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by
Jennifer Greger,
MD
Director,
Regional Anesthesia and Acute Orthopedic Pain Service
University of
Texas, Houston
Pain management has become a very important concept
in surgery, not only for humanitarian reasons, but to comply with JCAHO
guidelines. Clinicians now measure pain as the 5th vital sign. Using a 10-point
scale, patients are asked to rate their pain from 10, which is the worst pain
they can imagine to 1, which is no pain at all.
Dr. Greger begins her lecture by discussing, in
detail, the anatomy of the lumbar plexus, the femoral and sciatic nerves. With
this information in tow, we learn about sciatic, femoral, saphenous, tibial, and
peroneal nerve block techniques. Dr. Greger describes how nerve stimulators help
to locate specific nerves and help achieve a high level of success with blocks.
The lower extremity blockade at the ankle level is
reviewed in great detail. Year after year, freshman residents are asked which
five nerves are anesthetized in an ankle block. Dr. Greger does a public service
for these residents by describing the nerves in her lecture:
1. Saphenous (femoral)
2. Deep peroneal (peroneal)
3. Superficial
peroneal (peroneal)
4. Posterior tibial,
plantar digital (tibial)
5. Sural (peroneal and
tibial)
Postoperative pain is also addressed in Dr. Greger’s
lecture. We learn how “post operative surgical stress syndrome” contributes to
delayed recovery, immunosuppression, fatigue, hypoxia, nausea, and sleep
disturbances.
Some of the options to control postoperative pain
are discussed. For many years Opioids have been the mainstay drugs for
postoperative analgesia. Unfortunately, these drugs commonly cause nausea,
constipation, and respiratory depression.
Many physicians have turned to the new Cox 2
inhibitors for postoperative pain relief. These drugs offer better analgesic
relief than the NSAID’s. They are usually safer and do not significantly
interfere with anticoagulant and platelet function.
Dr. Greger also explains the use of the New Nerve
Block Infusion Systems, citing the I-Flow system as an example
http://www.i-flowcorp.com
by permission of I-Flow
These systems consist of a disposable balloon type
pump that provide a continuous infusion of local anesthetic via a small
catheter, which is inserted into the wound intra operatively.
I have personally found these systems to be simple
to use and patient friendly. It is very gratifying when your patients tell
others that they underwent extensive surgery, but never required postoperative
pain medication.
For additional information about local anesthetics
and nerve blocks of the foot, view Dr. Mark Beylin’s excellent lecture on “Principles
of Local Anesthetics”
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