Spinal Anesthesia in Day Surgery: Knee Arthroscopy - Essay Example

Spinal Anesthesia Spinal anesthesia in day surgery: Knee Arthroscopy Introduction Today the majority of patients who undergo surgery or diagnostic tests do not need to stay overnight in the hospital. In most cases, you will be well enough to complete your recovery at home. Spinal (or outpatient) anesthesia and surgical care has proven to be safe, convenient and cost-effective and can be performed in a variety of facilities. You may have your procedure done in a hospital, a freestanding surgery center or, in some cases, a surgeon's office. Your anesthesia care will be given or supervised by an anesthesiologist (Anesthesia & You, 2003). Spinal anesthesia is tailored to meet the needs of ambulatory surgery so you can go home soon after your operation. Short-acting anesthetic drugs and specialized anesthetic techniques as well as care specifically focused on the needs of the ambulatory patient are used to make your experience safe and pleasant. In general, if you are in reasonably good health, you are a candi- date for ambulatory anesthesia and surgery. Because each patient is unique, your anesthesiologist will carefully evaluate you and your health status to determine if you should undergo ambulatory anesthesia (Anesthesia & You, 2003). A number of new anaesthetic, analgesic and adjuvant drugs, each with more rapid onset of action and shorter duration of action, have been developed. As a result, the range of techniques and surgical procedures which can be performed on an ambulatory or day-case basis has increased. A variety of technological developments have allowed surgeons to respond to these new expectations by simplifying surgical procedures. Anesthesiologists are also responding Spinal Anesthesia 2 to the new challenges, and a search for ideal anaesthetic agents, which should yield a high standard of quality with reasonable costs, is under way. One of the challenges in the current health care environment is to rigorously examine whether these expensive new therapeutic modalities actually produce cost savings by permitting earlier discharge from hospital or by diminishing the need for other therapeutic interventions. Knee arthroscopy is commonly done on an ambulatory basis because the surgical procedure is short and rapid recovery is to be expected. This study is aim to compare spinal anaesthesia to general anaesthesia in terms of late recovery, costs, safety, and efficacy when performing outpatient knee arthroscopy. The overall aim of this study was to find out the most appropriate and economical method for adult ambulatory knee arthroscopy and to assess the factors that affect the immediate postoperative period and the one-week recovery profile at home. 2. Description Most arthroscopic procedures today are performed in same-day surgery centers where the patient is admitted just before surgery. The surgery is easier and safer to perform when the patient is completely relaxed, which general and spinal anesthesia permit. The patient is usually in the outpatient surgery area for four to five hours. (Goradia, n.d.). A few hours following the procedure, the patient is allowed to return home, although usually someone else must drive. Depending on the type of anesthesia used, the patient may be told not to eat for several hours before arriving. Before the procedure, the anesthesiologist will ask if the patient has any known allergies to local or general anesthetics. Airway obstruction is always Spinal Anesthesia 3 possible in any patient who receives a general anesthesia. Because of this, oxygen, suction, and monitoring equipment must be available. The patient's cardiac status should always be monitored in the event that any cardiac abnormalities arise during the arthroscopy. General or local anesthesia may be used during arthroscopy. Local or spinal anesthesia is usually used because it reduces the risk of lung and heart complications and allows the patient to go home sooner. In spinal anesthesia, the anesthetic is injected into the spinal cord or a main nerve supplying the area. This process is called a "block," and it blocks all sensation below the main trunk of the nerve. For example, a femoral block anesthetizes the leg from the thigh down (its name comes from femur, the thighbone). Most patients are comfortable once the skin, muscles, and other tissues around the joint are numbed by the anesthetic; however, some patients are also given a sedative if they express anxiety about the procedure. The advantages of spinal anaesthesia for ambulatory surgery include ease of administration, rapid onset and high reliability Alon et al. (2000). . The residual block protects the patient from initial pain after the block has worn out (Raeder 1999). Although spinal anaesthesia is considered a simple procedure with a high margin of safety, it is not entirely free from risks. 3. Feelings I feel that the goal of the health care team is to control the patient's pain and make them comfortable. The team which normally consists of the surgeon, the anesthesiologists, and the registered staff nurse, closely monitor the patient's pain and give them medication as needed. . The patient is informed that the choice of anesthetic is related to the patient's general condition and medical history, as well as the surgery or procedure to be done. Spinal Anesthesia 4 In this stage the patient is briefed clearly the importance of the procedure, that although spinal anaesthesia abolishes pain, they may be aware of some sensation in the relevant area, but it will not be uncomfortable. It is also explained that their legs will become weak or feel as if they don't belong to them any more. They are reassured that these sensations are perfectly normal and that if, by any chance, they feel pain they will be given a general anaesthetic (Casey, 2000). The interaction between patient and family and anesthesiologists is one of the most critical for the safety, efficiency, and comfort of patients. It is increasingly important for each to have a better understanding of the issues involved in day surgery. The continued reassurance of the patient by the health care team that nothing to worry about the upcoming surgery would free the patient from anxiety and cooperation is attained. However, at times nurses encounter strong emotions in patients, relatives, colleagues and their selves. The appropriate use of interpersonal skills at the correct juncture enables nurses to deal with strong emotions in a way that minimizes the psychological consequences for all Spinal Anesthesia 4 concerned. It is in this stage where the nurse should depart from becoming ritualistic in dispensing her actions towards the patient and the family as well. The use of rituals affects the nurse's ability to communicate effectively. 4. Evaluation To understand whether to use spinal anesthesia in knee arthroscopy was rational or whether it did more harm or good, it is necessary to review the normal and altered history of the patient. The orthopedic knee evaluation usually consists of a medical history, a physical Spinal Anesthesia 5 examination, and X-rays. During the medical history, the orthopedic surgeon will gather the information about the general health of the patient, and the surgeon will ask about the symptoms felt. A physical examination will be done to assess the motion and stability and muscle strength of the knee as well as the overall alignment of the leg. X-rays will be done to evaluate the bones of the knee. Your orthopedic surgeon may also arrange for you to undergo magnetic resonance imaging (MRI) to provide more information about the soft tissues of your knee. Blood tests may also be obtained to determine if you have arthritis. The orthopedic surgeon will then explain the potential risks and complications of knee arthroscopy, including those related to the surgery itself and those that can occur after the surgery. Other laboratory test may be required by the orthopedic surgeon to help plan the procedure. In perioperative environment, arthroscopy of the knee is typically performed in a general hospital surgical suite or an outpatient ambulatory surgical facility. In any setting, an established protocol to ensure the proper environment is essential. Nursing and ancillary staff should be properly trained. Almost all arthroscopic knee surgery is done on an outpatient basis for healthy patients. Arthroscopy can be performed under local, regional, or general anesthesia. Local anesthesia numbs your knee, regional anesthesia numbs you below your waist, and general anesthesia puts the patient to sleep. The patient is given the chance to choose the kind of anesthesia to be used in the procedure. However, it most cases local or spinal anesthesia is recommended for knee arthroscopy. Spinal Anesthesia 6 The preferred regional anesthetic technique in knee arthroscopy is single-injection spinal anesthesia. This method allows for an awake patient (if desired); and tourniquet can be applied and inflated, and the leg can be fully manipulated. With a skilled anesthesia team, it is usually a safe and effective choice (Wu & Richmond, 2002) The advantages of spinal anaesthesia for ambulatory surgery or knee arthroscopy include ease of administration, rapid onset and high reliability (Standl et al. 1996, Alon et al. 2000). The benefits of spinal anaesthesia are most evident in the postoperative phase. The residual block protects the patient from initial pain after the block has worn out (Dahl et al. 1997, Raeder 1999). Dahl et al. explained that alleviation of the initial, severe postoperative pain results in lesser activation of the pain-enhancing mechanisms in the medullary cord, thus preventing the amplification of pain usually seen when pain is inappropriately treated (Dahl et al. 1997). Spinal anaesthesia is associated with a lower incidence of postoperative nausea and vomiting (PONV), drowsiness and postoperative pain compared to general anaesthesia (Dahl et al. 1990, Mulroy & Willis 1995, Standl et al. 1996). These symptoms are the most frequently reported causes for delays in discharge time among ambulatory patients (Pavlin et al. 1998). Although spinal anaesthesia is considered a simple procedure with a high margin of safety, it is not entirely free from risks. The severe neurological complications associated with spinal anaesthesia and other central blocks may be due to the neurotoxic effects of local anesthetics, direct neural tissue injury caused by a needle or catheter and spinal cord compres- sion by an epidural hematoma or abscess (Alahuhta 2001) Although major complications are rare, they can be devastating to the patient and the anesthesiologist. For this reason, the patients must be postoperatively followed closely to detect Spinal Anesthesia 7 potentially treatable sources of neurologic injury (Horlocker & Wedel 2000). In recent years, the popularity of spinal anaesthesia has been growing among the outpatient population. Spinal anaesthesia involves putting local anaesthetic in the patient's back to "freeze" the lower part of the body. It is usually very safe and effective. It may be associated with less blood loss, and less risk of dangerous blood clots, than general anaesthesia. Spinal anaesthesia is suitable for many procedures in the lower half of the body. It involves injecting local anaesthetic into the cerebrospinal fluid (CSF), the fluid which surrounds the spinal cord. This produces a very intense nerve block very quickly, with only a small amount (half teaspoon) of local anaesthetic. Because spinal anesthesia can cause low blood pressure, the patient should probably have an intravenous line in place to keep the fluid levels and blood pressure up during the procedure. The patient will also be connected to various monitors to keep track of your blood pressure, pulse, and the oxygen content of your blood. Depending on how long the surgery will take, the patient may have a catheter put into their bladder to keep their urine drained (DeWitt, 2007). When more than one dose of spinal anesthesia might be required, the anesthetist will leave a tiny, flexible tube or catheter in place outside of the fluid sac surrounding your spinal cord. With this catheter in place, more anesthetic can be given easily if the operation takes longer than expected. Some surgical centers leave the epidural tube in place for 24 hours or more after surgery, using it to administer pain medications during the immediate post surgical period (DeWitt, 2007). The cost associated with spinal anesthesia is very minimal. It produces few adverse effects on the respiratory system as long as unduly high blocks are avoided. As control of the Spinal Anesthesia 8 airway is not compromised, there is a reduced risk of airway obstruction or the aspiration of gastric contents. However, this advantage may be lost if too much sedation is given. Blood loss during operation is less than when the same operation is done under general anaesthesia. This is because of a fall in blood pressure and heart rate and improved venous drainage with a resultant decrease in oozing. Because it increases blood flow to the gut, spinal anaesthesia may reduce the incidence of anastomotic dehiscence. The bowel is contracted during spinal anaesthesia and sphincters are relaxed although peristalsis continues. Normal gut function rapidly returns following surgery. Post-operative deep vein thromboses and pulmonary emboli are less common following spinal anaesthesia. Oyston, 1998 stressed that the major disadvantage of a spinal anaesthetic is a drop in blood pressure, caused by temporary blockage of the nerves that control blood flow into the legs. Other identified disadvantages of spinal anesthesia are: (1) Sometimes it can be difficult to find the dural space and occasionally, it may be impossible to obtain CSF and the technique has to be abandoned, (2) Hypotension may occur with higher blocks and the anaesthetist must know how to manage this situation with the necessary resuscitation drugs and equipment immediately to hand. As with general anaesthesia, continuous, close monitoring of the patient is mandatory, (3) Some patients are not psychologically suited to be awake, even if sedated, during an operation. They should be identified during the preoperative assessment. Likewise, some surgeons find it very stressful to operate on conscious patients, (4) Even if a long-acting local anaesthetic is used; a spinal is not suitable for surgery lasting longer than approximately 2 hours. Patients find lying on an operating table for long periods uncomfortable. If an operation unexpectedly lasts longer than this, it may be necessary to convert to a general anaesthetic or Spinal Anesthesia 9 supplement the anaesthetic with intravenous ketamine or with a propofol infusion if that drug is available, (5) When an anaesthetist is learning a new technique, it will take longer to perform than when one is more practiced. When one is familiar with the technique, spinal anaesthesia can be very swiftly performed, (6) There is a theoretical risk of introducing infection into the sub-arachnoid space and causing meningitis. This should never happen if equipment is sterilized properly and an aseptic technique is used. A postural headache may occur postoperatively. Most of the times, it is the family of the patient who are so inquisitive on the mechanics of the surgery. And some health care personnel find them a nuisance thus they may show lack of empathy towards the patient's family. Most families focused their query on the costs of the procedure, 5. Analysis To the surgeons and ancillary staff, there is much evidence that patients under spinal anesthesia can remain alert and, with proper techniques and agents, are able to be rapidly discharged with minimal side-effects and optimal pain control. Spinal anesthesia, alone or as part of general anaesthetic technique, offer major benefits to the ambulatory surgery patient (Rawal, 2001). Patient's benefit from day-surgery because it minimizes costs, decreases separation from their home and family environment, reduces surgery waiting times, decreases their likelihood of contracting hospital-acquired infections, and appears to reduce postoperative complications (White, 2004) Spinal anaesthesia can be used alone, in combination with sedation techniques or as part of balanced analgesia with general anaesthesia. Decreased requirements for opioids reduce the incidence of postoperative nausea, and the acceptance of the technique by surgeon and patient, Spinal Anesthesia 10 and the expertise of the anesthesiologist, are crucial. It is therefore essential that each unit audits its own complication rates, recovery room times and patient opinions to determine the relevance of regional or general anaesthesia. Day surgery performed under spinal anaesthesia is often the simplest, safest and cheapest. A low spinal block (below the umbilicus) has no effect on the respiratory system and is, therefore, ideal for patients with respiratory disease unless they cough a lot. Frequent coughing results in less than ideal conditions for the surgeon. A high spinal block can produce intercostals muscle paralysis, but this does not usually create any problems, unless the patient has a very limited respiratory reserve and is, for example, unable to lie flat. The use of arthroscopy under local anesthesia may be a suitable alternative if the patient desires to be alert and to participate during the surgical procedure. Arthroscopy under local anesthesia provides satisfactory operating conditions and a high patient acceptability for a variety of operative knee procedures (Reuben, 2001). Spinal anesthesia was sufficiently efficient to enable the performance of surgery, which reinforces the efficiency of achieving analgesic effect by unilateral spinal anesthesia with small doses of hyperbaric bupivacaine. The hemodynamic changes accounts for the larger volume of infusion solutions in order to maintain the circulatory parameters. Mild hypothermia is relatively frequent in spinal anesthesia. Often underestimated, it can cause some untoward side effects associated with the increased oxygen demands, especially in patients with limited cardiac and ventilation resources. The absence of changes in skin temperature during hyperbaric bupivacaine anesthesia can be considered as an advantage of the technique. Spinal Anesthesia 11 The spinal anesthesia is shorter than conventional anesthesia which means less need of postoperative observation and earlier discharge of patients. It is economically efficient alternative of total analgesia in operations of lower body parts and limbs (Stefanov, et al, 2006). The specific risks depend on your health, the type of anesthesia used, and your response to anesthesia. Age may be a risk factor. In general, the risks associated with anesthesia and surgery increase in older people. After spinal anesthesia the arm or leg could be numb and weak for up to 24 hours after. The limb to feel warmer or colder than other; this could last for 24 hours. It will need not use the arm or the legs until the numbness and weakness are gone. Be careful around hot, cold and sharp things until the numbness is gone. If these persist longer than 24 hours, please call the anesthesiologist (Brandi, 2007) 6. Action Plan It has been demonstrated that patient education and preoperative preparation can reduce postoperative pain associated with anxiety. Successful postoperative pain control depends on the knowledge and demands of the patient (Stefanov et al, 2006). In this view, the nurse and the health care team should inform the patient about the need to treat pain and about the various ways of managing pain. The information should be given verbally and in writing. Day patients with severe pain at home do not always take their medication as prescribed and may even mix in their own analgesics. Clear instructions are therefore mandatory For patients undergoing surgery with regional anaesthetic techniques, patient education during the pre-operative clinic visit is essential to improve patient acceptance of the use of regional anaesthesia. Audiovisual material and an information pamphlet are helpful tools, giving Spinal Anesthesia 12 patients time to make an intelligent decision and to be psychologically prepared for the block. Patient education will also help to allay apprehension about being awake during the surgery and to address the fear of pain during block. To ensure successful pain management at home, it is important to give parents appropriate information. Atkins and Murphy (1983) suggest three key stages in the process of reflection identified in this situation.. They are the awareness of uncomfortable feelings, and critical analysis of those feelings, leading to uncovering new perspectives. Having undergone this process, the healthcare team has positively allowed improvements in their care to be made and has action planned some ways in which to deal with the inner conflicts and individuality of the situation the patient experienced. Moreover, postoperative care is very important in knee arthroscopy which includes the following: Keep leg elevated as much as possible for the first few days after surgery. Apply ice as recommended by the orthopedic surgeon to relieve swelling and pain. Dressing can be removed the day after surgery. In taking shower, avoid directing water at the incisions. Do not soak in a tub. Keep incisions clean and dry. The orthopedic surgeon may advise the patient to use crutches, a cane, or a walker for a period of time after surgery. Then the patient can gradually put more weight on the leg as discomfort subsides and the patient regain strength in the knee. Encourage the patient to exercise the knee regularly for several weeks following surgery to strengthen the muscles of the leg and knee. A physical therapist may help with the exercise program if the orthopedic surgeon recommends specific exercises. The orthopedic surgeon may prescribe antibiotics to help prevent an infection and pain medication to help relieve discomfort following the surgery. Potential postoperative problems with knee arthroscopy include infection, Spinal Anesthesia 13 blood clots, and an accumulation of blood in the knee. These occur infrequently and are minor and treatable. 7. Conclusion This study has shown that unilateral spinal anesthesia with hyperbaric bupivacaine induces adequate analgesia comparable clinically with the effect of conventional anesthesia in knee arthroscopy. It caused significantly less hemodynamic changes and no changes in body temperature. The faster recovery of motor and sensory functions, the shorter hospital stay and the reduced infusion therapy brought about a considerable economic effect. For this, unilateral spinal anesthesia with hyperbaric bupivacaine is an economically beneficial and clinically effective alternative in operations of lower limbs (Stefanov, et al, 2006). The analysis of material expenses of spinal and general anesthesia in our patient sample showed spinal anesthesia with either selective or absolute use of attraumatic needles to be less expensive and clinically as safe as general anesthesia. Besides economic, spinal anesthesia is associated with well known clinical advantages in terms of lesser intraoperative and postoperative hemorrhage, and lower rate of complications in patients with metabolic impairments, and those with pulmonary, cardiac, hepatic or renal diseases. Accordingly, there are both clinical and economic reasons for the more frequent utilization of spinal anesthesia in operative procedures such as knee arthroscopy. Spinal Anesthesia 14 References: 1) Anesthesia & You, 2003, 'Anesthesia for Ambulatory Surgery', American Society of Anesthesiologists, http://www.asahq.org/patientEducation/ambulatoryAnes.pdf. 2) Brandi, L. 2007, 'Anesthesia: Information for Patients', http://www.brandianestesia.it/english/reganesth.html. 3) Atkins S, Murphy K. 1983, 'Reflection: a review of the literature', Journal of Advanced Nursing. 18, 8, 1188-1192. 4) Bonneau, R.M. 2004, 'Knee Arthroscopy'. http://www.bonneau ortho.com/surgery2.php>. 5) Casey, WF. 2000, 'Spinal Anesthesia: A Practical Guide', Is. 12, Art. 8, p.3, Update in Anesthesia. http://www.nda.ox.ac.uk/wfsa/html/u12/u1208_03.htm. 6) DeWitt, R.C., 2007, 'Spinal and Epidural Anesthesia', Health Information, Aurora Health Care, http://www.aurorahealthcare.org/yourhealth/healthgate/getcontent.asp URLhealthgate=%2243847.html%22. 7) Flaatten H, Felthaus J, Kuwelker M, Wiaborg T. 2000, 'Postural post-dural puncture headache', Prospective randomized study and a meta-analysis comparing two different 0, 40 mm O.D. (27 G) spinal needles. Acta Anaesthesiol Scand 44: 643- 8) Goradia, V. Knee Arthroscopy. Go Orthopedics. http://goortho.net/pdf/Knee/Knee_Arthroscopy.pdf. 9) Kuusniemi K. 2001, 'Spinal anaesthesia with a low dose of bupivacaine: Clinical studies on unilateral spinal anaesthesia and the effect of additional fentanyl', Department of Anaesthesia and Intensive Care, University of Turku, Finland. Annales Spinal Anesthesia 15 Universitatis Turkuensis. Painosalama Inc. 10) Moore, M. 2008, 'Tallahassee Anesthesiology', Dr Mark Moore MD Website Homepage http://www.drmarkmoore.com/ 11) Oyston, J. 1998, 'The patient's guide to local and regional anesthesia', Department of Anesthesia at Orillia Soldiers' Memorial Hospital. http://www.oyston.com/anaes/local.html 12) Pavlin DJ, Rapp SE, Polissar NL, Malmgren JA, Koerschgen M, Keyes H., 1998, 'Factors affecting discharge time in adult outpatients', Anesth Analg 87: 816-26. 13) Raeder J., 1999, 'Central blocks in day surgery ', Epidural blocks. In: Van Zundert A, editor. Highlights in regional anaesthesia and pain therapy - VIII. ESRA, Limassol, Cyprus, Hadjigeorgiou Printings. 101-6. 14) Reuben, S.S., 2001, 'Ambulatory Anesthesia in Knee Arthroscopy', Anesthesia & Analgesia. 92:556. http://www.anesthesia-analgesia.org/cgi/content/full/92/2/556. 15) Stefanov, C., Tilkijan, M., Dimov, E.1996-2008, 'Unilateral Spinal Anesthesia In Knee Arthroscopy: Clinical And Pharmacoeconomic Effects Of Application Of Hyperbaric Bupivacaine', The Internet Journal of Anesthesiology. ISSN 1092- 406X. ISPUB.com, http://www.ispub.com/ostia/index.phpxmlFilePath= journals/ija/vol10n2/unilateral.xml 16) White, P.F. 2004, 'Anesthesia for ambulatory surgery', Anesthesiologia. vol. 7, pp. 43- 51. http://www.medigraphic.com/pdfs/rma/cma-2004/cmas041f.pdf. Spinal Anesthesia 16 17) Wu, H.W. & Richmond, J.C., 2002, 'Arthroscopy of thee Knee: Basic Setup and Technique', Operative Arthroscopy. Google Book Search. 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