Journal of Clinical Anesthesia (2007) 19, 67 74

Review article

Patient comfort during regional anesthesia

Philip Hu FCARCSI (Specialist Registrar)a,*, Dominic Harmon MMedSci, MD, FCARCSI (Consultant Anaesthetist)b, Henry Frizelle MD, FFARCSI (Consultant Anaesthetist)c
a

Department of Anaesthesia, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland Department of Anaesthesia, Mid-Western Regional Hospital, Dooradoyle, Limerick, Ireland c Department of Anaesthesia, Mater Misercordiae University Hospital, Eccles St, Dublin 7, Ireland
b

Received 21 October 2005; revised 20 February 2006; accepted 21 February 2006

Keywords:
Patient comfort; Regional anesthesia

Abstract Regional anesthesia has many advantages, which include low cost, ease of administration, and avoidance of risks associated with general anesthesia. Injection of local anesthetic via a needle as part of a regional anesthetic technique can be a stressful experience. The goal is to produce a relaxed patient who is comfortable and cooperative throughout the duration of surgery. The topics of regional anesthetic techniques, drug combinations, and adjunct measures such as sedation have been described extensively in the literature. The issue of patient comfort has not been reviewed in its entirety. This review seeks to collate known information in a systematic format and provide a framework for patient comfort during regional anesthesia. D 2007 Elsevier Inc. All rights reserved.

1. Introduction
Advantages of regional anesthesia include low cost, ease of administration, and avoidance of risks associated with general anesthesia [1,2]. As with surgical and diagnostic procedures, regional anesthesia can be a stressful experience [3,4], and all measures to establish and maintain patient comfort should be considered. The goal is to produce a relaxed patient who is comfortable and cooperative throughout the duration of surgery. Patient needs and expectations must never be overlooked in our enthusiasm for regional anesthesia. In the high-risk patient in whom regional anesthesia is safer, any unneces-

sary pain may negate benefits. Patient comfort during regional anesthesia relates to comfort during needle insertion, peripheral nerve stimulation, duration of surgery, and the postoperative period. Patient comfort during regional anesthesia is also an important teaching point for trainees [5]. In ensuring patient comfort during regional anesthesia, several steps are involved (Fig. 1).

2. Preoperative preparation, psychology, and communication

Psychology and communication play an important part in the success of any anesthetic technique [6]. The anesthesiologist should communicate in a confident manner to establish rapport with the patient. Eye contact and a strong handshake are examples of nonverbal communication

* Corresponding author. Tel.: +353 1 8093000; fax: +353 1 8664007. E-mail address: kooliohu@hotmail.com (P. Hu). 0952-8180/$ see front matter D 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.jclinane.2006.02.016

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P. Hu et al. In some cases, particularly with elderly patients and in ambulatory surgery, premedication is omitted. Opioid premedication may be useful in patients who are in pain [19]. Patient response, however, may be unpredictable and may interfere with cooperation or cause adverse effects such as postural hypotension, nausea and vomiting, delayed gastric emptying, or respiratory depression [20]. Other options include light premedication with oral benzodiazepines. Nonsteroidal antiinflammatory drugs (NSAIDs), rectally or orally administered preoperatively, can counteract the pain and stiffness after a long period of immobility on a hard operating table [21]. The role of nonsteroidal antiinflammatory drugs is that of nonopioid analgesics, particularly effective in inflammatory and bone pain. They are useful also because they have no sedative or respiratory depressive effects when coadministered with benzodiazepines. NSAIDs also have an opioid-sparing effect [22]. Diclofenac premedication reduced the analgesic requirements during the first 8 hours after varicose vein repair with spinal anesthesia [23]. Diclofenac suppositories used perioperatively improved analgesia in adult [24,25] and pediatric [26] patients when combined with regional anesthesia. Perioperative administration of dexketoprofen 25 mg every 8 hours orally markedly improved analgesia and decreased opioid requirements after hip arthroplasty with spinal anesthesia [27]. Specific literature recommendations for different agents to improve patient comfort during block performance and surgery are limited. Rewari et al [28] used propofol (0.5 mg/kg per hour) and remifentanil (0.5 lg/kg per hour) intravenous (IV) infusions during placement of retrobulbar nerve blocks, with minimal respiratory depression. Krenn et al [29] reported that propofol (1 mg/kg per hour) was comparable with remifentanil (3 lg/kg per minute) for sedation during carotid endarterectomy surgery with regional anesthesia, but it was preferred because it caused less respiratory depression and bradycardia. Remifentanil (0.04 lg/kg per minute) provides comfort and analgesia without hampering mental status evaluation during carotid endarterectomy [30]. Low-dose ketamine (0.5 mg/kg) and midazolam (0.1 mg/kg) together provide analgesia during spinal anesthesia [31]. Low-dose ketamine infusion (0.3 mg/kg) in combination with midazolam (0.05 mg/kg) provides satisfactory intraoperative sedation and analgesia in plastic-surgery patients when used to supplement local anesthesia [32]. A comparison of propofol or propofolketamine found that the propofol-ketamine combination conferred hemodynamic stability during spinal anesthesia with similar sedation scores [33]. Premedication with oral dextromethorphan 90 mg compared with placebo decreases analgesic requirements by approximately 50% in the perioperative period in patients undergoing joint arthroscopy or inguinal herniorrhaphy [34]. Pain and sedation scores were also improved [34]. Clonidine (1 lg/kg) IV prolongs analgesia after psoas compartment block for hip fracture surgery [35].

Fig. 1 Steps in optimization of patient comfort during regional anesthesia.

cues to gain the patients trust [7]. Details of the regional anesthetic technique should be explained [8]. Simple and precise language aid understanding. Careful use of terminology is important. The term epidural has positive connotations, but spinal anesthesia has negativeassociated meanings [8]. Patient acceptance of subsequent regional anesthetic techniques is dependent on previous experience [9]. These experiences should be elicited and discussed [10,11]. Preanesthetic videos may improve the effectiveness of traditional preanesthetic consultation practices [12]. Understanding and mental preparation may aid the overall surgical experience for patients [13]. There is no added benefit in decreasing patient anxiety by expanding the routine to more detailed information [14]. Lonsdale and Hutchinson [15] have reported that patients older than 50 years in Canada and Scotland may not want to discuss the anesthetic technique at length. Klafta and Roizen [16] have shown that preoperative instruction in relaxation techniques decreases patient anxiety and postoperative pain. Informed consent must be obtained before administration of sedative medication.

3. Recommendation A
Patients previous experiences of regional anesthesia should be sought. Simple and precise language should be used.

4. Premedication
Pharmacologic premedication facilitates patient comfort during regional anesthesia performance [17]. Advantages of premedication include improved patient satisfaction, acceptance, and cooperation. Disadvantages include unpredictable response, adverse effects, and interference with cooperation [18].

Patient comfort during regional anesthesia

69 yielded significantly lower pain scores on infiltration than did either plain or alkalinized lidocaine alone [48].

5. Recommendation B
We recommend premedication with nonopioid analgesics when possible.

7. Recommendation C 6. Regional anesthetic technique performance

In the performance of regional anesthesia techniques, factors that impact on patient comfort should be optimized. On presentation for surgery, patients have usually assumed the most comfortable position in relation to their pathology. The use of analgesics immediately before patient positioning can help increase patient comfort [36]. Excess sedation can impair patients ability to communicate regarding symptoms of intraneural or intravascular injections, which is an important safety feature [37,38]. Supplementary regional blocks may also aid patient positioning and prolong postoperative analgesia [39,40]. Surgical positioning should be delayed until surgical anesthesia is established. If possible and if the stretcher is comfortable, the block can be performed on the stretcher before transfer to the operating table. The anesthetic room or a designated block room can be modified to maximize patient comfort. Skilled gentle digital palpation of surface anatomical landmarks is required. Maintenance of adequate communication with the patient and simple gestures such as handholding [41] during the block decrease anxiety. The choice of regional technique must take into account the patients pathology; for example, performance of spinal anesthesia with the patient placed in the lateral position, with the fractured limb nondependent, and use of a hypobaric local anesthetic solution. For fractures of the proximal humerus, blocks above the clavicle are more appropriate, thus avoiding abducting the upper limb required for an axillary block technique. Pain on skin puncture is the most negative aspect of patients experience with regional anesthesia [42]. The smallest gauge needle (25-30 G) should be used for infiltration of skin and subcutaneous tissues. Local anesthetic is best infiltrated tangentially rather than at a single insertion point. This action ensures both a superficial injection and allows for needle repositioning during block performance. Use of small-gauge needles before progressing to larger and longer needles for deeper subcutaneous infiltration can also improve patient comfort. Topical eutectic mixture of local anesthetic (EMLA) cream is effective in decreasing the pain of spinal and epidural needle insertion [43]. Slow injection and use of warmed (258C-408C) local anesthetic solutions [44,45] decreases stinging on infiltration. Pain from skin infiltration of lidocaine solutions can be diminished by adding bicarbonate, as reported by Steinbrook et al [46]. Gershon et al [47], however, reported that alkalinization of lidocaine did not decrease the pain associated with an intradermal skin wheal. A combination of warming and alkalinization of lidocaine We recommend warming local anesthetic solution to between 258C and 408C before injection. There is much debate regarding whether peripheral nerve stimulation or paresthesia is the optimum technique in nerve localization [49-51]. Appropriate gauge and length of needle is chosen for both nerve stimulation or paresthesia techniques. Peripheral nerve stimulation techniques may be more comfortable for the patient because paresthesias are not intentionally sought. Block onset is also quicker and more complete [52]. Deliberate needle-elicited paresthesias are at least a questionable standard [53]. The paresthesia method is less well accepted by patients because of discomfort during block performance [10]. The theoretical risk of nerve injury is also greater [52].

8. Recommendation D
We recommend the use of nerve stimulation techniques over paresthesia techniques. Whichever technique is chosen, a poorly performed technique will increase patient discomfort. Adequate knowledge of nerve stimulator fundamentals such as the concept of impedance, current density, and stimulation voltage and frequency, is necessary to locate the nerves and maintain safety standards. The nerve stimulator should be activated only after the skin is penetrated by the needle [54]. This action is particularly relevant for superficial target structures. Current used should be minimized (bone mA) to prevent excessive motor stimulation, especially in patients with fractured limbs. Good communication with the patient as to what to expect is important. The needle should be advanced slowly to avoid inadvertent intraneural puncture. Initial injection of local anesthetic should be made slowly using a large-volume syringe (20 mL) to avoid excessive force of injection and minimize pain on injection [55,56]. Multiple injection techniques when compared to single injection techniques are associated with a higher success rate but also increase patient discomfort [10]. Several recent articles evaluated the causes of patients discomfort during peripheral blocks (needle passes, local anesthesia injections, and nerve stimulation) and compared discomfort caused by different approaches. Koscielniak-Nielsen et al [57] compared patient discomfort during infraclavicular and axillary brachial plexus blocks, and concluded that infraclavicular block by single injection caused less discomfort and fewer adverse events than did axillary block by multiple injections [57]. Block effectiveness, onset time, and patients acceptance were similar [57]. Single-shot infraclavicular block is

70 as effective as a triple-nerve stimulation axillary block and more comfortable for the patient [58]. Koscielniak-Nielsen et al [59] also reported that electrical stimulation was the most unpleasant part of the block when comparing patients given axillary and humeral blocks. However, they failed to detect significant differences in the pain intensity among repeated needle passes, local anesthetic injections, or electrical stimulations [59]. Electrical stimuli is perceived as painful by 53% of patients, and this pain is more intense than with other block components in patients undergoing multiple-stimulation axillary blocks [4].

P. Hu et al. Tourniquet pain is thought to be mediated by unmyelinated slow-conducting C fibers. Clonidine depresses nerve action potentials in C fibers [73]. Intrathecal clonidine combined with local anesthetic decreases the incidence of tourniquet pain in the lower limb [74]. In patients undergoing upper limb IV regional anesthesia, clonidine added to the local anesthetic solution improves tourniquet tolerance [75]. Regional techniques should take into account the use of tourniquets in addition to the surgical site. Optimal regional anesthetic techniques can minimize tourniquet pain. Adequate communication should be maintained at all times with the patient, with frequent assessment of surgical anesthesia of the operative site. In the assessment of sensory block, pinprick, cold, warm air sensation, and touch can be used to determine the level of block [76]. Russell [77] reported that no patients felt pain or discomfort using either pinprick or cold sensations.

9. Recommendation E
We recommend that single-shot techniques be used instead of multiple injections to maximize patient comfort. A study investigating whether shorter electrical stimulation could improve patient comfort found no difference in short-current impulses (0.1 milliseconds) compared with conventional parameters [60]. Injection of local anesthetic should continue slowly, with frequent aspiration. Continuous peripheral block techniques can be used and extend analgesia in the postoperative period. Direct visualization of the distribution of local anesthetic by high-frequency ultrasound probes can improve the quality and avoid the complications of regional anesthesia [61]. Ultrasound-guided nerve blocks can decrease the number of needle passes required and avoid uncomfortable muscle twitches with electrical stimulation techniques that can cause patient discomfort [61]. Quality of block is improved [62]. Time taken to perform nerve blocks, onset of anesthesia, decreased complication rate, and volume of local anesthetic agents are all factors that improve patient comfort [61]. Ultrasound also improves learning curves for trainees [63]. Many factors are implicated in tourniquet pain [64]. Local pain from skin compression plays a role [65]. Topical local anesthetic application in association with chosen regional anesthetic technique decreases tourniquet pain [66]. In brachial plexus block, anesthesia of the medial cutaneous nerves by a skin infiltration of local anesthetic at the root of the arm improved arm tourniquet tolerance [67]. Other factors such as tourniquet size, inflation pressure, and duration impact on patient discomfort [68-71]. Another mechanism of tourniquet pain is ischemia of underlying nerves and muscles. Local nerve compression and mechanical deformation with tissue edema and microvascular compression can account for this pain [72].

11. Recommendation G
We recommend the cold test as the method of evaluation of sensory block. The anesthesiologist must be able to recognize and accept block failure. Plans for block failure should be discussed with the patient preoperatively. These plans may include other regional blocks, surgeon infiltration of local anesthetic, or conversion to general anesthesia. In the operating room, patient comfort is improved by keeping the patient warm and covered. The ambient temperature of the theatre should be kept at 268C where possible [78]. Shivering worsens any existing pain and anxiety, increasing patient discomfort [79].

12. Recommendation H
We recommend active warming of all patients undergoing regional anesthesia. Core temperature should be monitored. Warming of IV infusions can also improve patient comfort. Intravenous clonidine decreases shivering during regional anesthesia and can improve patient comfort in combination with its sedative and analgesic properties [80]. A soft mattress should also be used to prevent any pressure areas. Favorable music via a headset decreases patient-controlled sedation requirements in awake patients undergoing surgical procedures performed with regional anesthesia [81,82]. Intraoperative music chosen by the patient may assist by providing a familiar auditory environment, distracting the patient during the procedure. The use of headsets can screen out background operating theatre noise.

10. Recommendation F
We recommend that the lowest effective cuff pressure be used to maximize patient comfort.

Patient comfort during regional anesthesia

Table 1 Drug Midazolam Diazepam Fentanyl Remifentanil Propofol Ketamine Pharmacokinetic variables of sedative agents Initial bolus (mg/kg) 0.05-0.1 0.05-0.2 0.001-0.0005 0.1-0.2 lg/kg per minute 1 mg/kg or 0.0025-0.0075 mg/kg per minute 1-1.5 Mode of administration IV bolus IV bolus IV bolus IV infusion IV bolus or infusion IV bolus Onset (min) 2-3 4-6 2-3 3-5 2-3 1-2

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Duration of action (min) 45-60 120-180 20-30 5 after discontinuation 10 after discontinuation 40-60

Ketamine causes emergence phenomena and hallucinations and should be used in conjunction with a sedative such as a benzodiazepine or propofol.

Noise can increase anxiety levels [83], and this is an issue in the operating room and magnetic resonance imaging suite. Stermer et al [84] failed to show the beneficial effect of complete silence vs background music in the endoscopy room, but attempts to decrease noise levels in other areas have been found to be as effective as pharmacologic sedation. Medical remarks and conversations that may be misinterpreted by the patient should be kept to a minimum. Screening off the operative site is mandatory. Perioperative hypnosis in conjunction with pharmacologic sedation has been reported [85]. Imagery, suggestion, autosuggestion, and fixation are methods of hypnosis. Advantages of hypnosis over pharmacologic sedation include increased patient satisfaction and comfort, and decreased associated adverse effects [86]. Disadvantages include difficulties with patient acceptance, standardization, and reproducibility [87]. Sedation can minimize anxiety, improve patient comfort and cooperation, and provide amnesia [88,89]. Intraoperative sedation must be chosen with each individual patient in mind, considering factors such as nature of the surgery, type of block, general health, temperament of the patient, and experience and attitude of surgeon and anesthesiologist [89]. Patients benefit from pharmacologic sedation to allow them to rest quietly or sleep during the procedure. In prolonged procedures with awkward positioning, sedation can increase patient comfort [90]. Important objectives in regional anesthesia practice are to decrease patient anxiety, fear, pain, discomfort, and awareness during surgery [8,17]. Balanced sedative techniques use combinations of sedatives to meet the analgesic and anxiolytic needs of the patient [17]. Sedation and analgesia are distinct processes. Some patients require primarily sedation, some require primarily analgesia provided by opioids or additional local anesthetic agents, and some require both sedation and analgesia. Opioids and benzodiazepines have a proven synergistic effect [91]. The respiratory depressive effects of opioids and benzodiazepines are also synergistic when administered together [92]. Certain aspects of the regional technique often require both sedation and analgesia. Sedation alone in the presence of pain may cause confusion and restlessness. Conscious sedation is defined as a state of depressed consciousness that allows protective reflexes to be main-

tained and the patient to respond appropriately to physical and verbal stimulation [93]. Deep sedation is hazardous and exposes the patient to multiple risks not limited to cardiorespiratory compromise and potential nerve injury.

13. Recommendation I
We recommend that only conscious sedation be used to facilitate block placement. Sedation is limited to IV and inhaled routes, because the oral route is too slow with variable effects [17]. Intravenous anesthesia should be administered via slow infusion or small boluses to minimize fluctuations into general anesthesia [20]. The ideal sedative should have a short half-life, rapid clearance, predictable onset, and easy dose adjustment [94]. Other sedative agent choices are shown in Table 1. Appropriate equipment and monitoring facilities be available. Pulse oximetry and supplemental oxygen should always be administered in association with sedation and regional anesthesia [95,96]. Novel delivery methods for sedation include target-controlled infusions [97] and patientcontrolled sedation [98].

14. Recommendation J
We recommend that sedation scores be used to monitor patients during the intraoperative period.

15. Postoperative care

Slings to elevate the surgical limb should be used for postoperative comfort, because they decrease swelling. Rescue postoperative analgesia should be prescribed. Prescribing protocols can help improve standards of care and postoperative analgesia. Postoperative analgesia is best managed by a formal acute pain management team.

16. Quality
A quality assurance process can facilitate patient comfort during regional anesthesia. It has a demonstrated benefit in

72 improving postoperative analgesia [99]. Audit and quality assurance are also essential in improving patient satisfaction [100]. In a survey of the practice of regional anesthesia in Germany, Austria, and Switzerland, the authors concluded that concepts of training and quality assurance that are backed up by evidence-based medicine should be established to improve training and further education in regional anesthesia practice [101]. In a second survey, Grau et al [102] concluded that standards in regional anesthesia (including patient comfort) could be improved if basic techniques were audited and success rates recorded on a formal basis. The quality of the peripheral nerve block is an important factor in patient comfort. Repeated or rescue blocks and inadequate surgical anesthesia leading to intraoperative and postoperative pain increase patient discomfort.

P. Hu et al.
[10] Fanelli G, Casati A, Garancini P, et al. Nerve stimulator and multiple injection technique for upper and lower limb blockade: failure rate, patient acceptance and neurologic complications. Anesth Analg 1999;88:847 - 52. [11] Kinirons BP, Bouaziz H, Paqueron X, et al. Sedation with sufentanil and midazolam decreases pain in patients undergoing multiple nerve block. Anesth Analg 2000;90:1118 - 21. [12] Done ML, Lee A. The use of the video to convey pre-anesthetic information to patients undergoing ambulatory surgery. Anesth Analg 1998;87:531 - 6. [13] Miller SM, Mangan CE. Interacting effects of information and coping style in adapting to gynecologic stress. Should the doctor tell all? J Pers Soc Psychol 1983;45:223 - 36. [14] Elsass P, Eikard B, Junge J, et al. Psychological effect of detailed preanesthetic information. Acta Anaesthesiol Scand 1987;31:579 - 83. [15] Lonsdale M, Hutchinson GL. Patients desire for information about anaesthesia: Scottish and Canadian attitudes. Anaesthesia 1991;46: 410 - 2. [16] Klafta JM, Roizen MF. Current understanding of patients attitudes toward and preparation for anaesthesia: a review. Anesth Analg 1996;83:1314 - 21. [17] Tryba M. Choices in sedation. Eur J Anaesthesiol 1996;13(Suppl): 22 - 5. [18] Kenny GN. Patient sedation: technical problems and developments. Eur J Anaesthesiol 1996;13(Suppl 13):18 - 21. [19] Kelly DJ, Ahmad M, Brull SJ. Preemptive analgesia: physiological pathways and pharmacological modalities. Can J Anaesth 2001;48: 1000 - 10. [20] Mackenzie N. Sedation during regional anaesthesia: indications, advantages and methods. Eur J Anaesthesiol 1996;13(Suppl):2 - 7. [21] Charlton JE. The management of regional anaesthesia. In: Wildsmith JA, Armitage EN, editors. Principles and practice of regional anaesthesia. Edinburgh7 Churchhill Livingstone; 1982. p. 37 - 61. [22] Hubbard RC, Naumann TM, Traylor L, et al. Parecoxib sodium has opioid-sparing effects in patients undergoing total knee arthroplasty under spinal anaesthesia. Br J Anaesth 2003;90:166 - 72. [23] Rautoma P, Santanen U, Luurila H, et al. Preoperative diclofenac is a useful adjunct to spinal anaesthesia for day-case varicose vein repair. Can J Anaesth 2001;48:661 - 4. [24] Gadiyar V, Gallagher TM, Crean PM, et al. The effect of a combination of rectal diclofenac and caudal bupivacaine on postoperative analgesia in children. Anaesthesia 1995;50:820 - 2. [25] Lim NL, Lo WK, Chong JL, et al. Single dose diclofenac suppository reduces post-Cesarean PCEA requirements. Can J Anaesth 2001;48:383 - 6. [26] Dahl V, Hagen IE, Sveen AM, et al. High-dose diclofenac for postoperative analgesia after elective caesarean section in regional anaesthesia. Int J Obstet Anesth 2002;11:91 - 4. [27] Iohom G, Walsh M, Higgins G, et al. Effect of perioperative administration of dexketoprofen on opioid requirements and inflammatory response following elective hip arthroplasty. Br J Anaesth 2002;88:520 - 6. [28] Rewari V, Madan R, Kaul HL, et al. Remifentanil and propofol sedation for retrobulbar nerve block. Anaesth Intensive Care 2002; 30:433 - 7. [29] Krenn H, Deusch E, Jellinek H, et al. Remifentanil or propofol for sedation during carotid endarterectomy under cervical plexus block. Br J Anaesth 2002;89:637 - 40. [30] Marrocco-Trischitta MM, Bandiera G, Camilli S, et al. Remifentanil conscious sedation during regional anaesthesia for carotid endarterectomy: rationale and safety. Eur J Vasc Endovasc Surg 2001;22:405 - 9. [31] Yeh FC, Hsu CS, So EC, et al. Low dose ketamine and midazolam as supplements for spinal anaesthesia. Acta Anaesthesiol Sin 1999;37: 15 - 9. [32] Deng XM, Xiao WJ, Luo MP, et al. The use of midazolam and smalldose ketamine for sedation and analgesia during local anesthesia. Anesth Analg 2001;93:1174 - 7.

17. Conclusions
Regional anesthesia can be a stressful experience, and all measures to establish and maintain patient comfort should be considered. The aim is to produce a relaxed patient who is comfortable and cooperative throughout the duration of surgery. In practice, achieving this ideal may be the most challenging part of regional anesthetic practice. Multiple techniques and drug regimens exist. No single algorithm or guideline can address the management challenges for a heterogenous patient population. A patient-centered approach, with individualized regimens including procedures and drugs, will ensure a high standard of patient comfort without compromising safety.

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