Preface

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 methods, general anesthesia advanced substantially through technologic and pharmacologic developments as well as via objective physiologic monitoring. Taken together, these factors conspired to use and teach objective and reproducible general anesthetic techniques rather than regional anesthesia techniques. Although 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 regional 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 discussions.

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 emergency settings.

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 on anticoagulants.

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.