The war in Iraq has resulted in a high incidence of severe extremity injury requiring multiple surgical procedures and extensive rehabilitation. We describe the use of advanced regional anesthesia to meet this significant medical challenge.
From March 2003 to December 2004, 4,100 casualties have been evacuated to Walter Reed Army Medical Center (WRAMC). Of 1,400 inpatients, 750 have been battle-injured with 500 having extremity injuries. Of these, 287 (57%) received surgical care incorporating regional anesthesia including single-injection peripheral nerve blocks and continuous peripheral and epidural infusion catheters. Wounding, surgical, anesthetic, and outcomes data have been prospectively collected.
Over 900 operations (mean 4+/-2/patient) were performed on 287 casualties prior to arrival at WRAMC, and 634 operations (mean 2+/-1/patient) were performed at WRAMC. Thirty-five percent of this cohort was amputees. In the study group, 646 advanced regional anesthesia procedures, including 361 continuous peripheral nerve blocks (CPNBs), were performed with a mean catheter infusion time of 9 days (1-34). Catheter-related complications occurred in 11.9% of casualties and were technical or minor in nature. Catheter-related infection rate was 1.9%. In 126 casualties with indwelling CPNB catheters, a significant decrease in pain score over 7 days was apparent (mean 3.7+/-0.2 to 2.2+/-0.2, P<0.001).
Advanced regional anesthetic techniques allowed for safe perioperative surgical anesthesia and analgesia in the management of the modern combat casualty.
"Portable infusion devices can deliver local anesthetic for days after surgery, with actual duration depending on the reservoir volume and infusion settings  . Although the optimal duration for CPNB has not been previously studied, 2 to 7 days is commonly reported for hospitalized patients undergoing orthopedic surgery , with durations as long as 34 days at a United States military hospital . A recent metaanalysis comparing CPNB with single-injection peripheral nerve blocks shows that CPNB results in lower worst pain scores and pain scores at rest on postoperative day (POD) 0, 1, and 2; however, by POD 3, pain outcomes appear similar . "
"Longer durations of infusion are possible when managed carefully on the inpatient ward. A large inpatient case series of 361 perineural catheters from a military hospital has reported a mean infusion duration of 9 days (range 1–34 days) and only 7 catheter-related infections (1.9%) localized to the catheter insertion site with resolution following catheter removal (Stojadinovic et al., 2006). For perineural catheters inserted for indications other than postoperative analgesia (e.g., vasodilation to improve perfusion), the appropriate duration of infusion is unknown (Loland et al., 2009). "
[Show abstract][Hide abstract] ABSTRACT: Continuous peripheral nerve block techniques offer many benefits for the surgical patient in terms of target-specific pain control and avoidance of opioid-related side effects. There are many acceptable techniques for perineural catheter placement and infusion management, and practitioners are encouraged to obtain specialized training to develop a consistent practice and ensure patient safety. Emerging technology in ultrasound guidance may offer advantages in perineural catheter insertion accuracy and procedural efficiency. Various infusion devices are available that permit delivery of a basal rate and patient-controlled bolus for use in the event of breakthrough pain. A successful outpatient continuous peripheral nerve block program should include thorough patient education, detailed written instructions, daily telephone follow-up, and contact information for a healthcare provider familiar with these techniques who can answer questions and intervene when necessary.
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