Other regional techniques

Peripheral nerve blocks with long-lasting local anesthetics such as bupivacaine can produce postoperative analgesia lasting for several hours in the early postoperative period. Applications include ankle block for foot surgery, ilio-inguinal block for inguinal hernia repair, femoral nerve block for knee surgery, and penile block for circumcision. The patient must be given appropriate instructions to protect the anesthetized body part while it is insensitive and should be warned to inspect the field for bleeding and color change.

After major surgery, catheter techniques may be used to extend the duration of analgesia. Epidural local anesthetic infusions were the earliest example of these, but have problems with hypotension, motor blockade, and tachyphylaxis; these problems are largely avoided by using opioid-local anesthetic mixtures. Following thoracic or upper abdominal surgery, intercostal or paravertebral blocks provide useful analgesia but are limited by the duration of action of the local anesthetic. Intrapleural infusion of bupivacaine has been shown to have an opioid-sparing effect after unilateral flank surgery (e.g. subcostal incision for open cholecystectomy). However, it is less efficacious for analgesia after thoracotomy, where better analgesia may be achieved by infusion of the anesthetic into the chest wall in the extrapleural paravertebral space. Similarly, continuous anesthesia to the brachial or lumbar plexus can provide analgesia after major upper or lower limb surgery or optimize peripheral blood flow by inducing a sympathectomy (e.g. after microvascular digital reimplantation).

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