CHAPTER 2 Regional anesthesia in perspective

history, current role, and the future

The doctrine of specific energies of the senses, proclaimed by Johannes P. Mueller (1801–58) in 1826 – that it is the nerves that determine what the mind perceives – opened up a new field of scientific thought and research into nerve function.¹ This led directly to the theory that pain is a separate and distinct sense, formulated by Moritz S. Schiff (1823–96) in 1858.² Yet by 1845, Sir Francis Rynd (1801–61) had already delivered a morphine solution to a nerve for the purpose of relieving intractable neuralgia (Box 2.1).³ This appears to be the first documented nerve block as we understand the term today. Rynd, however, delivered his solution by means of gravity through a cannula. The first use of a syringe and hypodermic needle was not recorded until 10 years later, in 1855, by Alexander Wood (1817–84) in Edinburgh.⁴ Wood used a graduated glass syringe and needle to achieve the same end as Rynd.

Carl Koller (1857–1944) was an intern at the Ophthalmologic Clinic at the University of Vienna in 1884. He was searching for a topical local anesthetic and, on the advice of Sigmund Freud (1856–1939), studied cocaine. Following self-experimentation, Koller performed an operation for glaucoma under topical anesthesia on September 11, 1884. He immediately wrote a paper for the Congress of Ophthalmology (held on September 15 of that year), which was published soon after in the Lancet.⁵ The remarkable effectiveness of cocaine as an anesthetic agent led to its immediate widespread use in this area.^6,7

In the same year as Koller’s achievement, 1884, William Stewart Halsted (1852–1922) performed the first documented brachial plexus anesthetic under direct vision at Johns Hopkins,⁸ although it was 1911 before Hirschel and Kulenkampff performed the first percutaneous axillary and supraclavicular brachial plexus blocks.^9,10 By the 1890s, Carl Ludwig Schleich (1859–1922) in Germany and Paul Reclus (1847–1914) in France were seriously writing on the subject of infiltration anesthesia, first with water and later with weak solutions of cocaine.^11,12

Anesthesia as a specialty had not yet developed at this stage, because the surgeon infiltrated as he operated. Victor Pauchet (1869–1936) was the first to point out a new technique of regional anesthesia in which the procedure was carried out by an assistant in advance. In his 1914 textbook L’Anesthésie Régionale, the first of its kind, he stated that he had witnessed Reclus’s technique at first hand 25 years before, and now wished to emphasize the novel concept of regional anesthesia and the emergence of anesthesia or anesthesiology as a specialty.¹³

Sydney Ormond Goldan (1869–1944), describing himself as an anesthetist, had published the first anesthesia chart in 1900.¹⁴ It was designed for monitoring the course of ‘intraspinal cocainization’ and helped lay the foundation for the careful record-keeping that is a cornerstone of modern anesthesia.

Gaston Labat (1876–1934) worked and trained under Pauchet in France in 1917–18.¹⁵ He learned much from treating the casualties of World War I, and in 1922 published the first edition of Regional Anesthesia: Techniques and Clinical Applications, one of the first English-language texts on the subject.¹⁶ Many of his illustrations and techniques continue to have relevance today.

On September 29, 1920, Labat arrived at the Mayo Clinic, Rochester, Minnesota, to teach regional anesthesia to the clinic’s surgeons. From his brief 9-month period there and following tenure at Bellevue Hospital, New York University, he was to have a major influence on the development of the specialty of anesthesia in the USA.¹⁷ His influence on practitioners such as John Lundy, Ralph Waters, and Emory Rovenstine – pioneers in the development of the specialty – was substantial, and the American Society of Regional Anesthesia was initially to have been named after him.¹⁸

The American Board of Anesthesiology was formed in 1938 and held its first written examinations in March 1939. Here, Labat’s legacy continued. In the anatomy section all five questions related to regional anesthesia blocks; two of the five pharmacology questions dealt with local anesthetics in regional anesthesia; and one of the pathology questions dealt with regional anesthesia.¹⁹

Developments continued in the subspecialty through the 20th century (see Box 2.2) to the point where, in 1980, a survey of American anesthesiology residency programs reported the use of regional anesthesia in 21.3% of cases, in 1990 in 29.8% of cases, and in 2000 in 30.2% of cases.^20–22 The majority of these cases, however, involve obstetric anesthesia or pain medicine, which has raised concern in some quarters as to the future place of peripheral nerve blockade in peri-operative anesthetic practice. This future, indeed, may lie in the areas of acute pain management and patient satisfaction.

Continuous peripheral nerve blocks using catheters have been in use since 1946.²³ They have been shown to provide effective postoperative analgesia, be opioid-sparing, and result in improved rehabilitation and high patient satisfaction.^24–26 With refining of the techniques over the intervening half-century, a number of clinicians have used them with great effectiveness. To date, however, their use has been largely confined to inpatients because worries about motor weakness, patient injury, catheter migration, and local anesthetic toxicity have persisted. Concurrently, up to 70 or 80% of patients complain of severe pain following ambulatory surgery, requiring continued opioid medication for up to a week in many cases.^27,28

In the early 2000s, a number of authors reported the use of continuous peripheral nerve catheters in the ambulatory setting with a high degree of success, few complications, and good levels of patient acceptance and satisfaction.^29–32 As these techniques are still in their infancy, a number of special precautions were taken in these studies to ensure safety in the home environment. In addition, as the early pioneers had to defend their practice, it is certain these new pioneers will have to do likewise with these new developments. Further research will likely define the indications and limitations of this technology.

Long-acting peripheral nerve block has been used with a high degree of efficacy, safety, and satisfaction in the ambulatory setting, and is practiced by many anesthetists.^33,34 Single-injection extended-duration (72h) local anesthetic agents have been heralded for many years.³⁵ When, and if, they become a reality we may see a rapid expansion in the use of regional anesthetic techniques as well as the resurrection of the original infiltration techniques as practiced by Schleich and Reclus.

The concept of patient satisfaction has been often dismissed as a parameter too difficult to measure. Unfortunately, the lack of an accepted model of patient satisfaction has hindered progress.³⁶ In recent years, however, a few authors have described the development of global measurement tools and psychometrically constructed questionnaires that produce reliable results; these tools have been applied prospectively in large patient populations.^37,38 Parameters such as improved pain relief and reduced postoperative nausea and vomiting are some of the factors influenced positively by regional anesthesia, and these are also indicators of high patient satisfaction. It can be said that patient satisfaction has become an important indicator of quality of medical care and an important endpoint in outcomes research.³⁹

Ultrasound has been used over the last 15 years to facilitate peripheral nerve blockade. The Vienna group, including Drs Kapral and Marhofer, were early advocates. Ultrasound allows real-time identification of nerves and observation of appropriate local anesthetic spread around nerves. The popularity of ultrasound guidance has grown enormously with improved block success and decreased performance time.

Related posts:

Complications, toxicity, and safety Lumbar and sacral plexus anatomy Midhumeral block Ankle block Posterior sciatic block Femoral nerve block

Peripheral Nerve Blocks and Peri-Operative Pain Relief Periphera 2e