Annals of the Royal College of Surgeons of England (1990) vol. 72, 104-107
Local or general anaesthetic in day case arth roscopy? John A Fairclough FRCS Senior Lecturer
Geoffrey P Graham
FRCS
Senior Registrar
David Pemberton
FRCS
Lecturer
Department of Traumatic and Orthopaedic Surgery, Cardiff Royal Infirmary
Key words: Arthroscopy, local anaesthetic
A series of 66 patients who have undergone arthroscopy of the knee using three local anaesthetic techniques is presented. Over a similar period of time 70 patients had knee arthroscopy performed under general anaesthesia. In the local anaesthetic group the technique was successful in 50 cases, partially successful in 12 cases and totally unsatisfactory in 4 cases. In the general anaesthetic group all the procedures were successful. Local anaesthetic techniques were found to be satisfactory for diagnostic arthroscopy but general anaesthesia was better for operative procedures and was more acceptable to the surgeon and patient.
Patients and methods A series of 66 consecutive, randomly selected patients, undergoing both diagnostic and operative knee arthroscopy were operated on using three different local anaesthetic techniques. Over a similar period 70 patients were operated on under general anaesthesia. The sex and age range of the patients and the procedures performed were similar in the two groups. All the procedures were performed by one surgeon experienced in operative arthroscopy. The local anaesthetic techniques used are well described and were all performed by the same surgeon.
In recent years the diagnosis and treatment of knee pathology has changed dramatically with the introduction of arthroscopic techniques. The low morbidity associated with arthroscopic surgery allows early mobilisation of patients and hence makes it an ideal technique for day case surgery. Several authors have reported favourable results using local anaesthesia for knee arthroscopy (1-7). In this study we compare the use of local and general anaesthetic techniques during arthroscopy of the knee. Over a 4-month period, 66 consecutive arthroscopic procedures were performed under local or regional anaesthesia and compared with 70 procedures performed under general anaesthesia over a similar period. The benefits and drawbacks are described.
The local anaesthetic used in all cases was a mixture otf 20 ml of 0.25% bupivacaine (50 mg of bupivacaine hydrochloride) and 30 ml of 0.5% prilocaine (150 mg of prilocaine hydrochloride). The maximum safe dose of bupivacaine is 2 mg/kg/4 h and that for prilocaine is 6 mg/kg (manufacturer's recommendations). Because a combination of two anaesthetic agents was used, no more than 50% of the recommended maximum dose of each was given.
Correspondence to: Mr G P GrahaM FRCS, Department of Traumatic and Orthopaedic Surgery, Cardiff Royal Infirmary, Newport Road, Cardiff
Local infiltration The anatomical landmarks of the knee and proposed portals for the arthroscope and instruments were outlined in pen. Routine medial and lateral parapatellar
The methods of anaesthesia used were: 1 Local infiltration of the knee joint. 2 Femoral nerve block without tourniquet. 3 Femoral nerve block with tourniquet. 4 General anaesthesia.
Anaesthesia in day case arthroscopy portals were used for the arthroscope and instruments and these were infiltrated with 5 ml of the local anaesthetic solution. A drain site marked superolaterally was infiltrated with 5 ml of local anaesthetic solution and through this portal the remaining solution was injected into the knee. The patient's leg was then draped with a sterile towel and the patient was encouraged to move the knee in order to spread the solution throughout the joint. The patient was returned to the ward to allow the anaesthetic to take effect. The anaesthetic took approximately 5 min to work. Logistically, returning the patient to the ward was not a problem, as the Day Ward was adjacent to the theatre suite.
Femoral nerve block without tourniquet The patient was placed supine on an operating table and the anatomical landmarks of the anterior superior iliac spine pubic tubercle and the femoral artery were outlined. The femoral nerve was located by placing the needle just lateral to the femoral artery and advancing it until the patient felt tingling in the thigh, 25 ml of anaesthetic solution was then injected. The lateral cutaneous nerve of the thigh was blocked at a point 1 cm below and medial to the anterior superior iliac spine using 10 ml of anaesthetic solution. The patient was returned to the ward to allow the anaesthetic to take effect. The local anaesthetic took approximately 30 min to work and therefore took effect while the preceding patient had their arthroscopy performed. Anaesthesia in the distribution of the femoral nerve and weakness of the quadriceps were accepted as the signs of a successful nerve block.
General anaesthesia All the general anaesthetics were given by the same anaesthetist. No premedication was used. Induction was with intravenous propofol and alfentanyl according to weight. The patient was allowed to breathe spontaneously and the anaesthetic was maintained with nitrous oxide and enflurane via a face mask.
Results Local anaesthetic techniques
Table I shows the type of procedure performed using the local anaesthetic techniques. In only one case was it impossible to complete the procedure. This was on a patient in group 3 undergoing posterior horn excision and was due to deflation of the thigh tourniquet causing intra-articular bleeding and subsequent loss of vision. In the group of patients who underwent diagnostic arthroscopy alone there were no major problems with any of the three methods of local anaesthesia. All the patients found the procedure to be acceptable and none needed adjunctive sedation.
Table I. Procedures performed using local anaesthetic techniques Anaesthetic technique no. 1 Procedure
Femoral nerve block with tourniquet
The technique outlined for femoral nerve block without tourniquet was used and, in addition, the leg was exsanguinated with an Esmarch bandage and a thigh tourniquet was inflated just before the procedure began.
105
Diagnostic Menisectomy Loose body Lateral release Division of plica
(n = 13)
2 (n = 16)
3 (n = 37)
6 5 1 0 1
9 6 1 0 0
15 15 4 2 1
Table II. Benefits and potential problems associated with the different types of local anaesthesia Benefits I Local infiltration Allowed the patient to watch the procedure and enabled the surgeon to discuss the pathology and surgical treatment with the patient Avoids the risks of general anaesthesia 2 Femoral block without tourniquet As above Better relaxation 3 Femoral block with tourniquet As above No bleeding
Potential problems
Restricted access owing to poor muscle relaxation Discomfort for the patient during the procedure Predetermined portals restrict options Intra-articular bleeding Pain on entering the posterior aspect of joint Restricted access to posterior aspect of joint Quadriceps paralysis Bleeding As for 2. Ischaemic pain felt in the back of the thigh after approximately 20 min
106
J A Fairclough et al.
In the group of patients who underwent an operative procedure the results were less satisfactory. Twelve operative procedures were rated as only partially successful. This was due to either the patient experiencing some discomfort or the surgeon experiencing difficulty during the procedure attributable to the anaesthetic as described in Table II. Four cases were rated as totally unsatisfactory, although only one had to be abandoned (due to bleeding). A summary of the benefits and drawbacks of the local anaesthetic techniques is given in Table II.
General anaesthesia There were no major anaesthetic problems encountered in any of the 70 patients who had a general anaesthetic. From the point of view of the surgeon the procedures were all satisfactory and all the patients were able to go home the same day.
Discussion The use of day case surgery has been steadily increasing over the last few years. This has been supported both by the Royal College of Surgeons of England study group and various health authorities, as a cheaper and more efficient way of managing certain surgical conditions. Arthroscopy is an ideal procedure for day case surgery as it has a low morbidity. Recent publications support the use of regional anaesthesia for arthroscopy of the knee (1-7). The use of local anaesthetic in the knee has been shown to be safe, as blood levels of the local anaesthetic agents remain low throughout the procedure (2). The consistent benefit of local anaesthetic techniques was the ability to discuss the findings with the patient as the operation progressed. Patients were given the option of watching a video screen and all did so. There were no adverse reactions to this. Subsequent outpatient followup was facilitated as the patients had a better idea of what was wrong inside the knee. This was a particular advantage in patients who had degenerative changes in the knee. These patients found it easier to understand the reason for their pain and stiffness and accepted further treatment more readily after they had seen the damage for themselves. In the group where local infiltration was the method of anaesthesia, intra-articular bleeding was a major problem as a thigh tourniquet could not be used. The bleeding caused difficulty with visualisation of the joint. Increasing the fluid intra-articular pressure did not decrease the bleeding, although increasing the flow rate helped. A problem occurred where additional portals were needed as these sites had to be anaesthetised separately causing delay. Access was also difficult, particularly for operative procedures, as there was little muscle relaxation. The use of a combined block involving the femoral nerve and the lateral cutaneous nerve of the thigh proved to be satisfactory for diagnostic arthroscopy, although bleeding was again a problem when no tourniquet was
used. A tourniquet prevented bleeding but caused discomfort in the posterior part of the thigh which was not anaesthetised. The ischaemic pain was only a problem after 20-25 min and in the majority of patients it was well tolerated. A more serious problem was inadequate anaesthesia of the posterior part of the joint due to its innervation by the sciatic nerve. Any procedure performed on the posterior structures was therefore painful. As it is impossible to be sure before operation whether the posterior structures are damaged, the usefulness of the technique is limited. A major problem encountered with the combined femoral and lateral cutaneous nerve block was one of postoperative quadriceps paralysis. This usually lasted 4-6 h and the patients therefore had to go home in a cricket pad splint. Quadriceps wasting was also increased in patients who had a femoral nerve block; the average loss in thigh circumference 2 weeks after the procedure was 2 cm, compared with a 1 cm loss in patients who had a general anaesthetic. None of the above problems were encountered using general anaesthesia. Access was better due to muscle relaxation and the fact that the portals are not predetermined. The posterior aspect of the joint was easily entered and procedures could be performed without discomfort to the patient. There was no intra-articular bleeding as a tourniquet was used. Quadriceps palsy was not a problem postoperatively. In the past, the disadvantage of general anaesthesia has been the need for admission overnight after the procedure. However, with the new short-acting anaesthetic agents now available this is not necessary, and day case surgery with propofol is safe and acceptable to the patient and the anaesthetist (8,9). In over 400 arthroscopies performed as day cases using general anaesthesia in this department there have been no major complications attributable to the anaesthetic. It has been shown by other authors that general anaesthesia has a higher patient acceptance than local anaesthetic techniques for knee arthroscopy (2). In our experience, general anaesthesia is also more acceptable to the surgeon and the theatre staff as it is more efficient. The local anaesthetic techniques described are time consuming to carry out and the anaesthesia takes a variable amount of time to work. In our practice, and that of many others, an anaesthetist has to be available to administer either intravenous sedation or a general anaesthetic; the latter is necessary in 0-8% of patients (2,4,7). The potential benefits of local or regional anaesthesia seem outweighed by the problems that may be encountered. Local anaesthetic techniques are adequate for diagnostic arthroscopy but, unfortunately, in the majority of cases the surgeon cannot be sure that an operative procedure will not be necessary.
References 1 Besser MIB, Stahl S. Arthroscopic surgery performed under local anaesthesia as an outpatient procedure. Arch Orthop Trauma Surg 1986;105:296-7.
Anaesthesia in day case arthroscopy 2 Eriksson E, Haggmark T, Saartok T, Sebik A, Ortengren B. Knee arthroscopy with local anaesthesia in ambulatory patients. Orthopedics 1986;9:186-8. 3 Kirkby OJ, Aase S. Knee arthroscopy and arthrotomy under local anaesthesia. Acta Orthop Scand 1987;58: 133-4. 4 McGuire DA, Frost JD, Floerchinger SL. Local anaesthesia and arthroscopic surgery of the knee. Alaska Med
1986;April:20-4. 5 Minkoff J, Putterman E. The unheralded value of arthroscopy using local anaesthesia for diagnostic specificity and intraoperative corroboration of therapeutic achievement. Clin Sports Med 1987;6:471-90. 6 Patel NJ, Flashburg MH, Paskin S, Grossman R. A regional anaesthetic technique compared to general anaesthesia for outpatient knee arthroscopy. Anesth Analg 1986;65:185-7.
107
7 Wredmark T, Lundh R. Arthroscopy under local anaesthesia using controlled pressure irrigation with prilocaine. J Bone Joint Surg 1982;64B:583-5. 8 Herregods L, Capiau P, Rolly G, De Sommer M, Donadoni R. Propofol for arthroscopy in outpatients. Comparison of three anaesthetic techniques. Br J Anaesth 1988;60: 565-9. 9 Zuurmond WWA, Van Leeuwen L, Helmers JHJH. Recovery from propofol infusion as the main agent for outpatient arthroscopy. Anaesthesia 1987;42:356-9.
Received 5 September 1989
Book review Anaesthesia Databook by Rosemary A Mason. 529 pages. 1989. Churchill Livingstone, Edinburgh. £24.95. ISBN 0 443 04120 2. This is an excellent book which represents a remarkable tour de force for a single author. The aim of the book is to provide a vade-mecum for the experienced anaesthetist facing awkward problems. There is no discussion of basic principles or techniques since this is not a book for beginners. In just over 500 pages it is not possible to be comprehensive, but brevity of style allows a large amount of information to be presented. The book is divided into six sections. The first, which accounts for more than half the book, is called 'Medical disorders and anaesthetic problems'. A range of medical conditions is covered in alphabetical order from achondroplasia to WPW with some unusual ones in between such as Marcus-Gunn jaw winking phenomenon, Moya-moya disease and Miller's syndrome. Under each entry there is a brief account of the condition followed by descriptions of the relevant preoperative abnormalities, anaesthetic problems and management as well as a bibliography. Most entries take up less than three pages. The second and third sections of the book deal with pre- and postoperative drugs respectively. Section 4 describes 'perioperative emergency conditions' and covers, for example, Addisonian crisis, DIC, pulmonary oedema and TURP syndrome. Section 5, entitled 'Miscellaneous problems' deals mainly with resuscitation, but also includes an account of the diagnosis of brain death and management of the brain dead donor for organ harvest. Section 6 is devoted to tables of normal
values and a brief appendix gives useful addresses and telephone numbers. The aims of the book have in general been achieved admirably. When writing for the 'experienced anaesthetist' it is obviously very difficult to strike just the right balance between omitting relevant information on the one hand and teaching your grandmother to suck eggs on the other. For example, I would like to have seen a fuller discussion of the dangers of suxamethonium and of the preoperative management of untreated atrial fibrillation, but would have thought that the definition of 'pneumothorax' could have been left out, especially since it is wrong! There are several tables giving infusion rates for different drugs; these are unnecessary since there is a quick method for working them out in one's head. Although the author states that a conventional terminal index has deliberately been omitted, I think this is a shame. For a quick reference book it is essential to be able to find the relevant information easily and the indexing of each section of the book separately makes this difficult. The bibliographies which appear at the end of each entry are excellent and impressively up to date. They form a very useful guide to further reading and I hope that when this first edition has achieved the success it deserves, the bibliographies will be as good in future editions. For unusual cases this book should go a long way to helping us fulfil the maxim 'to be forewarned is to be forearmed'. R A F LINTON Consultant Anaesthetist St Thomas' Hospital, London
Local or general anaesthetic in day case arth roscopy? John A Fairclough FRCS Senior Lecturer
Geoffrey P Graham
FRCS
Senior Registrar
David Pemberton
FRCS
Lecturer
Department of Traumatic and Orthopaedic Surgery, Cardiff Royal Infirmary
Key words: Arthroscopy, local anaesthetic
A series of 66 patients who have undergone arthroscopy of the knee using three local anaesthetic techniques is presented. Over a similar period of time 70 patients had knee arthroscopy performed under general anaesthesia. In the local anaesthetic group the technique was successful in 50 cases, partially successful in 12 cases and totally unsatisfactory in 4 cases. In the general anaesthetic group all the procedures were successful. Local anaesthetic techniques were found to be satisfactory for diagnostic arthroscopy but general anaesthesia was better for operative procedures and was more acceptable to the surgeon and patient.
Patients and methods A series of 66 consecutive, randomly selected patients, undergoing both diagnostic and operative knee arthroscopy were operated on using three different local anaesthetic techniques. Over a similar period 70 patients were operated on under general anaesthesia. The sex and age range of the patients and the procedures performed were similar in the two groups. All the procedures were performed by one surgeon experienced in operative arthroscopy. The local anaesthetic techniques used are well described and were all performed by the same surgeon.
In recent years the diagnosis and treatment of knee pathology has changed dramatically with the introduction of arthroscopic techniques. The low morbidity associated with arthroscopic surgery allows early mobilisation of patients and hence makes it an ideal technique for day case surgery. Several authors have reported favourable results using local anaesthesia for knee arthroscopy (1-7). In this study we compare the use of local and general anaesthetic techniques during arthroscopy of the knee. Over a 4-month period, 66 consecutive arthroscopic procedures were performed under local or regional anaesthesia and compared with 70 procedures performed under general anaesthesia over a similar period. The benefits and drawbacks are described.
The local anaesthetic used in all cases was a mixture otf 20 ml of 0.25% bupivacaine (50 mg of bupivacaine hydrochloride) and 30 ml of 0.5% prilocaine (150 mg of prilocaine hydrochloride). The maximum safe dose of bupivacaine is 2 mg/kg/4 h and that for prilocaine is 6 mg/kg (manufacturer's recommendations). Because a combination of two anaesthetic agents was used, no more than 50% of the recommended maximum dose of each was given.
Correspondence to: Mr G P GrahaM FRCS, Department of Traumatic and Orthopaedic Surgery, Cardiff Royal Infirmary, Newport Road, Cardiff
Local infiltration The anatomical landmarks of the knee and proposed portals for the arthroscope and instruments were outlined in pen. Routine medial and lateral parapatellar
The methods of anaesthesia used were: 1 Local infiltration of the knee joint. 2 Femoral nerve block without tourniquet. 3 Femoral nerve block with tourniquet. 4 General anaesthesia.
Anaesthesia in day case arthroscopy portals were used for the arthroscope and instruments and these were infiltrated with 5 ml of the local anaesthetic solution. A drain site marked superolaterally was infiltrated with 5 ml of local anaesthetic solution and through this portal the remaining solution was injected into the knee. The patient's leg was then draped with a sterile towel and the patient was encouraged to move the knee in order to spread the solution throughout the joint. The patient was returned to the ward to allow the anaesthetic to take effect. The anaesthetic took approximately 5 min to work. Logistically, returning the patient to the ward was not a problem, as the Day Ward was adjacent to the theatre suite.
Femoral nerve block without tourniquet The patient was placed supine on an operating table and the anatomical landmarks of the anterior superior iliac spine pubic tubercle and the femoral artery were outlined. The femoral nerve was located by placing the needle just lateral to the femoral artery and advancing it until the patient felt tingling in the thigh, 25 ml of anaesthetic solution was then injected. The lateral cutaneous nerve of the thigh was blocked at a point 1 cm below and medial to the anterior superior iliac spine using 10 ml of anaesthetic solution. The patient was returned to the ward to allow the anaesthetic to take effect. The local anaesthetic took approximately 30 min to work and therefore took effect while the preceding patient had their arthroscopy performed. Anaesthesia in the distribution of the femoral nerve and weakness of the quadriceps were accepted as the signs of a successful nerve block.
General anaesthesia All the general anaesthetics were given by the same anaesthetist. No premedication was used. Induction was with intravenous propofol and alfentanyl according to weight. The patient was allowed to breathe spontaneously and the anaesthetic was maintained with nitrous oxide and enflurane via a face mask.
Results Local anaesthetic techniques
Table I shows the type of procedure performed using the local anaesthetic techniques. In only one case was it impossible to complete the procedure. This was on a patient in group 3 undergoing posterior horn excision and was due to deflation of the thigh tourniquet causing intra-articular bleeding and subsequent loss of vision. In the group of patients who underwent diagnostic arthroscopy alone there were no major problems with any of the three methods of local anaesthesia. All the patients found the procedure to be acceptable and none needed adjunctive sedation.
Table I. Procedures performed using local anaesthetic techniques Anaesthetic technique no. 1 Procedure
Femoral nerve block with tourniquet
The technique outlined for femoral nerve block without tourniquet was used and, in addition, the leg was exsanguinated with an Esmarch bandage and a thigh tourniquet was inflated just before the procedure began.
105
Diagnostic Menisectomy Loose body Lateral release Division of plica
(n = 13)
2 (n = 16)
3 (n = 37)
6 5 1 0 1
9 6 1 0 0
15 15 4 2 1
Table II. Benefits and potential problems associated with the different types of local anaesthesia Benefits I Local infiltration Allowed the patient to watch the procedure and enabled the surgeon to discuss the pathology and surgical treatment with the patient Avoids the risks of general anaesthesia 2 Femoral block without tourniquet As above Better relaxation 3 Femoral block with tourniquet As above No bleeding
Potential problems
Restricted access owing to poor muscle relaxation Discomfort for the patient during the procedure Predetermined portals restrict options Intra-articular bleeding Pain on entering the posterior aspect of joint Restricted access to posterior aspect of joint Quadriceps paralysis Bleeding As for 2. Ischaemic pain felt in the back of the thigh after approximately 20 min
106
J A Fairclough et al.
In the group of patients who underwent an operative procedure the results were less satisfactory. Twelve operative procedures were rated as only partially successful. This was due to either the patient experiencing some discomfort or the surgeon experiencing difficulty during the procedure attributable to the anaesthetic as described in Table II. Four cases were rated as totally unsatisfactory, although only one had to be abandoned (due to bleeding). A summary of the benefits and drawbacks of the local anaesthetic techniques is given in Table II.
General anaesthesia There were no major anaesthetic problems encountered in any of the 70 patients who had a general anaesthetic. From the point of view of the surgeon the procedures were all satisfactory and all the patients were able to go home the same day.
Discussion The use of day case surgery has been steadily increasing over the last few years. This has been supported both by the Royal College of Surgeons of England study group and various health authorities, as a cheaper and more efficient way of managing certain surgical conditions. Arthroscopy is an ideal procedure for day case surgery as it has a low morbidity. Recent publications support the use of regional anaesthesia for arthroscopy of the knee (1-7). The use of local anaesthetic in the knee has been shown to be safe, as blood levels of the local anaesthetic agents remain low throughout the procedure (2). The consistent benefit of local anaesthetic techniques was the ability to discuss the findings with the patient as the operation progressed. Patients were given the option of watching a video screen and all did so. There were no adverse reactions to this. Subsequent outpatient followup was facilitated as the patients had a better idea of what was wrong inside the knee. This was a particular advantage in patients who had degenerative changes in the knee. These patients found it easier to understand the reason for their pain and stiffness and accepted further treatment more readily after they had seen the damage for themselves. In the group where local infiltration was the method of anaesthesia, intra-articular bleeding was a major problem as a thigh tourniquet could not be used. The bleeding caused difficulty with visualisation of the joint. Increasing the fluid intra-articular pressure did not decrease the bleeding, although increasing the flow rate helped. A problem occurred where additional portals were needed as these sites had to be anaesthetised separately causing delay. Access was also difficult, particularly for operative procedures, as there was little muscle relaxation. The use of a combined block involving the femoral nerve and the lateral cutaneous nerve of the thigh proved to be satisfactory for diagnostic arthroscopy, although bleeding was again a problem when no tourniquet was
used. A tourniquet prevented bleeding but caused discomfort in the posterior part of the thigh which was not anaesthetised. The ischaemic pain was only a problem after 20-25 min and in the majority of patients it was well tolerated. A more serious problem was inadequate anaesthesia of the posterior part of the joint due to its innervation by the sciatic nerve. Any procedure performed on the posterior structures was therefore painful. As it is impossible to be sure before operation whether the posterior structures are damaged, the usefulness of the technique is limited. A major problem encountered with the combined femoral and lateral cutaneous nerve block was one of postoperative quadriceps paralysis. This usually lasted 4-6 h and the patients therefore had to go home in a cricket pad splint. Quadriceps wasting was also increased in patients who had a femoral nerve block; the average loss in thigh circumference 2 weeks after the procedure was 2 cm, compared with a 1 cm loss in patients who had a general anaesthetic. None of the above problems were encountered using general anaesthesia. Access was better due to muscle relaxation and the fact that the portals are not predetermined. The posterior aspect of the joint was easily entered and procedures could be performed without discomfort to the patient. There was no intra-articular bleeding as a tourniquet was used. Quadriceps palsy was not a problem postoperatively. In the past, the disadvantage of general anaesthesia has been the need for admission overnight after the procedure. However, with the new short-acting anaesthetic agents now available this is not necessary, and day case surgery with propofol is safe and acceptable to the patient and the anaesthetist (8,9). In over 400 arthroscopies performed as day cases using general anaesthesia in this department there have been no major complications attributable to the anaesthetic. It has been shown by other authors that general anaesthesia has a higher patient acceptance than local anaesthetic techniques for knee arthroscopy (2). In our experience, general anaesthesia is also more acceptable to the surgeon and the theatre staff as it is more efficient. The local anaesthetic techniques described are time consuming to carry out and the anaesthesia takes a variable amount of time to work. In our practice, and that of many others, an anaesthetist has to be available to administer either intravenous sedation or a general anaesthetic; the latter is necessary in 0-8% of patients (2,4,7). The potential benefits of local or regional anaesthesia seem outweighed by the problems that may be encountered. Local anaesthetic techniques are adequate for diagnostic arthroscopy but, unfortunately, in the majority of cases the surgeon cannot be sure that an operative procedure will not be necessary.
References 1 Besser MIB, Stahl S. Arthroscopic surgery performed under local anaesthesia as an outpatient procedure. Arch Orthop Trauma Surg 1986;105:296-7.
Anaesthesia in day case arthroscopy 2 Eriksson E, Haggmark T, Saartok T, Sebik A, Ortengren B. Knee arthroscopy with local anaesthesia in ambulatory patients. Orthopedics 1986;9:186-8. 3 Kirkby OJ, Aase S. Knee arthroscopy and arthrotomy under local anaesthesia. Acta Orthop Scand 1987;58: 133-4. 4 McGuire DA, Frost JD, Floerchinger SL. Local anaesthesia and arthroscopic surgery of the knee. Alaska Med
1986;April:20-4. 5 Minkoff J, Putterman E. The unheralded value of arthroscopy using local anaesthesia for diagnostic specificity and intraoperative corroboration of therapeutic achievement. Clin Sports Med 1987;6:471-90. 6 Patel NJ, Flashburg MH, Paskin S, Grossman R. A regional anaesthetic technique compared to general anaesthesia for outpatient knee arthroscopy. Anesth Analg 1986;65:185-7.
107
7 Wredmark T, Lundh R. Arthroscopy under local anaesthesia using controlled pressure irrigation with prilocaine. J Bone Joint Surg 1982;64B:583-5. 8 Herregods L, Capiau P, Rolly G, De Sommer M, Donadoni R. Propofol for arthroscopy in outpatients. Comparison of three anaesthetic techniques. Br J Anaesth 1988;60: 565-9. 9 Zuurmond WWA, Van Leeuwen L, Helmers JHJH. Recovery from propofol infusion as the main agent for outpatient arthroscopy. Anaesthesia 1987;42:356-9.
Received 5 September 1989
Book review Anaesthesia Databook by Rosemary A Mason. 529 pages. 1989. Churchill Livingstone, Edinburgh. £24.95. ISBN 0 443 04120 2. This is an excellent book which represents a remarkable tour de force for a single author. The aim of the book is to provide a vade-mecum for the experienced anaesthetist facing awkward problems. There is no discussion of basic principles or techniques since this is not a book for beginners. In just over 500 pages it is not possible to be comprehensive, but brevity of style allows a large amount of information to be presented. The book is divided into six sections. The first, which accounts for more than half the book, is called 'Medical disorders and anaesthetic problems'. A range of medical conditions is covered in alphabetical order from achondroplasia to WPW with some unusual ones in between such as Marcus-Gunn jaw winking phenomenon, Moya-moya disease and Miller's syndrome. Under each entry there is a brief account of the condition followed by descriptions of the relevant preoperative abnormalities, anaesthetic problems and management as well as a bibliography. Most entries take up less than three pages. The second and third sections of the book deal with pre- and postoperative drugs respectively. Section 4 describes 'perioperative emergency conditions' and covers, for example, Addisonian crisis, DIC, pulmonary oedema and TURP syndrome. Section 5, entitled 'Miscellaneous problems' deals mainly with resuscitation, but also includes an account of the diagnosis of brain death and management of the brain dead donor for organ harvest. Section 6 is devoted to tables of normal
values and a brief appendix gives useful addresses and telephone numbers. The aims of the book have in general been achieved admirably. When writing for the 'experienced anaesthetist' it is obviously very difficult to strike just the right balance between omitting relevant information on the one hand and teaching your grandmother to suck eggs on the other. For example, I would like to have seen a fuller discussion of the dangers of suxamethonium and of the preoperative management of untreated atrial fibrillation, but would have thought that the definition of 'pneumothorax' could have been left out, especially since it is wrong! There are several tables giving infusion rates for different drugs; these are unnecessary since there is a quick method for working them out in one's head. Although the author states that a conventional terminal index has deliberately been omitted, I think this is a shame. For a quick reference book it is essential to be able to find the relevant information easily and the indexing of each section of the book separately makes this difficult. The bibliographies which appear at the end of each entry are excellent and impressively up to date. They form a very useful guide to further reading and I hope that when this first edition has achieved the success it deserves, the bibliographies will be as good in future editions. For unusual cases this book should go a long way to helping us fulfil the maxim 'to be forewarned is to be forearmed'. R A F LINTON Consultant Anaesthetist St Thomas' Hospital, London
