CHOOSING AN APPROPRIATE ANESTHETIC TECHNIQUE



RECOMMENDATIONS ON CHOOSING AN APPROPRIATE ANESTHETIC TECHNIQUE.

 Choose peripheral nerve block in situations :
  • Surgery of the upper extremities 
  • Surgery of the lower extremities 
  • Surgery of the scalp, neck, and trunk 
  • Block of selected peripheral nerves (e.g., digital nerve block): technique to anesthetize the digits to perform surgery on the fingers or toes.

 Neuraxial (regional) anesthesia can provide excellent operating conditions in the lower extremities and lower abdomen. Higher levels of the neuraxial blockade (e.g., midthoracic to high thoracic) with surgical anesthesia concentrations of local anesthetic (e.g.,  epidural  2%  lidocaine) result in more profound sympathectomy and increased risk of hypotension, which may require infusion of vasoactive medications to maintain hemodynamic stability. 
regional anesthesia


 Situations in Which Regional Anesthesia May Not Be Appropriate:

  • Preferences and experience of the patient, anesthesia provider, and surgeon.
  • The need for an immediate postoperative neurologic examination in the anatomic area impacted by the regional anesthetic.
  • Coagulopathy.
  • Preexisting neurologic disease (e.g., multiple sclerosis, neurofibromatosis).
  • Infected or abnormal skin at the planned cutaneous puncture site.

Specific Considerations for Neuraxial Anesthesia.
Hypovolemia increases the risk for significant hypotension
Coagulopathy (including anticoagulant and antiplatelet medication therapy) increases risk of epidural hematoma
Increased intracranial pressure may result in cerebral herniation with intentional or inadvertent dural puncture.

  Clinical Cases Appropriate for General Anesthesia:


  • A requirement for systemic neuromuscular blockade.
  • A requirement for establishment of a secure airway:
    •  Due to surgical procedures that may compromise native airway integrity, oxygenation, or ventilation.
    • Due to level of consciousness required to provide immobility, analgesia, or anxiolysis.
  • Patient or procedural characteristics that are not appropriate for monitored anesthesia care.
    • Uncooperative patient or patient refusal.
    • Surgical pain not amenable to local or topical anesthesia.
    • Patient or procedural characteristics that are not suitable for regional anesthetic.
  • Preferences of the patient, anesthesia provider, and/or surgeon

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