Regional Anesthesia at Home
Unaffordable health care costs, inability to access medical providers and other social obstacles often prevent patients in the United States from receiving adequate care.1 At-home self-care aims to put patients’ care in their own hands, thus giving them more control over their health outcomes.2,3 In the age of technology, many of these at-home solutions now include the Internet, smartphones and wearables such as smartwatches.1,3,4 For some patients, even at-home self-administration of anesthesia can be possible.5 While oral analgesics, including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids, can be helpful, patients with severe pain may need further medication.6 Specifically, researchers and providers have allowed patients to self-administer regional anesthetics such as peripheral nerve blocks, especially in patients with recurrent pain.7 At-home regional anesthetics can empower patients, cut down on hospital stays and prevent use of addictive medications.6,8,9
Peripheral nerve blocks are a type of regional anesthesia, usually injected near a specific nerve or bundle of nerves to block pain sensation in a certain area.10 Depending on the area, the type of nerve block or site of injection may vary.11 Commonly used peripheral nerve blocks include ropivacaine, bupivacaine and levobupivacaine, among others.11 Patients often use nerve blocks after upper or lower limb surgery in order to reduce pain in a specific area for a short period of time.11 Nerve blocks are also helpful when anesthetizing parts of the body with a large surface area, as a large amount of a local anesthetic could cause side effects. Additionally, nerve blocks can be used in sensitive areas like the face, where injection of a local anesthetic could cause distortions.10 When patients take the proper precautions, peripheral nerve blocks can be administered at home.
There are various ways patients can use at-home anesthetics like peripheral nerve blocks. One study by Cheng et al. emphasized the efficacy of single-injection intraarticular techniques, as well as perineural (i.e., located around a nerve or nerve bundle) catheters.5 Meanwhile, Dadure et al. used a combination of catheters, intravenous injections and disposable pumps to successfully provide at-home treatment for recurrent pediatric complex regional pain syndrome.7,8 In a study by Rawal et al., 70 patients who had undergone a variety of surgical procedures were taught to use a subcutaneous catheter and pump system to deliver nerve blocks at home.6 Ilfeld and Enneking used a case study of a 77-year-old rotator cuff surgical patient who was able to effectively use a portable, programmable pump at home for continuous perineural anesthetic infusions.12 Another case study, by Nielsen et al., showed that four more patients who had undergone rotator cuff surgery successfully used an interscalene catheter connected to an automated infusion pump to self-administer anesthesia at home.13 This allowed for minimal opioid use, cost savings and possible improvements in outcomes.13 Overall, patients can self-administer anesthetic drugs in various ways at home, often leading to lower pain and reduced oral medication.12
Despite all the benefits of at-home anesthesia administration via intravenous or intraarticular injection, catheters, pumps and other routes,5,7 there are potential harms that come with self-administration. For example, a review on peripheral nerve blocks at home raises issues such as site infection, local anesthetic toxicity, catheter migration or occlusion, nerve injury, pump malfunction and lack of patient education.12 Rawal et al. express a concern with their pump method, in that the entire volume of local anesthetic could be delivered at once if the patient failed to close the clamp, along with risk of delayed wound healing and infection.6 For Cheng et al.’s study on children, complications included nausea, vomiting, cellulitis, tinnitus and difficulty removing a catheter.5 Finally, Sardesai et al. describe a case of lower left lung collapse following an interscalene local anesthetic infusion administered at home, likely due to lack of patient education and postoperative miscommunication.14
With the proper precautions and patient education, regional anesthesia self-administration can be an inexpensive, simple and safe way for patients to take control of their pain management at home.6 Future research should assess the feasibility of technological advances and possibilities for automation to reduce patients’ human error.
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10. Healthwise Staff. Peripheral Nerve Blocks for Anesthesia. December 13, 2018; https://www.uofmhealth.org/health-library/rt1576.
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13. Nielsen KC, Greengrass RA, Pietrobon R, Klein SM, Steele SM. Continuous interscalene brachial plexus blockade provides good analgesia at home after major shoulder surgery-report of four cases. Canadian Journal of Anesthesia. 2003;50(1):57–61.
14. Sardesai AM, Chakrabarti AJ, Denny NM. Lower Lobe Collapse During Continuous Interscalene Brachial Plexus Local Anesthesia at Home. Regional Anesthesia & Pain Medicine. 2004;29(1):65–68.