Superselective Scalp Block (SSB) and opiod sparing as an integral part of Enhanced Recovery After Neurosurgery (ERANS)

Abstract

Objectives:A key component of ERAS for different surgical patients relies upon techniques to minimise opioid use after surgery, because of several undesired effects associated with opioids. This is often achieved with coaxial analgesia or regional nerve blocks, which allow for early ambulation of ERAS patients. Recent studies demonstrated that patients undergoing craniotomies experience more postoperative pain than previously anticipated. Also, sedative effects of opioids are undesirable for monitoring of neurological functions after surgery. We hypothesised that using superselective scalp block (SSB) for patients undergoing craniotomies would provide better pain control and result in more awake patients. We evaluated the effectiveness and duration of SSB in patients undergoing awake craniotomies lasting more than 10 hours. Awake patients provide direct feedback about incisional pain during surgery, thus allowing us to monitor the duration of the SSB and to assess effects in the immediate postoperative period. Methods: After obtaining IRB approval, we reviewed the medical records of patients who had undergone awake craniotomies lasting more than 10 hours, using SSB with 0.5% ropivacaine. The duration of the block was measured from the time of injection until the patient began to feel pain at the scalp site. The effectiveness of the block was evaluated by assessing the patient's comfort and pain during surgery, performed under awake conditions with a goal of having zero pain. After the surgery the pain was assessed using a visual analog scale, in the 24-hour postoperative period, and measuring the use of pain medication after surgery. Results: There were 37 patients in our study. In all patients, the SSB provided complete scalp analgesia during the entire procedure. The analgesic effects extended into the postoperative period, as measured by low pain scores and low usage of pain medications in the first 24 hours after surgery. Conclusion: The SSB offers extended analgesia and warrants further investigation because of its potential to provide better postoperative pain control. Its opioid sparing effects makes it an attractive technique as part of ERAS in neurosurgery and warrants further investigation.Objectives: In 2013 there was an urgency to develop an Enhanced Recovery Programme at London Bridge Hospital. Requests from our consultants, Department of Health reports, pressure from private insurers and our own drive for world-class care were the catalysts to drive ERAS. Methods: Benchmarking ourselves against the NHS, we developed a core multi-disciplinary team (MDT), which included consultant surgeons, nursing, dietetics, physiotherapy and pharmacy. Our MDT Lead met with colorectal surgeons to confirm engagement with the process . We engaged with an ERAS Society expert, a professor of colorectal surgery from St.Mark's Hospital and signed up to the ERAS Implementation Programme. Our MDT undertook the implementation programme; conducting a baseline audit using the ERAS society database. We developed a data collecti...