4/16/2014 1 Regional Blocks Every Anesthesiologist Should Know 2014 Winter Anesthesia Seminar How to maximize efficacy and minimize failure Amanda Monahan, MD Assistant Professor Division of Regional Anesthesia UCSD Department of Anesthesiology Dr. Monahan has no relevant financial relationship with any commercial interest. Disclosures • Identify basic regional blocks and indications • Recognize techniques to optimize block Learning objectives efficacy • Review techniques to minimize complications or laterality errors
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Regional Blocks Every Anesthesiologist Should Know
2014 Winter Anesthesia Seminar
gHow to maximize efficacy and minimize failure
Amanda Monahan, MDAssistant Professor
Division of Regional AnesthesiaUCSD Department of Anesthesiology
Dr. Monahan has no relevant financial relationship with any commercial interest.
Disclosures
• Identify basic regional blocks and indications
• Recognize techniques to optimize block
Learning objectives
efficacy
• Review techniques to minimize complications or laterality errors
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• Femoral/Adductor
• Sciatic
• Interscalene
The blocks
• Infraclavicular
• 61 YOF 81kg with PMH severe COPD on 4L O2, Chiari malformation, DM, HTN, obesity, chronic pain and restless leg syndrome presents with a pulseless open ankle fracture for urgent I&D
(Block) failure is not an option:
– ABG: abysmal.– H/O prolonged intubation for COPD– Anxious, unable to lie flat, pursed lip breathing– “My doctor told me that I should never have
anesthesia.”– “I just need to move my legs all the time.”
(Block) failure is not an option:
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• Goals for the regional block– Intraop anesthesia vs. postop analgesia
– Desired onset time
Success for any block
– Desired duration time (single vs. catheter)
– Nerve distributions to be anesthetized
– Ambulatory vs. inpatient and motor block
• Patient selection: mental status, language
• Expectation management– Surgical anesthesia vs. postop analgesia
Prasugrel (Effient)FDA approval 2009.Oral platelet aggregation inhibitor for prevention and treatment of thrombotic events in patients with coronary stents.Elimination Half‐life: 7 hours. Onset: 1 hour. 3A4 t b li3A4 metabolism
Ticagrelor (Brilinta)FDA approval 2011.Oral platelet aggregation inhibitor indicated for prevention and treatment of thrombotic events in patients with Acute Coronary Syndrome or myocardial infarction with ST elevation.Elimination Half‐life: 7 hours. Onset: 1.5 hours. 3A4 metabolism
Case Reports of Neuraxial Hematoma with SSRIs, ASA, and Spinal Cord Stimulation
Jan/Feb 2014 Regional Anesthesia & Pain Medicine
73 yo woman with postlaminectomy pain syndrome and lumbar radiculopathy underwent SCS leadand lumbar radiculopathy underwent SCS lead placement on ASA 81mg/day for several years.
Conclusion: The only variable that could have led to our patient’s epidural hematoma is aspirin.
Stratifying Risks By Procedure.
All that we don’t know…
Dx SingleDx SingleDx SingleDx Single Tx SingleTx SingleTx SingleTx Single Indwelling CatheterIndwelling CatheterIndwelling CatheterIndwelling Catheter Implantable DevicesImplantable DevicesImplantable DevicesImplantable Devices
Vandermeulen. A retrospective analysis of case reports from MEDLINE 1906‐1994. 46 cases of consequential epidural hematoma. 68% had impaired coagulation.
1993
1994
LMWH (MedWatch System) 40 cases of neuraxial hematoma, 1/3000.Disparities compared to Europe attributed to dosing, timing, and preference for CSC in Europe.
ASRA states that they are against BID dosing of LMWH
Rates of neuraxial hematoma declined by the time of the 2nd ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation
1993 ‐ 1998
1998
2003
Horlocker T, A&A, 2013
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Moen. Anesthesiology. Retrospective analysis from 1990‐1999 in Sweden.Rate = 1/18,000 for continuous epidural analgesia.
Pöpping BJA Retrospective analysis from 1998 2006
History
2004
2008Pöpping. BJA. Retrospective analysis from 1998‐2006.Rate = 1/4741. 1/1000 for elderly women undergoing LE surgery
Bateman. A&A. Multicenter Perioperative Outcomes Group (MPOG). Consortium of academic anesthesia departments that pools period data.Eleven institutions involving obstetric and periop anesthesia. Rate = 7/62,450 in periop epidural placement. 0/79,837 in obstetric4 of the 7 detracted from ASRA Guidelines.
Peripheral Regional Anesthesia & AntithromboticsA standardized set of recommendations for all peripheral regional anesthetics cannot be made at this time.
No regional anesthesia. No regional anesthesia. No regional anesthesia. No regional anesthesia.
No antithrombotics. No antithrombotics. No antithrombotics. No antithrombotics.
Institute of Medicine 2011 ReportInstitute of Medicine 2011 ReportInstitute of Medicine 2011 ReportInstitute of Medicine 2011 Report
Understanding the risks and benefits.Understanding the risks and benefits.Communicating the risks and benefits.Communicating the risks and benefits.Making an informed AND shared decision with your patientMaking an informed AND shared decision with your patient
Understanding the risks and benefits.Understanding the risks and benefits.Communicating the risks and benefits.Communicating the risks and benefits.Making an informed AND shared decision with your patientMaking an informed AND shared decision with your patient
Chronic Pain affects 100 million AmericansChronic Pain affects 100 million Americans2525--40% have chronic pain from surgery or trauma40% have chronic pain from surgery or trauma
Medical Costs and Lost ProductivityMedical Costs and Lost ProductivityPain: Pain: $635,000,000,000 $635,000,000,000 Heart Disease: Heart Disease: $309,000,000,000$309,000,000,000Cancer: Cancer: $243,000,000,000$243,000,000,000Diabetes: Diabetes: $188,000,000,000$188,000,000,000
Chronic Pain affects 100 million AmericansChronic Pain affects 100 million Americans2525--40% have chronic pain from surgery or trauma40% have chronic pain from surgery or trauma
Medical Costs and Lost ProductivityMedical Costs and Lost ProductivityPain: Pain: $635,000,000,000 $635,000,000,000 Heart Disease: Heart Disease: $309,000,000,000$309,000,000,000Cancer: Cancer: $243,000,000,000$243,000,000,000Diabetes: Diabetes: $188,000,000,000$188,000,000,000
Gaskin et al. Appendix C.
Economic Costs of Pain
IASP
Legal Ramifications?
1) Communication1) Communication2) Communication3) Communication
Increased demand for antithrombotic prophylaxis and therapy.
The incidence of neuraxial hematoma is higher than previously considered…p yAwareness, statistical methodology, or trend?
New drugs continue to be developed… Without safe reversibility.
The importance of Regional Anesthesia and Interventional Pain Medicine
Requires education and systems-based safety measures.
Standards provide rules or minimum requirements for clinical practice. They are regarded as generally accepted principles of patient management. Standards may be modified only under unusual circumstances, e.g., extreme emergencies or unavailability of equipment.
Guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies.
ASA Standards, Guidelines, and Statements
In addition, practice guidelines are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert opinion, open forum commentary, and clinical feasibility data.
Statements represent the opinions, beliefs, and best medical judgments of the House of Delegates. As such, they are not necessarily subjected to the same level of formal scientific review as ASA Standards or Guidelines. Each ASA member, institution or practice should decide individually whether to implement some, none, or all of the principles in ASA statements based on the sound medical judgment of anesthesiologists participating in that institution or practice.
References• Cove CL, Hylek EM. An Updated Review of Target‐Specific Oral Anticoagulants Used in Stroke Prevention in Atrial Fibrillation, Venous Thromboemb olic Disease, and
Acute Coronary Syndromes. J of Am Heart Assoc. 2013 Oct 23;2(5):e000136.
• Horlocker TT et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy. American Society of Regional Anesthesia and Pain Medicine Evidence‐Based Guidelines (third edition). Reg Anesth Pain Med 2010; 35:64‐101.
• Gogarten W et al. Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology. Eur J of Anaesthesiol 2010; 27:999‐1015 ESRA
• Breivik H et al. Nordic guidelines for neuraxial blocks in disturbed haemostasis from the Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiol Scand 2010; 54: 16‐41.
• Bateman BT et al. The Risk and Outcomes of Epidural Hematomas After Perioperative and Obstetric Epidural Catheterization: A Report from the Multicenter Perioperative Outcomes Group Research Consortium. Anesthesia & Analgesia. June 2013; 116 (6): 1380‐1385. MPOG
• Horlocker T, Kopp S. Epidural hematoma after epidural blockade in the United States: it's not just low molecular heparin following orthopedic surgery anymore. Anesth Analg. 2013 Jun; 116(6):1195‐7.
• Horlocker TT, Wedel DJ: Spinal and epidural blockade and perioperative low molecular weight heparin: Smooth sailing on the Titanic. Anesth Analg 1998; 86:1153–6
• Vandermeulen EP, Van Aken H, Vermylen J: Anticoagulants and spinal‐epidural anesthesia. Anesth Analg 1994; 79:1165–77
• Douketis JD, Berger PB, Dunn AS, Jaffer AK, Spyropoulos AC, Becker RC, Ansell J, The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence‐Based Clinical Practice Guidelines (8th Edition). American College of Chest Physicians. Chest. 2008 Jun; 133(6 Suppl):299S‐339S.
• Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ, Svensson PJ, Veenstra DL, Crowther M, Guyatt GH; Evidence‐based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence‐Based Clinical Practice Guidelines.Chest. 2012 Feb;141(2 Suppl):e152S‐84S. doi: 10.1378/chest.11‐2295.
• Moen V, Dahlgren N, Irestedt L: Severe neurological complications after central neuraxial blockades in Sweden 1990–1999. Anesthesiology 2004; 101:950–9
• Heller AR, Litz RJ. Why do orthopedic patients have a higher incidence of serious complications after central neuraxial blockade? Anesthesiology. 2005 Jun; 102(6):1286; author reply 1287‐8.
• Pöpping DM, Zahn PK, Van Aken HK, Dasch B, Boche R, Pogatzki‐Zahn EM. Effectiveness and safety of postoperative pain management: a survey of 18 925 consecutive patients between 1998 and 2006 (2nd revision): a database analysis of prospectively raised data. Br J Anaesth. 2008 Dec;101(6):832‐40
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CSA Fall Anesthesia SeminarOctober 27- 31, 2014 | Kohala Coast, HI
Fairmont Orchid Hawaii
Upcoming Events
CSA Winter Anesthesia SeminarJanuary 12-16, 2015 | Wailea Maui, Hawaii
Fairmont Kea Lani
Visit www.csahq.org/CMEevents for more information.
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JeanJean--Louis Horn, MDLouis Horn, MDProfessor, ChiefProfessor, ChiefDivision of Regional AnesthesiaDivision of Regional AnesthesiaDepartment of Anesthesiology, PeriDepartment of Anesthesiology, Peri--Operative and Pain MedicineOperative and Pain MedicineStanford University Medical CenterStanford University Medical Center
Continuous Regional Anesthesia: How to Make it Continuous Regional Anesthesia: How to Make it Work?Work?
Disclosure
• Consultant for I-Flow• Consultant for Arrow
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Overview
Rationale and benefits of regional anesthesia
Effective regional anesthesia program
Data on the home pump program
The future
Conclusions
Overview
Rationale and benefits of regional anesthesia
Effective regional anesthesia program
Data on the home pump program
The future
Conclusions
Continuous PNB: an Old Story
Dr. Ambros, 1946
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Postoperative Pain:Myth or Reality ?
Survey of Postoperative Analgesia Following AmbulatorySurgery (n=1035, 94.1% returned questionnaire)
Inguinal Hernia 62% Inguinal Hernia 62%
Ortho 41%
Severity of pain did NOT decrease over 48 hours
20% difficulty sleeping due to severe pain, 20% N, 20% tiredness, 8%
95% were satisfied with care
Rawal et al. Acta Anaesth Scan, 1997
Systemic Review and Analysis of Post-Discharge Symptoms afterOutpatient Surgery
45% pain (25-35% moderate to severe – 16% severe after ortho)
42% drowsiness
21% fatigue
Wu et al. Anesthesiology 96(4):994-1003, 2002
21% fatigue
17% N
8% V
Pain
Deleterious consequences of poor pain control on pain and recovery
CRPS prevalence following wrist fracture: 8-22%
Poorly controlled acute pain favors the development of chronic pain condition
Pain is major predictor for poor recovery and increasing medical cost $
Lancet. 1999;354(9195):2025-8.
Anesthesiology, 2004;101:1215-25
JBJS, 2007;1343-58
Anesth & Analg, 2007;105:228-32
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From Acute Pain to Chronic Pain
• 56% of surgical patients will develop chronic postsurgical pain
• Some studies indicate percentage may be much higher
• Complex process involving multiple factors,, social-environmental, and patient-related factors
D i f l hi h l i l i• Duration of surgery, low-versus high-volume surgical unit
• Psychological and social
• Younger age, female sex, increased pain and incidence
Katz J. ASRA News. February, 2009.
Regional Anesthesia and Reduction of Chronic painContinuous PNB reduces the prevalence of chronic pain after breast cancer surgery
• 1 month: Intensity of motion-related pain lower in CPNB group (P = 0.005) vs. control group
• 6 month: Prevalence of any pain symptoms lower in• 6 month: Prevalence of any pain symptoms lower in CPNB group (P = 0.029) vs. control group
• 12 month: Prevalence of pain symptoms (P = 0.003), intensity of motion-related pain (P =0.003), and intensity of pain at rest (P = 0.011) all lower in CPNB group vs. control group
Kairaluoma PM, et al. Anesth Analg. 2006;103:703-708.
RA vs. GA in Ambulatory Surgery: Meta-Analysis
Increased induction time (19.6 min vs 8.8, p<0.001)
bypass of Phase 1 recovery (81% vs 31.5% p<0.001)
Decreased PACU time (9.6 min vs 35.8 min p<0.001)
Decreased PACU pain VAS 9.6 mm vs 35.8 mm, and long term pain
Evans H, et al. Anesth Clin North Am 2005;23(1):141-62
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Meta-analysis: CPNB vs. Opioids
Mean VASMean VAS24h24h 48h48h
InfraclavInfraclav 1 0 vs 4 31 0 vs 4 3 p<0 001p<0 001 0 6 vs 4 00 6 vs 4 0 p<0 001p<0 001InfraclavInfraclav 1.0 vs. 4.31.0 vs. 4.3 p<0.001p<0.001 0.6 vs. 4.00.6 vs. 4.0 p<0.001p<0.001
InterscalInterscal 1.4 vs. 3.61.4 vs. 3.6 p<0.001p<0.001 0.5 vs. 2.30.5 vs. 2.3 p<0.001p<0.001
Fem/LPFem/LP 2.1 vs. 4.02.1 vs. 4.0 p<0.001p<0.001 1.6 vs. 3.21.6 vs. 3.2 p<0.001p<0.001
SciaticSciatic 0.9 vs. 4.60.9 vs. 4.6 p<0.001p<0.001 0.9 vs. 3.50.9 vs. 3.5 p<0.001p<0.001
Richman JM, et al. A&A 2006;102:248Richman JM, et al. A&A 2006;102:248
N/V, sedation, pruritus and opioid usage significantly decrease at all time point and for all block areas
Pain, Opioid Usage, Side Effects and Satisfaction Meta-analysis CPNB vs. single-injection block: 21 studies (702
subjects) included
MetaMeta--analysis: CPNB vs. Single Shotanalysis: CPNB vs. Single Shot
Bingham AE, et al. RAPM 2012;37:583Bingham AE, et al. RAPM 2012;37:583
Benefits of CPNB for Outpatients
RCT: 32 patients scheduled for outpatient shoulder surgery with an US-guided interscalene nerve block
All subjects received a nerve block catheter and one-time ropivacaine bolus
After surgery, subjects discharged home with portable infusion device
Half received ropivacaine infusion for 2 days
Half received saline infusion for 2 days
Mariano ER, et al. A&A 2009;108:1688Mariano ER, et al. A&A 2009;108:1688
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Results
Mariano ER, et al. A&A 2009;108:1688Mariano ER, et al. A&A 2009;108:1688
Results
Subjects who received ropivacaine suffered fewer sleep disturbances and consumed less oral opioid medication
Subjects who received ropivacaine reported higher satisfaction with recovery
Mariano ER, et al. A&A 2009;108:1688Mariano ER, et al. A&A 2009;108:1688
Improving Range of Motion
25 patients s/p total shoulder arthroplasty with continuous interscalene block (CISB) compared to matched controls (PCA) (Retrospective study)
Primary outcome: ability to achieve surgeon-defined physical therapy goals
Secondary outcome: pain scores
IlfeldIlfeld BM, et al. RAPM 2005; 30:429BM, et al. RAPM 2005; 30:429--3333
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Improving Range of Motion
0
90
150
0 10 30
Elevation: 85%(CISB) vs. 33%(PCA), p=.048Elevation: 85%(CISB) vs. 33%(PCA), p=.048
Ext Rotation: 100%(CISB) vs. 17%(PCA), p<.001Ext Rotation: 100%(CISB) vs. 17%(PCA), p<.001
Worst Pain score: 2.0 (0.0Worst Pain score: 2.0 (0.0--8.7) vs. 8.5 (1.88.7) vs. 8.5 (1.8--10.0), p<.00110.0), p<.001IlfeldIlfeld BM, et al. RAPM 2005; 30:429BM, et al. RAPM 2005; 30:429--3333
45 -30
US vs. NS for CPNB
4 IRB-approved randomized clinical trialsRandomized(n=160, not blinded)
Nerve StimulationStimulating Catheter
UltrasoundNonstimulating Catheter
Primary outcome: catheter placement time (min)Primary outcome: catheter placement time (min)
Secondary outcomes: pain during placement, Secondary outcomes: pain during placement, venous puncture and leakage rates, pain on POD 1venous puncture and leakage rates, pain on POD 1
Mariano ER, et al. JUM 2009;28:1453Mariano ER, et al. JUM 2009;28:1453Mariano ER, et al. JUM 2010;29:329Mariano ER, et al. JUM 2010;29:329
Mariano ER, et al. RAPM 2009;34:480Mariano ER, et al. RAPM 2009;34:480Mariano ER, et al. JUM 2009;28:1211Mariano ER, et al. JUM 2009;28:1211
ResultsPopliteal
Mariano ER, et al. RAPM 2009;34:480Mariano ER, et al. RAPM 2009;34:480Mariano ER, et al. JUM 2009;28:1211Mariano ER, et al. JUM 2009;28:1211Mariano ER, et al. JUM 2009;28:1453Mariano ER, et al. JUM 2009;28:1453Mariano ER, et al. JUM 2010;29:329Mariano ER, et al. JUM 2010;29:329
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Results
US: less inadvertent vascular punctures
Femoral, infraclavicular
US: higher success rate US: higher success rate
Infraclavicular
Mariano ER, et al. RAPM 2009;34:480Mariano ER, et al. RAPM 2009;34:480Mariano ER, et al. JUM 2009;28:1211Mariano ER, et al. JUM 2009;28:1211Mariano ER, et al. JUM 2009;28:1453Mariano ER, et al. JUM 2009;28:1453Mariano ER, et al. JUM 2010;29:329Mariano ER, et al. JUM 2010;29:329
Anesthesia-Controlled Time and Turnover Timeper anesthesia technique (minutes)
30
35
40
45
ACL reconstruction, n=369
RA block room, vs. GA in OR
Turnover times: no differences across techniques
0
5
10
15
20
25
GA GA/RA RA
ACTTOTTotal
RA: lowest ACT and total time (ACT + TOT) 9-minute OR time savings
Improve rehabilitation after major joints replacement (TKA)• Singelyn: Better pain relief and faster knee rehabilitation
with CPNB than IV PCA with morphine
• Capdevila: RA techniques improve early rehabilitation andCapdevila: RA techniques improve early rehabilitation and effectively pain control after major knee surgery
• Chelly: CPNBs reduced postop morphine requirement, postoperative bleeding and provided better recovery than IV PCA with morphine or an epidural
Singelyn FJ, et al. Anesth Analg. 1998;87:88-92.Capdevila X, et al. Anesthesiology. 1999;91(1):8-15.Chelly JE, et al. J Arthroplasty. 2001;16(4):436-445.
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Continuous Peripheral Nerve Blocks: Decreased Time to Discharge
• Ambulatory 4-day CPNB associated with decreased time to discharge after TKA
• Primary end points: 3 important discharge criteria
• Adequate analgesiaAdequate analgesia
• Independence from IV analgesia
• Ambulation ≥30 m
Ilfeld BM, et al. Anesthesiology. 2008;108:703-713.
Time (hours)
Data presented are Kaplan-Meier estimates of the cumulative percentages of patients meeting all 3 discharge criteria at each time point and subsequent time points. Reprinted from Ilfeld BM, et al. Anesthesiology. 2008;108:703-713.
Median time to discharge: 25 h for CPNB group vs. 71 h for control group
Cost Savings With Ambulatory Regional Anesthesia
• Ilfeld et al (2007)
• Retrospective, case-control study of TKA patients
•10 received ambulatory continuous femoral nerve block (CFNB)
•10 received inpatient CFNB only (control group)
M di t f h it li ti• Median costs of hospitalization
•$5292 ambulatory CFNB group
•$7974 inpatient control group
•34% decrease with ambulatory CFNB, P <0.001
• Total charges
•$33,646 ambulatory CFNB group
•$39,100 control group
•14% decrease with CFNB, P <0.001
Ilfeld BM, et al. Reg Anesth Pain Med. 2007;32:46-54.
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• Retrospective study from HSS• N=400,000 primary total joint arthroplasty• Neuraxial patients were OLDER than GA patients
Perioperative Comparative Effictiveness of Anesthetic in Orthopedic Patients
When neuraxial anesthesia was used:• Less 30-day mortality (P < 0.001)• Lower incidence of prolonged (>75th percentile) length of stay• Lower cost variability; fewer in-hospital complications• Most favorable complication risk profile
Doesn’t detail nerve blocks at all.
Memtsoudis S et al. Anesthesiology 2013; 118(5):1046-1058
Neuraxial and Avoided GA ComplicationsAnesthesiology 2013; 118(5):1046-1058
Memtsoudis S et al. Anesthesiology 2013; 118(5):1046-1058
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Review 190,000 TKA.1.6% had in-hospital fall
• Risks:
Risks of Fall and RAClinical Science Best Abstract 11 ASA 2013
• Risks:• Advanced age• Male sex• Increased co-morbidity• Use of GA without neuraxial
• Non-factors• Neuraxial with/without GA• Peripheral nerve block use
RA and Sympathectomy
Even at very low concentrations, local anesthetics effectively block sympathetic nerves
Improving microcirculation
increase skin temperature of crushed fingers after replantation
Major flap surgery?
Decrease wound infection (TKA)
Cancer Outcome and RA
Can anesthetic technique for primary breast cancer surgery affect recurrence or metastasis? 94% vs. 84% and 77% at 24 and 36 months
Exadaktylos AK et al Anesthesiology 2006 October ;Exadaktylos AK, et al .Anesthesiology. 2006 October ; 105(4): 660–664
Similar data for thyroid, ovarian and prostate cancer
Is it opioid sparing effect, GA, anesthetic gas, stress and pain relate effect, immunomodulation, decrease long term pain ???
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Overview
Rationale and benefits of regional anesthesia
Effective regional anesthesia program
Data on the home pump program
The future
Conclusions
Make a RA Program Work
RA - Organization & Set Up
Surgeons collaboration
Patient evaluation/selection/education
Logistics
Patient flow from scheduling to follow-up
Many parties involved:The real challenge is organization
Anesthesia tech/nursing support
Block cart/area (resuscitation equipment)
Pharmacy involvement for meds and pumps
Hospital support: for all of the above and liability
Education program for patients, nursing, surgeons, and colleagues
Separate team for block placement and follow-up
-B.D. O’Donnell and G. Iohom. Current Opinion in Anesth 2008,21:723–728-G.S. Cheng, et al. Current Opinion in Anesth 2008, 21:488–493
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Surgeon Involvement
First to identify patients and to make the primary decision aboutRA, and to inform the patient
Collaborate on follow-up, supplemental analgesics (prescribed by the surgeons at our institution) and rehab (immobilizer…)
Need to be educated about: our delivery system skills and Need to be educated about: our delivery system, skills and organization
Collaborate on pathway and update practice according to new publications
= communication and collaboration
The Orthopedic Perspective( Adam Mirarchi, MD)
Orthopedic questions:#1 I thi i t ff t t ?#1 Is this going to affect turn over?#2 Does this $%#@ work? #3 What’s in it for me?#4 For what cases is it indicated?#5 I’m not sure…
RA vs. GA in Ambulatory Surgery: Meta-Analysis
Increased induction time (19.6 min vs 8.8, p<0.001)
bypass of Phase 1 recovery (81% vs 31.5% p<0.001)
Decreased PACU time (9.6 min vs 35.8 min p<0.001)
Decreased PACU pain VAS 9.6 mm vs 35.8 mm, and long term pain
Pain (Remind about supplemental medications and expectations)
More Serious Problems
Block Failure: 0% to 25% either primary
or secondary catheter failureor secondary catheter failure
Hematoma/Bruising common.
Rarely significant, even in anticoagulated patients
Infections: rare and usually resolve with a course of antibiotic
Now the serious things
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Serious: Nerve Injury
Rare event, incidence determined with observational population studies
Incidence of transient neuropraxia following surgery may be as high as 10%. Short lived, localized numbness, paresthesia or weaknessparesthesia or weakness
Incidence of severe and prolonged nerve injury may be as high as 4 per 10,000 to as low as 1:100,000.
Several studies from the Mayo Clinic show that adding a PNB for major joint replacement does not increase the incidence of nerve injury but may increase the severity
Importance of early diagnosis and aggressive treatment, especially for inflammatory neuropathy
Mechanisms of Nerve Damage
Multifactorial and likely require more than 1 insult
Pain Score Reported in 401 Patients Contacted over an 8 Month Period
Average Pain Score at rest: 2.8/10
Average Pain Score 5.86
7
el
Pain Score
At Rest With Movement
with movement: 4.6/10
Subjective assessment of overall pain relief: Good
3 3
3.5
2.4
3
2
3.7
2.8
4
4.5 4.64.2
4.65
4.6
0
1
2
3
4
5
Ave
rag
e P
ain
Lev
e
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Side Effects in 401 Patients Contacted Over an 8 Month Period
10.7 % average
25%
21%20%ec
ts
Side Effects
0%
5%
10%
15%
20%
7%
0%
14%
9%
20%
11%10%
% o
f P
ts W
/Sid
e E
ffe
Patients
Specific Side Effects
N/V and sleepiness are low compare to historical valueMany of the side effects are not present for inpatients
Unplanned Return to HospitalDue to Complication With the Block
Reasons for Unplanned Return
May June July Aug Sept Oct Nov Dec 33.5
etu
rns
Unplanned ReturnsPatients
Pump not working
2 0 0 0 0 0 0 0
Pump accidently disconnected/ catheter pulled out
1 1 1 0 0 0 0 0
Redness at catheter site
0 0 0 0 1 0 0 0
Wound closure and hematoma evacuation
0 1 0 0 0 0 0 0
2
1
0
1
0 0 0
0
0.5
1
1.5
2
2.5
3
Nu
mb
er o
f U
np
lan
ned
Re
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Satisfaction with Pain Control
High satisfaction with pain control
Overall postoperative pain control:• 291 out of the 353 patients (82%) were satisfied • 18% of patients did not feel that their pain was well managed.
.
Patient Satisfaction
89% of patients were either satisfied or very satisfied.
6% of patients answered negatively because of side effect or pain.
Would choose the block again?
Patients were asked “If you were to have a similar surgery would you choose to receive a nerve block again?”
• 87% of patients would have a nerve block placed again.
• 13% of patients would not have a block placed again.
•Is that good enough?
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Overview
Rationale and benefits of regional anesthesia
Selling it to our Surgeons and Administrator
Effective regional anesthesia program
Data on the home pump program
The future
Conclusions
Future #1
Additives, i.e. epinephrine, clonidine, dexamethasone, buprenorphine, to LA may increase the duration up to 40 hrs,
BUT neurotoxicity???? Need better ones
Encapsulated/liposomial bupivacaine???
New drug or drug regimen/delivery system
Future #2
New injectates: encapsulate bupivacaine, botulin toxin…
New multimodal approaches: Vit C, CBT, neuromodulation
Dynamic block managementDynamic block management
Outpatient TJR
Track your data
Collaborative research on outcome
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Overview
Rationale and benefits of regional anesthesia
Selling it to our Surgeons and Administrator
Effective regional anesthesia program
Data on the home pump program
The future
Conclusions
Conclusions
• The RA program can improve recovery profile,
decrease LOS, unplanned admission and cost,
and improve and patient satisfaction
• Keys for success reside in the organization: collaboration of all teams involved, clear plan including multimodal analgesia, define pathway, careful patient selection and education (especially expectation), and follow-up
• Serious complication are rare, but minor issues are frequent and can be minimized with proper buy in from all parties
A well planed organization will keep your patients safe and avoid
serious problems
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Thank You
CSA Fall Anesthesia SeminarOctober 27- 31, 2014 | Kohala Coast, HI
Fairmont Orchid Hawaii
Upcoming Events
CSA Winter Anesthesia SeminarJanuary 12-16, 2015 | Wailea Maui, Hawaii
Fairmont Kea Lani
Visit www.csahq.org/CMEevents for more information.