Assessing the Safety and Efficacy of Regional Anesthesia for Lower Extremity Microvascular Reconstruction: Enhancing Recovery

Qing Zhao Ruan; Shawn Diamond; Scott Zimmer; Matthew L. Iorio

doi:10.1055/s-0037-1621726

Journal of Reconstructive Microsurgery, Inhaltsverzeichnis

J Reconstr Microsurg 2018; 34(04): 293-299
DOI: 10.1055/s-0037-1621726

Original Article

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Assessing the Safety and Efficacy of Regional Anesthesia for Lower Extremity Microvascular Reconstruction: Enhancing Recovery

Autoren

Qing Zhao Ruan

¹Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
Shawn Diamond

¹Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
Scott Zimmer

²Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
Matthew L. Iorio

¹Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts

³Department of Orthopaedics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts

Abstract

Background Perioperative pain, increased sympathetic tone, and peripheral vasospasm may be safely managed with regional nerve blockade during microvascular reconstruction in the lower extremity. Limited reports exist in this setting; therefore, we evaluated our use of peripheral nerve catheters (PNCs) during microvascular limb salvage to determine safety and efficacy for both patient and flap.

Methods A single-institution, retrospective review of a prospectively maintained database on all patients with lower extremity free tissue transfers between 2012 and 2017 was completed. Patients were matched into groups based on PNC utilization. The use of intravenous narcotics including patient-controlled analgesia (PCA), oral narcotics, antiemetics, length of stay (LOS), associated pain scores, flap-related performance, and patient morbidity was recorded.

Results Of 48 patients who underwent lower extremity free tissue transfer, 35 satisfied criteria for comparison. Of these, PNC was utilized in 83%. The mean pain score in the immediate postoperative period was 3.84 ± 2.47 (10-point Likert scale). PCA and narcotic use were decreased in the PNC group, and no adverse effects of the catheter were identified. Microsurgical outcomes were not adversely affected in comparison.

Conclusion PNC utilization for lower extremity free flap transfer significantly reduced concurrent narcotic use and attained a shorter LOS. The technique provided for safe analgesia during lower extremity free flap reconstructions satisfying the microsurgeon and the anesthesiologist.

Keywords

lower extremity reconstruction - microsurgery - peripheral nerve block - free flap - nerve catheter

Volltext

Referenzen

References
1 Mustoe TA, Buck II DW, Lalonde DH. The safe management of anesthesia, sedation, and pain in plastic surgery. Plast Reconstr Surg 2010; 126 (04) 165e-176e
2 Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg 2003; 97 (02) 534-540
3 Hagau N, Longrois D. Anesthesia for free vascularized tissue transfer. Microsurgery 2009; 29 (02) 161-167
4 Hahnenkamp K, Theilmeier G, Van Aken HK, Hoenemann CW. The effects of local anesthetics on perioperative coagulation, inflammation, and microcirculation. Anesth Analg 2002; 94 (06) 1441-1447
5 Kurt E, Ozturk S, Isik S, Zor F. Continuous brachial plexus blockade for digital replantations and toe-to-hand transfers. Ann Plast Surg 2005; 54 (01) 24-27
6 Wenger A, Amr A, Schaller HE, Rothenberger J. Skin perfusion changes within 12 h after axillary plexus block. Eur Surg Res 2017; 58 (5-6): 227-234
7 Laskowski IA, Muhs B, Rockman CR. , et al. Regional nerve block allows for optimization of planning in the creation of arteriovenous access for hemodialysis by improving superficial venous dilatation. Ann Vasc Surg 2007; 21 (06) 730-733
8 Hingorani AP, Ascher E, Gupta P. , et al. Regional anesthesia: preferred technique for venodilatation in the creation of upper extremity arteriovenous fistulae. Vascular 2006; 14 (01) 23-26
9 Macdonald DJ. Anaesthesia for microvascular surgery. A physiological approach. Br J Anaesth 1985; 57 (09) 904-912
10 Kettner SC, Willschke H, Marhofer P. Does regional anaesthesia really improve outcome?. Br J Anaesth 2011; 107 (Suppl. 01) i90-i95
11 Seth AK, Diamond S, Iorio ML. Outcomes of an early protocol for dependent conditioning in lower extremity microsurgical free flaps. J Reconstr Microsurg 2017; 33 (09) 670-678
12 Seth AK, Iorio ML. Super-thin and suprafascial anterolateral thigh perforator flaps for extremity reconstruction. J Reconstr Microsurg 2017; 33 (07) 466-473
13 van Twisk R, Gielen MJ, Pavlov PW, Robinson PH. Is additional epidural sympathetic block in microvascular surgery contraindicated? A preliminary report. Br J Plast Surg 1988; 41 (01) 37-40
14 Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002; 109 (07) 2219-2226 , discussion 2227–2230
15 Suh HS, Oh TS, Hong JP. Innovations in diabetic foot reconstruction using supermicrosurgery. Diabetes Metab Res Rev 2016; 32 (Suppl. 01) 275-280
16 Macedo FI, Mittal VK. Does enhanced recovery pathways affect outcomes in open ventral hernia repair?. Hernia 2017; 21 (05) 817-818
17 Majumder A, Fayezizadeh M, Neupane R, Elliott HL, Novitsky YW. Benefits of multimodal enhanced recovery pathway in patients undergoing open ventral hernia repair. J Am Coll Surg 2016; 222 (06) 1106-1115
18 Batdorf NJ, Lemaine V, Lovely JK. , et al. Enhanced recovery after surgery in microvascular breast reconstruction. J Plast Reconstr Aesthet Surg 2015; 68 (03) 395-402
19 Spanjersberg WR, van Sambeeck JD, Bremers A, Rosman C, van Laarhoven CJ. Systematic review and meta-analysis for laparoscopic versus open colon surgery with or without an ERAS programme. Surg Endosc 2015; 29 (12) 3443-3453
20 Peng YP, Seow C, Low CK, Chew WY, Pho RW. Continuous local anaesthesia for post-operative mobilization of injured digits. J Hand Surg [Br] 2003; 28 (06) 513-519
21 Koh DL, Lim BH. Postoperative continuous interscalene brachial plexus blockade for hand surgery. Ann Acad Med Singapore 1995; 24 (4, Suppl): 3-7
22 Büttner J, Klose R, Hammer H. Continuous axillary catheter plexus anesthesia–a method of postoperative analgesia and sympathetic nerve block following hand surgery [in German]. Handchir Mikrochir Plast Chir 1989; 21 (01) 29-32
23 Conacher ID, Paes ML, Jacobson L, Phillips PD, Heaviside DW. Epidural analgesia following thoracic surgery. A review of two years' experience. Anaesthesia 1983; 38 (06) 546-551