الفهرس 
ANATOMICAL CONSIDERATIONSOnly 14 pages are availabe for public view
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Abstract
Local anesthetic techniques are widely used in high-risk surgical patients. They may be used alone or in combination with general anesthesia to provide anesthesia and analgesia both intraoperatively and postoperatively. Awide variety of local anesthetic techniques are used varying from simple techniques such as wound infiltration through field and nerve blocks to major regional anesthesia.
Many shoulder and neck procedures can be carried out with regional anesthesia alone, but a combination of regional and general anesthesia may be more appropriate for prolonged major procedures or where discomfort in other areas may limit comfortable positioning on the operating table. There are many techniques which can be used for regional blockade in neck and shoulder surgery including interscalene brachial plexus block, cervical plexus block, and cervical epidural anesthesia.
An interscalene approach to the brachial plexus is the most appropriate block to provide analgesia for the shoulder. Cervical plexus block anesthetizes the pain sensitive structures in the neck, shoulder and skin of upper chest up to sternal angle which is suitable for operations in the neck and shoulder.
The use of cervical epidural anesthesia has been reported for carotid endarterectomy, various neck surgeries, thyroidectomy, thymectomy as well as upper limb and shoulder surgeries. This technique is advantageous and attributes enhanced safety and reduction in morbidity. The main limitations are technical skill and patient’ acceptance.
Because local anesthetic drugs are used widely for the provision of anesthesia and analgesia both intra- and post- operatively, understanding the pharmacology of these agents as a group, as well as the differences between specific drugs, enables the anesthetist to use them safely to maximum effect. While using local anesthetic drugs, we must take care that there are many side effects and complications which range from localized skin reactions up to systemic toxicity and death.
Treatment of adverse local anesthetics reactions depends on their severity. Minor reactions can be allowed to resolve spontaneously. Local anesthetics-induced seizures should be managed by protecting the airway and providing oxygen. Seizures may be terminated with intravenous thiopental, midazolam, or propofol. If LA intoxication produces cardiac arrest, the guidelines for advanced cardiac life support (ACLS) are reasonable. With unresponsive bupivacaine cardiac toxicity, intravenous lipid or cardiopulmonary bypass may be considered ”Lipid rescue”.
Finally, we should ensure full monitoring of vital data during the surgical procedure and to have at hand all facilities for resuscitation to deal with cardiotoxicity or neurotoxicity from local anesthetic which may occur or complications due to the procedure itself.