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Challenges in Modern Surgery

Safety and Efficacy of Forefoot Surgery under Ankle Block. D. Russell, A. Pillai, K. Anderson, C.S. Kumar Glasgow Royal Infirmary. Challenges in Modern Surgery. Waiting List Personnel: funding / trainees / staff Patient expectation Early rehabilitation Early mobilisation

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Challenges in Modern Surgery

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  1. Safety and Efficacy of Forefoot Surgery under Ankle Block.D. Russell, A. Pillai, K. Anderson, C.S. Kumar Glasgow Royal Infirmary

  2. Challenges in Modern Surgery • Waiting List • Personnel: funding / trainees / staff • Patient expectation • Early rehabilitation • Early mobilisation • Minimal intervention / invasion / stress response • Co-morbidity • Obesity • Cardiovascular disease, diabetes

  3. Challenges for the Service • Targets in set number of sessions • Increasing scope and demand for day surgery • Ward care • Pre-operative assessment • Improve safety • Cost-effective practice • Professional training & education

  4. Ankle Block Recognised technique for post op pain relief V. Dhukaram, C.S. Kumar Foot and ankle Surgery 10 (2004) 1-3

  5. Potential Patient Benefits of RA • Reduces significant side effects / risks / fear of general anaesthesia • Surgery on high risk pt • Prolonged post-op pain relief • Early mobilisation

  6. $ Potential Service Benefits £ • Requires surgeon only • Reduced pre-op assessment, no anaesthetist, enhanced role of surgeon (training, education) • Increased list productivity • Block room, reduced turn-around time • Same day discharge • Ambulation, reduced PONV, reduced pressure on beds

  7. Objectives of Observational StudyIs forefoot surgery under ankle block working? • Patient satisfaction • Has it been safe so far? • Are patients staying in beyond one day? • How soon can they mobilise? • Level of post-operative pain and analgesia requirement

  8. Technique • Local anaesthetic • Blocks performed by consultant surgeon or consultant anaesthetist • Mixture of 10ml 2% Lignocaine with 10ml 0.5 % Bupivacine • Anatomical landmarks (no USS / stimulators) • Superficial peroneal nerve • Deep peroneal nerve • Posterior tibial nerve • Saphenous nerve • Tourniquet

  9. Patients • 21 forefoot procedures • 17 female and 1 male • Age range 33-67y

  10. Questions • Expectations • Concerns • Block administration • Failure of anaesthesia, operation pain • Post-operative pain • Mobility, PONV, length of stay • Impression, satisfaction

  11. Results • Pain during injection • 5 patients (27 %) Average pain score 1.2 • Pain during surgery • None

  12. Results • No patients reported any pain during their operation • None reported nausea • No overnight stays • All discharged walking same day • No patient required opiate analgesics • All would recommend surgery under ankle block rather than a general anaesthetic to family or friends

  13. Message • Forefoot surgery under ankle block alone is effective. • Anaesthesia obtained permits the majority of forefoot procedures • Provides lasting post-operative analgesia. • Combined with use of ankle tourniquet and same day discharge, it has very high patient acceptance and satisfaction.

  14. AIM • Excellent post-operative analgesia • Early mobilisation • Same day discharge • Avoid • Significant systemic stress / response • Nausea and vomiting

  15. Conclusion from Small Observational Study • Hypothesis • Ankle block is the simplest, safest and most effective method of anaesthesia • Future study • Expanding retrospective cohort • Prospective comparison RA vs GA, similar questions • Discussion • Ideas • Other areas to study / question

  16. Thank-you

  17. Advantages of Regional vs GA Improved cognitive recovery1 Better analgesia2 Increased speed of recovery3 Reduced in patient stay3 Improved functional outcome3 1. O’Dwyer PJ et al. Annals of Surgery 2003;237:574-579. 2. Chan VWS et al. Anesth Analg 2001;93:1181-1184. 3. Brown AR et al. Arthroscopy 1993;9:295-300.

  18. Risks of Regional Anaesthesia Local anesthetic toxicity Infection Bleeding/Haematoma Nerve Damage Specific to each block PDPH Respiratory compromise CV collapse with spinal and aortic stenosis Total spinal with lumbar plexus etc etc

  19. Nerve Damage and RA Neuraxial blockade Permanent Damage Rare approx 1:10000 paraplegia 1:220000 Transient Damage Uncommon approx 1:3000 for neuraxial blocks Peripheral nerve blockade Injury more likely, but more often temporary approx 1:100 Risk factors – block location, pre-existing neuropathy

  20. Less pain Less opioid consumption Earlier discharge Increased patient satisfaction

  21. Summary RA reduces pain and opioid related SE’s Patient satisfaction Chronic pain RA reduces morbidity (? Mortality) It may have a role (as part of a package) rehabilitation length of stay economic benefit ? of benefit to the actual surgery Risk / benefits

  22. The Future • Shorter hospital stays • More peripheral nerve blocks • ? Nurse /anaesthetic practitioner sedationists • Safer & more reliable RA? • Domiciliary regional anaesthesia • Improved outcomes?

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