Clinical Pharmacology in Athletic Training

298 | Clinical Pharmacology in Athletic Training source of the blood for the patch is the antecubital vein. Without use of the blood patch, the headache is likely to resolve in 7 to 10 days. Peripheral Nerve Block Peripheral nerve blocks are increasingly used for pain control associated with traum...

298 | Clinical Pharmacology in Athletic Training source of the blood for the patch is the antecubital vein. Without use of the blood patch, the headache is likely to resolve in 7 to 10 days. Peripheral Nerve Block Peripheral nerve blocks are increasingly used for pain control associated with trauma and surgery. A peripheral nerve block has many patient-centered benefits relative to pain control, more prompt recovery, and shorter stay in the surgical facility.14 Generally, local anesthetics are injected percutaneously using anatomic landmarks, ultrasound guidance, or fluoroscopic techniques to safely deliver the anesthetic near the specific targeted nerve. Anesthetics can be delivered as bolus injections (single shot or, occasionally, repeated nerve block) or as continuous infusions via catheters that are inserted near the target nerve. Single-shot injections may be used to provide short-term anesthesia for a procedure. For example, femoral nerve blocks often use continuous infusions of local anesthetics to control pain from a hip fracture, both prior to and for days after surgery. Peripheral nerve blocks are also used in the management of trauma. Intercostal nerve blocks can reduce pain after rib fracture, possibly improving lung mechanics and reducing rates of pulmonary complications such as pneumonia. Examples of other useful peripheral blocks include transversus abdominis plane (TAP) block for the anterior abdominal wall; interscalene, cervical plexus, and brachial plexus blocks for shoulder and arm surgery; and femoral and popliteal blocks for the distal lower limb.5 Local Field Block A local field block is used for smaller areas such as the wrist, fingers, and toes. This approach is more viable if the surgery is <60 minutes. To create a bloodless field, a pneumatic tourniquet is used that restricts blood flow and minimizes blood loss by obstructing arterial supply to the limb. With the limb elevated, a soft rubber bandage (Esmarch’s bandage) is systematically applied from the fingertips down toward the tourniquet to expel venous blood (exsanguination) from the limb so that the surgical procedure can be completed.21 Common Applications of Anesthesia in Sports Medicine Anesthesia is commonly administered in the sports medicine setting to prevent pain from an incision, tissue manipulation, and suturing. Based on the procedure, anesthesia may be provided locally or as general anesthesia. Spinal anesthesia may be used when the surgical site is too large or deep for a local block, but general anesthesia may not be desirable. With local and spinal anesthesia, the surgical site is anesthetized, but the patient can remain conscious or minimally sedated. In contrast, general anesthesia renders the patient unconscious and paralyzed during surgery. The patient is intubated and placed on a mechanical ventilator, and anesthesia is produced by a combination of injected and inhaled agents. Choice of surgical method and anesthetic technique aims to reduce the risk of complications, shorten the time needed for recovery, and minimize the surgical stress response. General anesthesia such as propofol and sevoflurane has been used for knee arthroscopy, although there may be an increase in incidence of nausea and vomiting associated with sevoflurane. The combination of propofol and sevoflurane requires less recovery time in the PACU compared to epidural and spinal techniques. Spinal or epidural anesthesia for the lower extremity using bupivacaine or lidocaine is considered reliable and can be accomplished with 1 injection to the spine.22 Lower-Extremity Surgery Nerve blocks are commonly used for hip, knee, and ankle surgery (table 22.2).14,21 For example, a femoral nerve block is frequently used for outpatient knee arthroscopy. For open reduction with internal fixation of an ankle fracture, a popliteal nerve block with ropivacaine may be used and possibly be complemented by a saphenous nerve block. The popliteal block is a relatively comfortable anesthesia for the patient to tolerate.14 TABLE 22.2 Common Lower-Extremity Peripheral Nerve Blocks Category of block Target or application Femoral neve Patella, knee, procedures involving the anterior thigh 3-in-1 Femoral, obturator, lateral cutaneous nerve Saphenous nerve Distal to the knee; available for ankle if combined with a popliteal block Sciatic nerve Surgery distal to the knee Popliteal Foot or ankle surgery Ankle Foot procedures Digital Minor toe procedures M.A. Cleary, T.E. Abdenour, and M. Pavolvich, Clinical Pharmacology in Athletic Training, Champaign, IL: Human Kinetics, 2022). For use only in Clinical Pharmacology Course 6–Sport Medics. Chapter 22 • Surgery | 299 In the case of an anterior cruciate ligament (ACL) reconstruction, the femoral block is a traditional and commonly used regional anesthesia. A femoral block with 30 mL of 0.5% ropivacaine is viable for 12 to 18 hours.4 This medication can be complemented with the IV administration of midazolam or propofol prior to surgery and bupivacaine administered as a spinal injection.12 However, there is a concern of quadriceps muscle weakness 6 months after surgery.26 To minimize this risk, an adductor canal block has been advocated in lieu of the femoral block with the consideration that anesthesia of the adductor canal promotes a sensory blockade of the quadriceps muscles without compromising the motor fibers of the femoral nerve that innervate the quadriceps. Results of a study comparing outcomes of ACL reconstructions using the femoral nerve block or adductor canal blocks indicated comparable ability to complete an immediate postoperative straightleg raise and isokinetic knee extension strength at 3 or 6 months after surgery. However, the adductor canal group demonstrated better proprioception soon after surgery;26 thus, this approach may have benefits relative to athletic performance. surgery.21,23 The medications ropivacaine or bupivacaine are appropriate choices for these blocks. Both interscalene and suprascapular blocks are easy to administer and comfortable for the patient. Injury to the elbow medial collateral ligament in throwing and overhead athletes responds well to an axillary, interscalene, or Bier block in conjunction with intravenous sedation.23 The regional nerve blocks result in less nausea and vomiting in the PACU, whereas general anesthesia may allow more complete relaxation of the upper body and trunk. Preparation for a Surgical Procedure Preparation for surgery includes specific patient instructions, including having the patient remove personal items such as contact lenses and jewelry. The anesthesiologist will review the patient’s pertinent medical history for conditions such as diabetes or sickle cell trait that may predispose her to regurgitation and respiratory aspiration.2 Upper-Extremity Surgery RED FLAG General anesthesia is commonly used for upper-extremity surgery—for example, rotator cuff surgery. However, the interscalene block and subscapular block are options, either used alone or as an adjunct (table 22.3) to general anesthesia in upper-extremity Sickle Cell Trait and Surgical ­Complications TABLE 22.3 Common Upper-Extremity Peripheral Nerve Blocks Category of block Target or application Interscalene Proximal procedure of the arm; need ulnar nerve block for hand or forearm procedures Supraclavicular Arm, elbow, forearm Infraclavicular Elbow, forearm, hand Axillary Radian, median, ulnar nerves; procedures of elbow, forearm, or hand Elbow Hand specific to ulnar, median, and radial nerves or musculoskeletal nerve Wrist General hand or site specific Digital Fingers; minor procedures Literature is lacking relative to people with the sickle cell trait who experience complications secondary to surgery. Despite a scarcity of evidence-based guidelines, management of anesthesia for the sickle cell patient is left to the surgeon and anesthesiologist, who base decisions on their personal experiences.25 To be prudent, the AT working with an athlete with the sickle cell trait who needs surgery should alert the surgeon prior to the procedure to ensure that risk management procedures are undertaken. As described in the Adverse Effects of Anesthesia section, ATs can consistently recommend that patients follow the principle of no eating after midnight the night before surgery. Fasting prior to surgery is intended to prevent regurgitation, which could cause aspiration during surgery. The American Society of Anesthesiologists recommends that patients follow these fasting timelines prior to receiving general or regional anesthesia:2 M.A. Cleary, T.E. Abdenour, and M. Pavolvich, Clinical Pharmacology in Athletic Training, Champaign, IL: Human Kinetics, 2022). For use only in Clinical Pharmacology Course 6–Sport Medics. 300 | Clinical Pharmacology in Athletic Training • 2 hours before: Consume nothing. • 2-6 hours before: Clear liquids (excluding alcohol) permitted. • 6-8 hours before: Milk, juice, or light food such as cereal or toast permitted. • 8 hours before: From this point on, avoid heavy foods, such as fried food, fatty foods, and meats. During the procedure, the anesthesiologist monitors the airway, pulse, and respiration rate for the anesthesia. Recovery From a Surgical Procedure Recovery from general anesthesia should proceed quickly so that patients can maintain their own airways as soon as possible following surgery. In general, the stages of recovery from anesthesia occur in the opposite sequence from those of anesthesia induction, including the unpleasant excitement stage.32 Postsurgical pain can be treated in multiple ways, including an intravenous administration of ibuprofen prior to the start of surgery or ketorolac as surgery concludes.30 An additional nerve block can be used for the lower extremity. For rotator cuff surgery, an indwelling perineural catheter can be used to manage postsurgical pain, delivering local anesthetic for 48 to 72 hours.21 Complementing anesthesia is postoperative pain management, which may include a separate peripheral nerve block, analgesic administered through a catheter, or an intravenous NSAID. An analgesic such as bupivacaine or ropivacaine can be administered with an intraarticular injection to extend the anesthetic effect for several hours. Another postsurgical option is the multimodal regimen, which uses acetaminophen, an NSAID, or oral opioid that minimizes parenteral opioid use. Anesthesiologists and surgeons are advised to avoid prescribing opioids as much possible during the postsurgical period.14 Adverse Effects of Anesthesia Adverse effects of anesthesia manifest themselves in a variety of ways. The most common effect of anesthesia is PONV; however, inhaled anesthetics, which resolve faster, minimize the prospects of this occurring. Severe or catastrophic outcomes, such as the incidence of an embolism, are statistically rare but still of significant concern. In a study of >700 adolescent patients who underwent knee arthroscopy, 0.67% reported either a deep vein thrombosis (DVT) or pulmonary embolism (PE), while 0.27% sustained a venous thromboembolism (VTE).18 In a study of nearly 5,000 ACL reconstruction patients, 0.55% required treatment for a DVT and 0.12% presented with a postsurgical PE. Although these adverse outcomes are rare, the AT and surgeon should be cognizant of the patient that presents with deep posterior lower leg pain, swelling, and heat secondary to surgery. There is also concern for an adverse effect associated with the use of a nerve block for ACL reconstruction. In 2018, a professional football player initiated a malpractice claim against his surgical team and anesthesiologist for an adductor canal block that was improperly administered several years prior. The block in this case was administered once the arthroscopy began after the surgeons realized a more advanced surgical procedure was necessary. As a result of the misplaced injection, it was claimed that the player’s femoral and saphenous nerves were damaged and argued that this nerve damage compromised his quadriceps musculature intervention and function as a skilled football player.7 RED FLAG Risk of Extended Tourniquet Times Tourniquet time >120 minutes increases the risk of developing a DVT and other VTEs.3 The postsurgical complication rate of VTE is estimated to be low (1% to 2%) following arthroscopic knee surgery, but rises to 7% to 30% following total knee arthroplasty.13 Also, people with the sickle cell trait have an approximately 1.5-fold increased risk for VTE in general, and this risk extends to postsurgical conditions.11 There is no direct concern of anesthesia for the patient with the sickle cell trait. However, it may be beneficial for the AT to alert the surgeon prior to surgery on a patient with the sickle cell trait, considering this population’s VTE risks. Summary As an important member of the interprofessional health care team, the AT should be aware of anesthesia options or a surgeon’s preferences. The AT can M.A. Cleary, T.E. Abdenour, and M. Pavolvich, Clinical Pharmacology in Athletic Training, Champaign, IL: Human Kinetics, 2022). For use only in Clinical Pharmacology Course 6–Sport Medics.