Head of Anesthesia Department
Fremap Hospital, Madrid, Spain
Comments a recent paper about the Ambulatory Surgery
Gray AT, Laur JJ.
Int Anesthesiol Clin. 2011 Fall;49(4):13-21
Peripheral nerve blocks certainly fulfill the demands required outpatient surgery system. They have recognized advantages over general anesthesia in terms of, care in the post-anesthesia recovery unit, incidence of nausea and vomiting and postoperative pain, although they are not associated with shorter stay in the Ambulatory Surgical Unit Disadvantages are blamed like largest perform time and onset time, block failed or incomplete requiring high sedation level or converted to general anesthesia, which would lose some of its advantages. With the application of ultrasound (US) as an exclusive localization method, or combined with neurostimulation (NS), it has been reported that it shortens the perform time, reduces the number of needle passes, less latency time is consumed, and lower anesthetic local volume is requires. The block is said to be more predictable, and potentially with a lower morbidity, which reinforces its choice in Ambulatory Surgery. Studies reviewed by the American Society of Regional Anesthesia confer an evidence level Ib, grade A that ultrasound guidance results in faster sensory block onset and higher surrogate rates of block success in upper-extremity blocks. Less undesirable effects are achieved with the aid of US, such as diaphragmatic hemiparesis or systemic toxicity, and avoids complications like, pneumothorax, peritoneal puncture or vascular puncture that could cause a hematoma, occasionally very spectacular (Figure 1) or with serious consequences. When faced with any of these situations, and prior to discharging from the One Day Unit, US may be used to rapidly and effectively rule out or confirm a diagnosis. In the reference article, these contributions of US are mentioned, although generically, with a brief reference to its effect on the safety and care of outpatients surgery. The discussion of the significant differences that US has made in regional anesthesia for Ambulatory Surgery, as regards its study, are focused on aspects that are not exclusively for the ambulatory patient, such as the controversy over the anesthetic volumes used, the tests for checking the surgical block, the possible serious consequences of a vascular puncture hematoma, systemic toxicity due to local anesthetics (LAST), and the diagnosis of the pneumothorax by US. Of what there is no doubt is the great welcome that this tool has had in different medical specialties, and in Anesthesiology in particular, the extraordinary interest that it has stimulated in peripheral nerve blocks.
Graduated in Medicine and Surgery, University Complutense, Madrid in 1977
Training as an Anaesthesiology and Resuscitation specialist in Hospital Gregorio Marañon, Madrid. National MIR (Internal Medicine Residency) Qualification, 1978.
First in National Competitive Exam of Career Public Employees, Physicians and Specialists in Anaesthesiology and Resuscitation Scale (Official State Bulletin 7 Dec 1985).
Head of Anaesthesiology and Resuscitation in the FREMAP Hospital,Majadahonda-MADRID-SPAIN
MastersDegree in “Biomechanics of the LocomotorApparatus”, UniversityComplutense, Madrid
Communications on Regional Techniques in 53 courses, meetings and conferences.
Teacher and Instructor in Ultrasound –Guided Regional Blocks in 15 courses.
Organiser and Presenter of 7 Regional Anaesthesia Workshops (3 in Ultrasound in Anaesthesiology and Pain).
Participation on Clinical Sessions on Ultrasound-Guided Blocks, in 14 University Hospitals of the Spanish Public Health System.
Different publications in Journals
Formal Training of IV year medical Residentsof the Spanish and Portuguese Public Health System, on Loco-Regional Techniques.
ENRIQUE MONZÓ MD
Interview with the expert
1- Dr Monzó began doing and teaching regional anaesthesia with neurostimulation and progressively walked toward the ultrasound guided technique. How do you see that change and what do you currently use neurostimulation for?
The change is not easy for regionalists accustomed to neurostimulation(NS). There are two barriers to overcome, the deeply-rooted conviction: “why should I change it if what I do has good results”; and laziness that comes with having to learn an unknown method with an “a priori”long learning curve, which requires anatomy, anatomy, anatomy.
I have not used neurostimulation as an exclusive method again. I have lost confidence in it, because now I have a lot of doubts: how will the local anesthetic spread? ; will it get surround the nerve?, and how many intraneural injections?. Also the vascular punctures with the usually several entrances and withdraws needle. Currently only use NS as a supplement to Ultrasound, when I have doubts about any nerve, as often happens with the obturator nerve or the cutaneous of the leg and foot nerves.
2- Which ultrasound guided block do you feel like‘your best’?
For the upper limb I really used to like the parasagittal infraclavicular, now it is supraclavicular that attracts me most, even for hand surgery. For the lower limb, the subgluteal sciatic with a single puncture“keepit simple”, and the obturator, which continues to be a challenge.
3- You have a wide experience in ambulatory surgery. What is coming in regional anaesthesia for one day surgery?
A local anaesthesia with a differential effective block would be ideal in One Day Surgery. Among the many sensory nerve blocks would be those desirable in the outpatient, in such a way that motor function is preserved. This, in the lower limb, can be achieved with blocks at leg or ankle level in the lower limb, as such that the patient may be able to support and walk without delaying discharge. For the upper limbs, in certain surgeries of the forearm or the hand, it would also be able to maintain the function, blocking the cutaneous nerves of the elbow, the sensory branch of the radial in the forearm, and the median and cubital in the distal third of the forearm. Trunk nerve blocks are sensory and useful for post-operative analgesia in general surgery of the ambulatory patient.