Mayo Clinic Analgesic Pathway: Peripheral Nerve Blockade for Major Orthopedic Surgery PDF

PREFACE

"Regional anesthesia has come to stay." These words by surgeon William J. Mayo, M.D., opened the foreword to Regional Anesthesia: Its Technic and Clinical Application, by Gaston Labat, M.D. Published in 1922, Labat's text popularized regional anesthesia in the United States by describing techniques already familiar to European surgeons and anesthesiologists. Importantly, Labat described the use of infiltration and peripheral, plexus, and splanchnic blockade (using cocaine and procaine) for head and neck, intrathoracic, intra-abdominal, and extremity surgery. The techniques of peripheral neural blockade were developed early in the history of anesthesia, and over time neuraxial and general anesthesia, with their improved safety, supplanted their use.

Recently, the introduction of long-acting local anesthetics and adjuvants, the refinement of imaging methods to facilitate neural localization, and innovations in equipment technology, including stimulating needles, catheters, and portable infusion devices, have increased the success rate and popularity of peripheral blockade. Undoubtedly, peripheral nerve blocks represent a new era in regional anesthesia and analgesia. Competence in these techniques is crucial to future practice models. However, adequate training and proficiency affect utilization. A nationwide survey reported that 98% of anesthesiologists perform peripheral techniques but most perform fewer than five per month (although the majority predict increased use in the future). Likewise, despite improvements in needle and catheter technology and neural localization, these blocks often remain underutilized and challenging. Studies evaluating proficiency in technical skills have noted that regional anesthetic procedures are significantly more difficult to learn than the basic manual skills necessary for general anesthetic procedures, such as intubation and arterial cannulation. Also, the majority of resident training programs do not provide formal instruction in peripheral blockade.

In 2003, a multidisciplinary group of surgeons, anesthesiologists, nurses, pharmacists, and physical therapists implemented the Mayo Clinic total joint analgesic pathway, a multimodal approach that utilized peripheral regional techniques and oral analgesics (no long-acting or intravenous opioids were administered). The results were truly remarkable. With the use of strict dismissal criteria, 95% of patients undergoing total knee arthroplasty and 80% of patients undergoing total hip arthroplasty could be dismissed in less than 48 hours. Importantly, 90% of patients were dismissed to home rather than to a rehabilitation facility. These results were the impetus for the creation of our text.

This book is a practical guide in the application, performance, and management of lower extremity peripheral regional techniques. Labat noted that "The practice of regional anesthesia is an art. It requires special knowledge of anatomy, skill in the performance of its various procedures, experience in the method of handling patients, and gentleness in the execution of surgical procedures." In concordance, we have included original illustrations depicting the surface and internal anatomy for lower extremity blockade, including figures that show the positions of the patient and the proceduralist. The techniques are described in detail, including needle redirection cues based on the associated bony, vascular, and neural structures. In addition, because the perioperative management of patients undergoing major lower extremity surgery necessitates a team approach, instructions for care of peripheral catheters, the dosing regimens of oral analgesics, and the implications of antithrombotic medications are provided. This book is not intended to be a comprehensive text of peripheral nerve block. Rather, the clinician is encouraged to consult the recommended reading lists at the ends of chapters (which include both classic and alternative regional techniques) and anatomical texts, sections, and simulators.

We extend our appreciation and gratitude to the members of the Section of Orthopedic Anesthesia and the Department of Orthopedic Surgery for their collegiality in developing this project, to Duane K. Rorie, M.D., Ph.D., for his meticulous anatomical dissections and instruction, to Mr. Stephen N. Boyd and Ms. Joan Beck for the skillful execution of the original illustrations, and to the nursing staff for providing the highest level of care in the operating suite, hospital ward, and the hospital pain service.

Finally, although over the years the art and science of regional anesthesia have been supported and advanced by countless men and women, we dedicate this book to the two visionaries who brought these techniques to Mayo Clinic: William J. Mayo, M.D., who stated, "Regional anesthesia has come to stay," and Gaston Labat, M.D., who made it so.