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    Using Continuous Local Anesthetic Infusion to Manage Postoperative Pain

    By Jennifer Decker Arevalo, MA, contributor.      

    Continuous local anesthetic infusion is a state-of-the-art procedure that uses innovative technology to minimize a patient’s postoperative pain. Instead of general anesthesia or the traditional “single shot” peripheral nerve block that loses its effectiveness over time, continuous local anesthetic infusion constantly “bathes” the specific nerve or nerve plexus responsible for pain at the surgical site, thus maintaining analgesia during and after surgery, for as long as necessary.

    To accomplish this, an anesthesiologist or nurse anesthetist inserts an insulated nerve block needle into the appropriate location on the patient’s body to place a stimulating peripheral nerve catheter as close as possible to the nerve or nerve plexus. Electrical currents at the distal end of the catheter excite the nerve, thereby identifying its location and increasing the probablity that the catheter will be correctly positioned under peripheral nerve stimulator guidance. If a typical motor response to low-voltage electrical stimulation is observed, then the Teflon-coated, hollow, flexible-wire catheter has hit its target. All of this is done prior to the administration of any local anesthetic to the nerve.

    According to the New York School of Regional Anesthesia Web site, a specialized ultrasound probe is sometimes used to visualize neural anatomy and the surrounding structures in real-time, enabling the anesthesiologist or CRNA to position the catheter in as little as 15 minutes with minimal complications. Ultrasonography is the most suitable imaging modality for regional anesthesia.

    Once in position, the anesthetist removes the needle and performs a preliminary test dose by injecting a very small amount of local anesthetic, sometimes with epinephrine, through the catheter to make sure the catheter has not dislodged. According to the Regional Anesthesia Study Center of Iowa Web site, if the catheter tip electrically stimulates the nerve as the test dose is starting to be injected, then all muscle twitching will stop and provide further confirmation that the block will be successful (a positive Raj test). A simple subcutaneous tunneling technique is used to secure the catheter in place. The anesthesiologist or CRNA can then administer the remaining bolus in small increments via the catheter to establish initial analgesia.

    Since it is connected to a battery-powered, portable electronic or an elastomeric or spring-activated infusion pump, the catheter will continuously infuse local anesthetic into the nerve causing a temporary block in the conduction of nerve impulses responsible for pain. Continuous infusion of a diluted concentration of local anesthetics, such as ropivacaine or bupivacaine, allows analgesia to last for several days, if necessary, and blocks 90 to 100 percent of the pain for most patients. The recent development of small, lightweight, portable infusion pumps also allows the patient to control postoperative pain with a local anesthetic infusion at home.

    Continuous peripheral nerve block analgesia via a stimulating catheter has many benefits, such as reduced recovery room admissions, decreased cost and improved postoperative analgesia.

    A study showed that patients who received continuous infusion local anesthetic had lower resting and breakthrough pain and took fewer oral pain medications, compared to those taking only oral opioids, like morphine, to manage their pain. Additionally, the side effects of pain medication, such as nausea, vomiting, respiratory depression, itching, drowsiness, urinary retention, constipation, excessive sedation and mental status changes are eliminated.

    Since this procedure helps to expedite postoperative recovery, patients regain their mobility quickly, thus reducing the risk of developing post-surgical complications, like DVTs. Additional benefits, as mentioned in an article by Basavaraj Nagappala, MD, an anesthesiologist at both Petaluma Valley and Santa Rosa Memorial Hospitals in California, include:

    • a more positive experience due to better pain management, so less depression.
    • a quicker return to alertness.
    • the ability to eat and move within hours of surgery without pain.
    • the ability to better participate in physical therapy.
    • the prevention of chronic disabling pain syndromes.

    Patient safety is also improved, as the patient does not require general anesthesia or need to be intubated during surgery. Since there is less blood loss intraoperatively, the procedure can safely be performed in the presence of anticoagulation.

    As with any procedure there are some risks, such as bleeding, insertion site infection, intravascular injection, allergic response, migrating catheter, inadequate pain surface area coverage, local anesthetic toxicity and nerve injury, but the benefits of the procedure outweigh the minimal risks. The best candidates for continuous local anesthetic infusion are those in need of orthopedic surgery; it is not necessary or recommended for minor surgeries.

    An article in the December 2000 issue of Anesthesiology News highlights a Duke University Medical Center study in which nearly 800 continuous peripheral nerve block techniques were performed over a two-year period resulted in a 93 percent success rate. Almost 99.85 percent of the patients were without any severe complications, 75 to 96 percent of the patients did not need narcotics after major surgery, and more than 90 percent of the patients were very satisfied with the procedure.

    The procedure is quickly becoming accepted and used nationwide as the demand for outpatient surgery continues and better medical devices, catheter insertion techniques, medications and drug delivery systems are developed. Since patients experience better postoperative pain relief and can recuperate in the comfort of their home, patient satisfaction and clinical outcomes are optimized.




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