What the Anesthesiologist Should Know before the Operative Procedure
This is an elective procedure, and the major variables are (1) the duration anticipated, (2) use of a skin graft or not, and (3) presence of any preexisting anticoagulation therapy.
1. What is the urgency of the surgery?
What is the risk of delay in order to obtain additional preoperative information?
2. Preoperative evaluation
The most common issue is the presence of coexisting diabetes.
Medically unstable conditions warranting further evaluation include:myocardial ischemia and poorly controlled diabetes. Delaying surgery may be indicated if the patient has acute chest pain.
3. What are the implications of co-existing disease on perioperative care?
b. Cardiovascular system
Acute/unstable conditions: New-onset ischemia or failure should be evaluated by a cardiologist.
Baseline coronary artery disease or cardiac dysfunction – Goals of management: If stable disease is present, continue current medications. Only exception might be antiplatelet drugs used in the presence of a recent intracoronary stent..
Chronic obstructive pulmonary disease
This should include severity of disease, typically assessed with a preoperative assessment of symptoms (dyspnea, cough, wheezing, prior hospitalizations, exacerbations requiring hospital admissions/intubation, and/or systemic steroid therapy), functional capacity, and recent pulmonary infections. Laboratory examination such as arterial blood gases, pulmonary function testing, or chest radiographs is rarely necessary.
Perioperative risk reduction
This includes maintaining all chronic medications, aggressive pulmonary hygiene, and ideally avoiding instrumentation of the airway to decrease the risk of perioperative pulmonary complications.
Obstructive sleep apnea
Obstructive sleep apnea (OSA) patients should have the severity of the disease assessed, and appropriate strategies should be developed to reduce the potential for postoperative exacerbation of their disease by opioid-induced respiratory depression. They should continue the use of their continuous positive airway pressure (CPAP) therapy in the perioperative period.
Reactive airway disease (asthma)
The perioperative evaluation and risk reduction strategies are similar to those for patients with chronic obstructive pulmonary disease (COPD).
If diabetes is present, the patient should be evaluated for potential renal insufficiency. Also, gastric emptying may be delayed, and all patients should be evaluated for the presence of gastroesophageal reflux disease (GERD).
Diabetes may predispose to peripheral neuropathy.
Acute onset of new neurological deficits should be assessed prior to the procedure, requiring a full history and physical examination. Neurology consultation may be warranted and deferring the elective procedure until such time as these issues can be evaluated and/or stabilized is absolutely indicated.
Perioperative risk reduction
Again, this is an elective procedure; any acute neurologic changes should be fully investigated before proceeding to surgery.
If neuropathy is present, thorough preoperative documentation is needed.
Again, diabetes is the most likely concern, and management should be optimized to reduce the potential for infection or delayed wound healing. Since most of these patients are outpatients, they can return rapidly to self-management of their disease.
g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
4. What are the patient's medications and how should they be managed in the perioperative period?
There are no medications specific for this process. All preoperative medication should be continued, with the exception of anticoagulants.
h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
i. What should be recommended with regard to continuation of medications taken chronically?
All preoperative medications should be continued.
Antiplatelet drugs will probably be discontinued by the surgeon 1 week prior to surgery (including herbal medications), with the possible exception of therapy given for intracoronary stent. In that case, consultation with a cardiologist is necessary.
j. How To modify care for patients with known allergies –
Avoid medications to which the patient is allergic
k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
Remove all latex products from the OR and ensure that the OR staff is aware of the patient’s latex allergy.
l. Does the patient have any antibiotic allergies?
m. Does the patient have a history of allergy to anesthesia?
Documented: avoid all trigger agents such as succinylcholine and inhalational agents:
Proposed general anesthetic plan:
Ensure malignant hyperthermia (MH) cart available including Malignant Hyperthermia Association of the United States (MHAUS) protocol
Family history or risk factors for MH: use regional technique and avoid triggering agents.
Local anesthetics/ muscle relaxants: There are two types of local anesthetics: esters and amides. Most allergies involve esters because of the preservatives; amide allergies are exceedingly rare. A thorough history from the patient can elucidate what the reaction was and from what type of local anesthetic. If the patient is a poor historian, avoidance of regional anesthesia may be necessary (provided old records cannot be obtained). If the patient has allergies to muscle relaxants, general anesthesia should be avoided and a regional technique should be used
5. What laboratory tests should be obtained and has everything been reviewed?
None are necessary unless indicated for coexisting disease.
Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
Regional anesthesia is ideal for these procedures.
Several approaches would be adequate, including supraclavicular block, infraclavicular block, axillary block, and distal nerve blocks of the arm (less desirable if a tourniquet is to be used).
Neuraxial: not relevant.
Peripheral nerve block
Benefits: excellent anesthesia and postoperative analgesia.
Drawbacks: requires skill of the operator, and perhaps a little more time for onset of anesthesia.
Issues: if a skin graft is to be used from an area other than the arm, local anesthesia may be required for the other site.
This is needed in the event the patient refuses a regional technique.
Benefits: avoids regional blockade.
Drawbacks: requires instrumentation of the airway (an LMA is usually sufficient); risk of nausea; no intrinsic postoperative analgesia.
Airway concerns: none due to procedure; management by routine evaluation.
Monitored anesthesia care
Monitored anesthesia care is not usually effective because of deep dissection.
6. What is the author's preferred method of anesthesia technique and why?
The author prefers a selective block of the nerves of the forearm, the “mid-humeral” approach to axillary block, for the reasons outlined above. Again, if a tourniquet is to be used, a higher level of block or supplemental sedation may be necessary.
What prophylactic antibiotics should be administered?
None are indicated.
What do I need to know about the surgical technique to optimize my anesthetic care?
Use of a skin graft (and its source) is the major question.
What can I do intraoperatively to assist the surgeon and optimize patient care?
Nothing is indicated.
What are the most common intraoperative complications and how can they be avoided/treated?
Surgical pain may occur if a nerve is inadequately blocked (or not enough time is allowed); local infiltration by the surgeon is usually sufficient to allow continuation. Tourniquet pain after 45-60 minutes may require sedation.
Cardiac and pulmonary complications are unlikely. Neurologic complications are unique to procedure: nerve inury can occur in the palm, or very rarely from the anesthetic technique.
b. If the patient is intubated, are there any special criteria for extubation?
c. Postoperative management
What analgesic modalities can I implement?
The block will usually provide adequate analgesia for 8 to 18 hours, depending on the choice of local anesthetic. Oral multimodal analgesics provide sufficient analgesia after that, or rescue analgesia if there is pain despite block. A continuous catheter technique is not usually necessary.
What level bed acuity is appropriate?
These are usually outpatient procedures.
What are common postoperative complications, and ways to prevent and treat them?
Necrosis of a skin graft is a potential. Finger necrosis is possible if an artery is damaged. Trauma to a digital nerve may produce sensory loss. Hand stiffness from surgery and postoperative immobilization is possible.
What's the Evidence?
Bouaziz, H, Narchi, P, Mercier, FJ, Khoury, A, Poirier, T, Benhamou, D. “The use of a selective axillary nerve block for outpatient hand surgery”. Anesth Analg. vol. 86. 1998. pp. 746-8. (This study shows that one of the advantages of humeral block or other selective blocks is their ability for injecting long-lasting local anesthetics on the ulnar and median nerves [to provide long-lasting analgesia] while injecting short-acting local anesthetics on the radial and musculocutaneous nerves to provide intraoperative analgesia and thus enabling the patient to move the elbow after surgery while maintaining long postoperative analgesia in the operated hand.)
Bouaziz, H, Narchi, P, Mercier, FJ, Labaille, T, Zerrouk, N, Girod, J, Benhamou, D. “Comparison between conventional axillary block and a new approach at the midhumeral level”. Anesth Analg. vol. 84. 1997. pp. 1058-62. (The authors demonstrate the efficacy of an axillary block when injecting selectively the musculocutaneous nerve before injecting the remaining dose in the neurovascular area to infiltrate the three other main nerves [median, ulnar, and radial] compared to a more distal humeral block, where the four nerves are injected separately.)
Sia, S, Lepri, A, Campolo, MC, Fiaschi, R. “Four-injection brachial plexus block using peripheral nerve stimulator: a comparison between axillary and humeral approaches”. Anesth Analg. vol. 95. 2002. pp. 1075-9. (This study shows that when the four nerves are sought with nerve stimulation, both the axillary and the humeral approaches provide a high success rate and a rapid onset of sensory anesthesia.)
Koscielniak-Nielsen, ZJ, Rotbøll Nielsen, P, Risby Mortensen, C. “A comparison of coracoid and axillary approaches to the brachial plexus”. Acta Anaesthesiol Scand. vol. 44. 2000. pp. 274-9. (The authors showed that the axillary approach to the brachial plexus using four injections of ropivacaine results in a faster onset of block and a better spread of analgesia than the coracoid approach using two injections.)
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- What the Anesthesiologist Should Know before the Operative Procedure
- 1. What is the urgency of the surgery?
- What is the risk of delay in order to obtain additional preoperative information?
- 2. Preoperative evaluation
- 3. What are the implications of co-existing disease on perioperative care?
- b. Cardiovascular system
- c. Pulmonary
- d. Renal-GI:
- e. Neurologic:
- f. Endocrine:
- g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
- 4. What are the patient's medications and how should they be managed in the perioperative period?
- h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
- i. What should be recommended with regard to continuation of medications taken chronically?
- j. How To modify care for patients with known allergies -
- k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
- l. Does the patient have any antibiotic allergies?
- m. Does the patient have a history of allergy to anesthesia?
- 5. What laboratory tests should be obtained and has everything been reviewed?
- 6. What is the author's preferred method of anesthesia technique and why?
- What prophylactic antibiotics should be administered?
- What do I need to know about the surgical technique to optimize my anesthetic care?
- What can I do intraoperatively to assist the surgeon and optimize patient care?
- What are the most common intraoperative complications and how can they be avoided/treated?
- c. Postoperative management