphazard fashion, and certainly very much less often. Infinitives are split with gay abandon throughout, which still grates an old fashioned pedant like me. However, these are small points which do not, in the end, detract significantly from the value of the book, nor my enjoyment in reading it. Aimed at trainees and those more senior who wish to refresh or extend their knowledge of block techniques, it provides clear instruction in the art of peripheral nerve blockade which will support and underpin practical training. Every theatre where peripheral nerve blockade is practised should have a copy on the shelf and there will be many anaesthetists of all levels who will enjoy the book, because it is a lovely book, and learn from the descriptions, even of the blocks they do routinely.

Ankle block for forefoot surgery: patient choice and efficacy

One hundred consecutive patients made an informed preoperative choice for elective forefoot surgery between general anaesthetic (GA) and ankle block (AB). Fourteen patients requested GA, 57 AB and 29 were ambivalent, but chose to proceed with AB and sedation anaesthesia after further explanation. The ambivalent group had a higher level of preoperative concerns ( P < 0.03) and required more intraoperative sedation, but were equally satisfied at review. AB patients had longer postoperative pain relief and fewer required strong analgesia on both the day of operation and the next day ( P < 0.05). One AB patient required unplanned conversion to GA for tourniquet pain. With adequate preoperative counselling and additional sedation anaesthesia, if required, there is a high voluntary acceptance of ankle block and good subjective outcome for forefoot surgery.

The Art and Science of Peripheral Nerve Blocks

In this issue of Anesthesia and Analgesia, Marhofer et al. (1) have clearly demonstrated both the art and science of peripheral nerve blocks. Their magnetic resonance imaging (MRI) study of the distribution of local anesthetic after three-in-one block has laid to rest one of the most frequently discussed issues in regional anesthesia during the past 25 yr. They demonstrated that local anesthetic spread can be observed on MRI and that, after the injection of the femoral nerve in the inguinal region by using nerve stimulation, it is lateral, caudal, and slightly medial. This finding contradicts the long-standing teaching that the solution reliably spreads cephalad and bathes the lumbar plexus. This is the most objective evidence of local anesthetic distribution after peripheral nerve blockade. MRI opens a window to the rigorous scientific examination of peripheral nerve blockade that has not previously been available. Haven’t you ever wondered why microscopic changes of needle position can change the “twitch” observed with nerve stimulation, what difference bevel orientation makes to the success of peripheral nerve blocks, and whether additives change the distribution of local anesthetics during peripheral nerve blockade? This technology should help answer some of these basic questions. Why do we care about these questions? Regional anesthesia has never been more popular or in more demand by surgeons. Peripheral nerve blocks have enjoyed a resurgence because of their ability to improve home readiness after ambulatory surgery. A variety of factors influence discharge times after ambulatory surgery, but the most common reasons for delay in discharge are persistent pain, nausea, and drowsiness. Peripheral nerve blocks reduce the incidence of these factors by reducing the use of narcotics and eliminating the need for general anesthesia. In a study of factors influencing home readiness, peripheral nerve blockade for upper extremity surgery improved home readiness time by more than 70 min compared with “fast track” general anesthesia techniques (2). D’Alessio et al. (3) documented a 30-min improvement in street readiness after shoulder arthroscopy with interscalene block compared with general anesthesia. For lower extremity surgery, peripheral nerve blockade techniques are less well established but likely to be at least as effective as upper extremity peripheral nerve blockade. Ankle block has long been recognized as a safe and effective technique with a very high patient satisfaction rating (4). Vloka et al. (5) recently compared popliteal block to spinal anesthesia for short-vein stripping. The patients who received peripheral nerve blockade were discharged 70 min faster than those who received spinal anesthesia. Continuous peripheral nerve blocks improve rehabilitation scores and improve patient satisfaction compared with IV narcotic therapy after orthopedic surgery for both upper and lower extremity procedures. Borgeat et al. (6) improved pain scores and improved satisfaction for patients receiving continuous interscalene blockade for analgesia after major shoulder surgery compared with patients receiving IV narcotics. These authors particularly noted the improvement in analgesia during physical therapy. Rehabilitation is particularly important after total knee arthroplasty. Two studies have recently shown improvement in rehabilitation outcome after this procedure when continuous peripheral nerve blockade was compared with IV narcotics analgesia (7,8). Both studies confirmed lumbar plexus blockade to be as efficacious as epidural analgesia after total knee arthroplasty. However, continuous lumbar plexus blockade has several distinct advantages compared with epidural analgesia, including unilateral block, reduced urinary retention, and reduction of the low but real risk of spinal hematoma in the anticoagulated patient receiving epidural analgesia. Clearly, the time to spread the gospel of peripheral nerve blockade techniques has arrived. The importance of these techniques in providing safe and highly effective analgesia is no longer questioned. Our challenge now is to obtain a deeper understanding of the nuances of peripheral nerve blockade in order to demystify it for the rest of the world. Regional anesthesia has enjoyed a unique niche in the anesthesia world. It has defied scientific innovation in our technology-obsessed specialty. It remains a mystery to most of our anesthesia brethren. Regional anesthesia enthusiasts are viewed as part shaman, part acupuncturist, and part artist by many of their colleagues. Nonregional enthusiasts are usually that because of the inconsistencies that have seemed inherent in the practice of regional anesthesia. Even in the study of Marhofer et al. (1), there is objective evidence of local anesthetic distribution encompassing the femoral and lateral femoral cutaneous nerve in all patients. Yet only two of seven patients had complete obliteration of all sensation in the distribution of these nerves. As we are pushed to be more cost effective and time efficient, we must rigorously study the nuances of peripheral nerve blockade technique. Marhofer et al. (1) are to be congratulated for opening this window and shedding some scientific light on this timely topic.

Lower extremity blocks for day surgery

A combined block of the lower extremity offers many advantages over spinal or epidural anesthesia, such as less hypotension, no bladder paralysis or postspinal headache, and fewer concerns regarding coagulation problems. Furthermore, the extent of sensory and motor blockade of the lower extremity achieved with a combination of a sciatic and a dorsal lumbar plexus nerve block, by using a peripheral nerve stimulator, is by all means comparable to a central nerve block when used for knee surgery. For the surgery distal to tuberositas tibiae, the popliteal sciatic nerve block, alone or combined with a saphenous nerve block is a reasonable choice; for foot surgery an ankle block is probably the best method, so far as regional anesthesia is considered. The choice of local anesthetics is mostly directed by the duration of the surgery but the attention should be paid to the possibility of systemic toxicity because combined proximal nerve blocks of the lower extremity frequently require amounts approximate to the maximal recommended doses. The increased time investment, the impossibility of blocking all nerves of the lower extremity from one injection site, and certain failure rate which have to be accepted are frequently raised as arguments against the use of peripheral nerve blocks for day surgery. However, by adequate explanation of the procedure to the patient, proper organization of the time-frame table, and home transportation facilities, most of traditional restraints regarding peripheral nerve blocks for ambulatory surgery can be overcome or even acclimated. Copyright © 2000 by W.B. Saunders Company

Ankle block

Ankle block

Handbook of Clinical Anesthesia, 3rd Edition

Assistant Professor of Anesthesiology; Wake Forest University School of Medicine; Medical Center Boulevard; Winston-Salem, North Carolina, 27157–1009;jthomas@wfubmc.eduJames C. Eisenach, M.D., EditorHandbook of Clinical Anesthesia, 3rd Edition. Edited by Paul G. Barash, Bruce F. Cullen, and Robert K. Stoelting. Philadelphia, Lippincott-Raven, 1997. Pages: 932. Price:$39.95.The 3rd edition of the Handbook of Clinical Anesthesia is well organized and well written. I have never loved handbooks; I find they usually fall into one of two categories:(1) small with too little clinical information or (2) large and impossible to carry. This text attempts to break these molds: it is a useful clinical reference book that fits in a waistpack. The handbook parallels the comprehensive parent textbook, Clinical Anesthesia, by the same editors and has undergone considerable changes since the 2nd edition. The book consists of 57 small chapters and six important appendices. These are subdivided into seven sections, expanded from its earlier edition. The focus is on perioperative treatment of patients, with chapters describing preoperative evaluation, intraoperative techniques, anesthesia subspecialties, and postoperative care. New chapters describe the economics of healthcare delivery and practice management. The organization of the chapters and overall flow of the book have been improved. The text is far from complete, but it provides an excellent quick reference and review for residents, nurse anesthetists, and staff anesthesiologists. It is also a nice teaching tool for the busy academic physician.Section I of the book, entitled "Introduction to Anesthesia Practice," is the most radical alteration from the 2nd edition and is my least favorite. The section contains completely new material, providing first a brief history of anesthesia and then a discussion of practice management. It also contains chapters that describe experimental design and statistics, hazards in the operating room, and risk management. These chapters are well written and informative; however, it is not the type of information I usually look for while working in the operating room. I found that these chapters just got in the way when I was trying to find something quickly. However, the section is brief, only 31 pages, and I can appreciate the authors' trying to follow the parent textbook as closely as possible, thereby making the handbook a better review text.Sections II and III discuss basic principles of anesthesia practice. There are terrific new chapters on possible mechanisms of anesthesia and electrical safety. These additional chapters are important because they are subjects with which residents frequently have difficulty. The pharmacology chapters are updated and well organized; newer drugs are covered, and shaded charts make critical information easy to find. The authors have added a chapter describing basic pharmacologic principles, which really enhances this section.Section IV (previously section I/VI) covers preoperative and postoperative concerns. A new chapter on anesthesia and coexisting disease, along with the classic pharmacogenetics chapter, make this section an excellent quick reference.The real core of this handbook is Section V. The subspecialty areas are discussed individually, and there are improved reviews of related physiology. In addition, there are new chapters describing laparoscopic surgery, monitored anesthetic care, and the allergic response. The chapter on peripheral nerve blocks is a great reference at the bedside, but it needs to be expanded. More illustrations like the diagram of the ankle block would be helpful.The appendices in this book are potentially useful quick references to use in the operating room. They contain a few formulas, an electrocardiogram atlas, a common drug list, American Heart Association resuscitation protocols, new standards of the American Society of Anesthesiology, and difficult airway algorithms. I found the list of commonly used drugs to be the most useful part of the appendices. The list is updated and contains the newest agents (e.g., remifentanil). I was disappointed that the section on difficult airway algorithms was outdated and does not contain recommendations for the laryngeal mask airway.In summary, although it is not a perfect handbook, this text does a nice job. Overall, the new edition has achieved the authors' goal of enhancing "rapid access" to information in as comprehensive a manner as a handbook allows. The price of $39.95 may seem a little high compared with other small reference books, but I think this text gives you more for your money. It is more complete in its review of the field and, in addition, it fits in my waistpack.John A. Thomas, M.D.Assistant Professor of Anesthesiology; Wake Forest University School of Medicine; Medical Center Boulevard; Winston-Salem, North Carolina, 27157–1009;jthomas@wfubmc.edu(Accepted for publication March 18, 1999.)

Ankle block

Block of the five nerves supplying the foot, performed slightly proximal or distal to the level of the malleoli, is a simple, safe, and reliable technique that does not require patient cooperation, elicitation of paresthesia, or the use of a nerve stimulator. It can provide anesthesia for any type of foot surgery, thus avoiding the potential complications of general anesthesia or neuraxial block. Ankle block can also supply long lasting analgesia without motor block, allowing early ambulation. Modifications to the original technique, which consist of blocking the deep peroneal and posterior tibial nerves more distally where they are more superficial, have improved the success rate of the ankle block dramatically. By using a technique in which, after the initial injection, subsequent injections are made through previously anesthetized areas, patient discomfort during the placement of the block is minimal. When a tourniquet is required, placement at the ankle is effective, safe, and well tolerated.

Remifentanil versus propofol as adjuncts to regional anesthesia

Study Objective: To compare the safety and efficacy of remifentanil and propofol as adjuncts to regional anesthesia in patients undergoing orthopedic or urogenital surgery. Design: Prospective, randomized study. Setting: Multicenter university hospitals. Patients: 107 ASA physical status I, II, and III adult patients who underwent orthopedic or urogenital surgery with axillary, ankle, or spinal block. Interventions: Patients were randomized to receive either an infusion of remifentanil 0.2 μg/kg/min or propofol 100 μg/kg/min 5 minutes before nerve block placement. The infusions were decreased by 50% on block completion, increased by 50% for patient discomfort, and decreased by 50% for hypoventilation (<8 breaths/min) or hemodynamic instability. Measurements and Main Results: Pain, discomfort, anxiety, and sedation were assessed by both patient and investigator. Vital signs and adverse events were recorded. Fewer patients in the remifentanil group experienced pain during block placement (6%), and were oversedated (7%) than patients in the propofol group (23% and 26%, respectively; p < 0.05). Hypoventilation during and after block placement (21% and 25%, respectively) and nausea and vomiting during and after block placement (60% and 21%, respectively) were more common in the remifentanil group than in the propofol group (0% and 3%; 17% and 6%, respectively; p < 0.05). The incidence of hypoventilation in remifentanil-treated patients was higher in patients over 65 years of age ( p < 0.05), but was transient, resolving within minutes of discontinuing the infusion. Conclusions: At the doses studied, remifentanil was more effective than propofol in minimizing pain without producing excessive sedation. Remifentanil was associated with more transient respiratory depression and short-term nausea. Our findings indicate that the initial remifentanil rate should be 0.1 μg/kg/min (50% lower than the study's initial rate) and should be further decreased an additional 50% in the elderly to minimize adverse effects.