Medicine is a dynamic and constantly changing art. However, regional anesthesia,
as a discipline, has often lagged behind the progress and developments
of other subspecialties of anesthesiology. This is due, in part, to the
fact that regional anesthesia is both the oldest and, in some respects,
the youngest discipline of anesthesiology. It is the oldest because the
introduction of cocaine
for ocular surgery by Karl Koller in 1884 marked
the beginning of what could be called modern anesthesiology
. It is
the youngest because, despite its 150-year-long history, it has only recently
begun to acquire the means and technology necessary to make it as reproducible
and objective as other medical subspecialties.
This lack of objectivity in regional anesthesia stems from the fact that
most procedures have relied on subjective “feel” rather than
an objective, quantifiable methodology. “Feel” techniques traditionally
have been taught by a relatively small number of enthusiastic, charismatic,
and uniquely capable “masters.” While regional anesthesia,
throughout the 20th century, depended almost entirely on subjective
general anesthesia advanced substantially through technologic
as well as via objective
physiologic monitoring. Taken together, these
factors conspired to use and teach objective and reproducible general anesthetic
rather than regional anesthesia techniques.
neuraxial regional anesthesia has been in widespread use (especially in
obstetric anesthesia), peripheral nerve block techniques were almost forgotten
until a resurgence in the 1990s, which continues today.
Research efforts, data on improved patient outcomes with regional anesthesia
and better pain management, and the rapid growth of ambulatory surgery
have come together to provide an exciting environment for a renaissance
of regional anesthesia and its role in perioperative management of acute
pain. That being so, there is probably no better time for the publication
of this book because it coincides with what must be one of the most exciting
periods in the development of modern regional anesthesia.
Today, regional anesthesia and acute pain management are undoubtedly among
the most discussed, researched, and lectured areas of clinical anesthesiology.
Ongoing research in functional regional anesthesia anatomy, wider availability
of training in regional anesthesia, and rapid development of better techniques
and equipment for regional anesthesia have fueled the interest and the
development of this field and have made techniques much more reproducible.
For example, continuous perineural catheters; sophisticated nerve stimulators;
depth-coded, insulated, stimulating needles; injection pressure monitoring;
and real-time, ultrasound-guided peripheral nerve blocks are now commonly
available. Contrary to conventional practice, in which the practitioner
chooses either regional anesthesia or pharmacologic management of pain,
it has become clear today that management of acute pain is a multimodal
approach. This book aims to provide the anatomic, physiologic, and pharmacologic
bases for the practice of regional anesthesia and its integration into
pharmacologic management of acute pain. To accomplish this aim, I have
recruited key opinion leaders from within the United States and abroad
and have asked them not only to share the in-depth science that is their
area of expertise but also to present their practical approaches to managing
a spectrum of scenarios in clinical practice of regional anesthesia and
acute pain management.
The book consists of 83 chapters. The first part of the book discusses
the history of regional anesthesia, its roots, and its early developments.
Readers should realize, however, that the history of regional anesthesia
does not end with these events of the past. Au contraire, the history of modern
anesthesia is being created by the pioneers of the 1990s onward.
The chapter on embryology provides substantial background regarding dermatomes,
osteotomes, and myotomes as well as relevant information necessary for
understanding the development of nerves and plexi. The chapters on anatomy,
pharmacology, and electrophysiology are written to give the reader insight
into the basic principles, techniques, pharmacologic issues, and instruments
used in regional anesthesia.
Part III, “Clinical Practice of Regional Anesthesia,” begins
with a chapter on local anesthesia. Because local anesthesia is administered
more often by surgeons than by anesthesiologists, I have invited surgical
colleagues to contribute the expertise that they rely upon in their everyday
practice. To provide authentic, solid, and practical information, the same
principle has been followed in all chapters: that is, practical information
from practicing physicians was favored over purely academic, theoretical
Neuraxial anesthesia comprises spinal, epidural, and caudal anesthesia;
separate, in-depth chapters are provided covering a wide range of neuraxial
techniques. Following the introductory remarks and the chapter on equipment
for peripheral nerve blocks, chapters on a variety of peripheral nerve
block techniques are organized according to body regions. Each chapter
begins with a brief historical review, followed by the indications and
contraindications, discussion of the relevant anatomy, and various aspects
of the techniques and perioperative management. As is the case for other
chapters in the book, the information here focuses primarily on practical
aspects. Substantial information and literature review also are devoted
to the recent developments in the field, outcome data, variations in the
techniques, and complications and their prevention.
Subsequent parts of the book focus on new developments in the instrumentation
and monitoring used in regional anesthesia, ultrasound-assisted techniques
for nerve blocks in both adult and pediatric populations, and the use of
regional anesthesia in the obstetric patient.
When applied skillfully and for correct indications, regional anesthesia
can improve patient outcomes. However, this may not be the case in patients
with concomitant medical or surgical disease. For this reason, substantial
information is provided on the implications and use of regional anesthesia
in patients with cardiac and other medical diseases. The use of regional
anesthesia in special patient populations or in special settings must be
tailored to the specific needs of such patients in these special scenarios.
Several chapters are devoted to the use of regional anesthesia in pediatrics,
community practice, austere environments, critically ill patients, and
Because the risk of complications is one of the major factors impeding
the wider use of regional anesthesia, separate chapters provide information
on etiology, prevention, and management of complications related to the
use of regional anesthesia. These comprise chapters on systemic, infectious,
and neurologic complications of neuraxial anesthesia and peripheral nerve
blocks. Similarly, the widespread perioperative use of potent anticoagulants
mandates careful consideration of their effects on the safety of regional
anesthesia techniques. Separate chapters are devoted to managing patients
Part XIII, “Regional Anesthesia & Acute Patient Management,”
includes chapters on pre-emptive analgesia, acute pain management, and
integration of regional anesthesia into modern pain management pathways.
Part XIV, “Documentation & Training of Regional Anesthesia,”
includes chapters on documenting regional anesthesia procedures and residency
and fellowship training in regional anesthesia. The book ends with a chapter
focusing on research design in regional anesthesia. This last chapter has
been prepared to acquaint the young investigator with specific research
methodologic issues and methods of importance to designing and conducting
quality research in regional anesthesia. A separate section of this chapter
presents the reader with practical examples of common mistakes encountered
in manuscripts submitted for publication in major anesthesia journals.
As can be seen from the table of contents, this textbook is intended as
both an in-depth reference text for academicians, teachers, and scholars
of regional anesthesia and a down-to-earth practical guide for the practicing
clinician. It is my hope that its content will promote the more widespread
use of regional anesthesia techniques and foster research for its improvement
for future generations.
Admir Hadzic, MD, PhD