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Resume Les agonistes alpha-adrenergiques sont utilises depuis quarante ans comme adjuvants des anesthesiques locaux pour ameliorer la qualite et prolonger la duree du bloc anesthesique ainsi que l’analgesie. Une abondante litterature sur le sujet existe concernant la clonidine et plus recemment la dexmedetomidine agoniste alpha2-adrenergique plus selectif. Le mecanisme d’action repose probablement essentiellement sur la stimulation des recepteurs de la corne posterieure de la moelle. Les agonistes alpha2-adrenergiques provoquent des effets secondaires genant dans le contexte perioperatoire (hypotension et bradycardie) qui dependent de la dose. L’administration systemique a egalement des effets, dont la puissance est discutee par rapport a l’administration perineurale.

The direct costs of anesthesia and analgesia (including anesthesia fee) represents only 2–4% of the total cost of a surgical procedure. the type of surgical procedure or its duration can make regional anesthesia less expensive or more expensive than general anesthesia. However, optimization of the total time spent inside the OR represents the main factor of the total bill (50–60%). Such a reduction in the total OR time leads to a significant decrease in personnel costs which represents 70% of the cost. Thus, scheduling, organizing flow of patients through the OR is the first improving factor to control. In this field, regional anesthesia can significantly reduce this major cost factor through multiple mechanisms: (1) setting a “block room” to perform blocks in a dedicated space outside the OR for high output short surgical procedures (hand surgery cases) improves the efficiency of the OR by 56%. (2) Regional anesthesia techniques reduce the duration of stay in PACU compared to general anesthesia and even allows more easily to encourage PACU bypass (10–82% of patients). (3) Regional anesthesia and analgesia significantly increase the percentage of surgical procedures which are performed on an ambulatory basis, compared to general anesthesia. Such a shift towards ambulatory surgery leads to a major decrease in nursing budgets for the hospital. (4) Finally, all ERAS surgical procedures require somehow the administration of local anesthetics which can go from intravenous lidocaine (associated to general anesthesia), to infiltration techniques, to nerve blocks. In conclusion, Regional anesthesia techniques, when combined to a strict optimisation of the management of patients flow throughout the whole process, are 2 major factors that significantly improve hospital business.

Resume Des effets secondaires particuliers des anesthesiques locaux et des anti-inflammatoires utilises pour l’analgesie postoperatoire en chirurgie orthopedique ont ete decrits. Les anesthesiques locaux et notamment la bupivacaine a concentration superieure ou egale a 0,25 % pourraient etre impliques dans la survenue de chondrolyse articulaire apres chirurgie de l’epaule notamment lorsque l’administration a ete intra-articulaire et continue. La chondrotoxicite des solutions d’anesthesiques locaux les plus concentrees a en effet ete demontree sur des modeles experimentaux. Les anti-inflammatoires non steroidiens, selectifs ou non, semblent reduire la survenue de calcification ectopiques apres prothese totale de hanche. Ils ont ete impliques dans le retard a la formation du cal osseux ou le descellement de protheses mais cela reste a demontrer.

This chapter addresses the increasing incidence of spinal haematoma after central neuraxis anaesthesia in patients receiving drugs that affect coagulation. Administration of low-molecular-weight heparins in the perioperative period is highlighted because these drugs remain the 'gold standard' for prophylaxis against deep-vein thrombosis. The performance of spinal anaesthesia in patients already receiving antiplatelet drugs is discussed--as well as special warnings in such a setting. In addition, issues such as those concerning the administration of unfractionated heparin, anti-vitamin K drugs or new antiplatelet and antithrombotic medications are addressed. Finally, specific recommendations regarding each class of drug are defined in order to avoid the occurrence of a rare but catastrophic event such as spinal haematoma.

Background Serious complications related to regional anesthesia have previously been described primarily in case reports and retrospective surveys. The authors prospectively evaluated a multicenter series of regional anesthetics, using preplanned criteria to measure the incidence and characteristics of associated serious complications. Methods Requests were sent to 4,927 French anesthesiologists in advance of a subsequent 5-month study period. Participating anesthesiologists were asked for detailed reports of serious complications occurring during or after regional anesthetics performed by them during the study interval. Details regarding each complication then were obtained via a second questionnaire. Results The number of responding anesthesiolgists was 736. The number of regional anesthetics performed was 103,730, corresponding to 40,640 spinal anesthetics, 30,413 epidural anesthetics, 21,278 peripheral nerve blocks, and 11,229 intravenous regional anesthetics. Reports of 98 severe complications were received, with follow-up information being obtained for 97. In 89 cases, complications were attributed fully or partially to regional anesthesia. Thirty-two cardiac arrests, seven of which were fatal, occurred during the study. Of these, 26 occurred during spinal anesthesia, with 6 being fatal, 3 occurred during epidural anesthesia, and 3 more occurred during peripheral blocks. The higher incidence of cardiac arrest during spinal anesthesia (6.4 +/- 1.2 per 10,000 patients) compared with all other regional anesthesia (1.0 +/- 0.4 per 10,000 patients) was statistically significant (P < 0.05). Of 34 neurologic complications (radiculopathy, cauda equina syndrome, paraplegia), 21 were associated either with paresthesia during puncture (n = 19) or with pain during injection (n = 2), suggesting nerve trauma or intraneural injection. Twelve patients who had neurologic complications after spinal anesthetics had no paresthesia during needle placement and no pain on injection. Of these 12 patients (7 with radiculopathy and 5 with cauda equina syndrome), 9 received intrathecal hyperbaric lidocaine, 5%. The incidence of neurologic injury was significantly greater after spinal anesthesia (6 +/- 1 per 10,000 cases; P < 0.05) than after each of the other types of regional procedures (1.6 +/- 0.5 per 10,000 cases for the weighted average). Seizures attributed to elevated serum levels of local anesthetics occurred in 23 patients, but none suffered a cardiac arrest. Conclusions (1) The incidence of cardiac arrest and neurologic injury related to regional anesthesia were very low, but both were more than three SDs greater after spinal anesthesia than after other regional procedures. (2) Two thirds of the patients with neurologic deficits had either a paresthesia during needle placement or pain on injection. (3) Seventy-five percent of the neurologic deficits after nontraumatic spinal anesthesia occurred in patients who had received hyperbaric lidocaine, 5%.

BACKGROUND Serious complications related to regional anesthesia have previously been described primarily in case reports and retrospective surveys. The authors prospectively evaluated a multicenter series of regional anesthetics, using preplanned criteria to measure the incidence and characteristics of associated serious complications. METHODS Requests were sent to 4,927 French anesthesiologists in advance of a subsequent 5-month study period. Participating anesthesiologists were asked for detailed reports of serious complications occurring during or after regional anesthetics performed by them during the study interval. Details regarding each complication then were obtained via a second questionnaire. RESULTS The number of responding anesthesiolgists was 736. The number of regional anesthetics performed was 103,730, corresponding to 40,640 spinal anesthetics, 30,413 epidural anesthetics, 21,278 peripheral nerve blocks, and 11,229 intravenous regional anesthetics. Reports of 98 severe complications were received, with follow-up information being obtained for 97. In 89 cases, complications were attributed fully or partially to regional anesthesia. Thirty-two cardiac arrests, seven of which were fatal, occurred during the study. Of these, 26 occurred during spinal anesthesia, with 6 being fatal, 3 occurred during epidural anesthesia, and 3 more occurred during peripheral blocks. The higher incidence of cardiac arrest during spinal anesthesia (6.4 +/- 1.2 per 10,000 patients) compared with all other regional anesthesia (1.0 +/- 0.4 per 10,000 patients) was statistically significant (P < 0.05). Of 34 neurologic complications (radiculopathy, cauda equina syndrome, paraplegia), 21 were associated either with paresthesia during puncture (n = 19) or with pain during injection (n = 2), suggesting nerve trauma or intraneural injection. Twelve patients who had neurologic complications after spinal anesthetics had no paresthesia during needle placement and no pain on injection. Of these 12 patients (7 with radiculopathy and 5 with cauda equina syndrome), 9 received intrathecal hyperbaric lidocaine, 5%. The incidence of neurologic injury was significantly greater after spinal anesthesia (6 +/- 1 per 10,000 cases; P < 0.05) than after each of the other types of regional procedures (1.6 +/- 0.5 per 10,000 cases for the weighted average). Seizures attributed to elevated serum levels of local anesthetics occurred in 23 patients, but none suffered a cardiac arrest. CONCLUSIONS (1) The incidence of cardiac arrest and neurologic injury related to regional anesthesia were very low, but both were more than three SDs greater after spinal anesthesia than after other regional procedures. (2) Two thirds of the patients with neurologic deficits had either a paresthesia during needle placement or pain on injection. (3) Seventy-five percent of the neurologic deficits after nontraumatic spinal anesthesia occurred in patients who had received hyperbaric lidocaine, 5%.