Considerations for Regional Anesthesia in the Trauma

PatientEdward R. Mariano, M.D., M.A.S.

Professor of Anesthesiology, Perioperative & Pain Medicine

Stanford University School of MedicineChief, Anesthesiology and Perioperative CareVeterans Affairs Palo Alto Health Care System

@EMARIANOMD

Regional Anesthesia in Trauma

Financial Disclosures Halyard, B Braun – Unrestricted

educational program funding paid to my institution

The contents of the following presentation are solely the responsibility of the speaker without input from any of the above companies.

Regional Anesthesia in Trauma

Overview Benefits of regional anesthesia Risks of regional anesthesia Review of the evidence Training in regional anesthesia The bottom line—yes or no

Regional Anesthesia in Trauma

Overview Benefits of regional anesthesia Risks of regional anesthesia Review of the evidence Training in regional anesthesia The bottom line—yes or no

Regional Anesthesia in Trauma

What is Regional Anesthesia?

Regional anesthesia generally involves the introduction of local anesthetic medications to temporarily interrupt sensation to a specific part of the body

Regional Anesthesia in Trauma

Why Do Regional Anesthesia?

Regional Anesthesia in Trauma

Gadsden & Warlick. Loc Reg Anes 2015;8:45

Regional Anesthesia in Trauma

Overview Benefits of regional anesthesia Risks of regional anesthesia Review of the evidence Training in regional anesthesia The bottom line—yes or no

Regional Anesthesia in Trauma

What Are the Risks? Local anesthetic toxicity Other risks

– Bleeding– Infection– Nerve injury

Incidence of nerve injury not clear: 1/41851 – 3/1002

1. Auroy Y, et al. Anesth 2002;97:1274

2. Brull R, et al. A&A 2007;104:965

Regional Anesthesia in Trauma

Meta-Analysis of Nerve Injury

Data from 32 studies (1/1/95 - 12/31/05) in adult patients

Rates of occurrence (any neurologic symptoms):– CNB = <4:10,000 or 0.04% – PNB = <3:100 or 3% (site-dependent)

Permanent neurological injury– CNB = 0-7.6:10,000– PNB = insufficient data (1 case)

Brull R, et al. A&A 2007;104:965

Regional Anesthesia in Trauma

Acute Compartment Syndrome

Many factors 6 classic

signs/symptoms:– Pain– Pressure– Pulselessness– Paralysis– Paresthesia – Pallor

Concern over analgesia delaying diagnosis

Olson SA, et al. J Am Acad Ortho 2005;13:436

Regional Anesthesia in Trauma

Acute Compartment Syndrome

Gadsden & Warlick. Loc Reg Anes 2015;8:45

Regional Anesthesia in Trauma

Acute Compartment Syndrome

Systematic review to evaluate effect of pain management on diagnosis

All case reports and series (Level 3 evidence; 28 reports)

No randomized clinical trials to date

Mar JG, et al. BJA 2009;102:3

Regional Anesthesia in Trauma

Beware of Falls!

Regional Anesthesia in Trauma

Overview Benefits of regional anesthesia Risks of regional anesthesia Review of the evidence Training in regional anesthesia The bottom line—yes or no

Regional Anesthesia in Trauma

Pre-Hospital Fascia Iliaca Blocks

Case series: 27 patients with presumed femur fx

Patients approached at scene of accident

Fascia iliaca blocks performed blindly with 20 ml 1.5% lido with epi 5 mcg/ml

1 block failure

“…performed by senior anesthesiologists trained in emergency medicine and regional techniques.”

Lopez S, et al. RAPM 2010;28:203

Regional Anesthesia in Trauma

Blocks in the Emergency Dept

Double-masked RCT of fascia iliaca blocks in 48 subjects with femur fx1

– 67% success rate

– Lower pain scores and morphine consumed in fascia iliaca group

Case series from ED2,3

1. Foss NB, et al. Anesth 2007;106:7732. Beaudoin FL, et al. Am J Emerg Med

2010;28:763. Stewart B, et al. Emerg Med J 2007;24:113

“All investigators were junior anesthesiologists...”

Regional Anesthesia in Trauma

Pediatric ED Experience Fascia iliaca blocks vs. IV

morphine (n=55) for femur fx1

– Lower pain scores – Less supplemental

analgesics in block group

Axillary blocks vs. sedation (n=43) for fx manipulation2

– No difference in pain scores– 2/20 failed blocks– 11/20 incomplete blocks

1. Wathen JE, et al. Ann Emerg 2007;50:162

2. Kriwanek KL, et al. J Ped Ortho 2006;26:737

Regional Anesthesia in Trauma

Overview Benefits of regional anesthesia Risks of regional anesthesia Review of the evidence Training in regional anesthesia The bottom line—yes or no

Regional Anesthesia in Trauma

How Hard Can It Be?

NYSORA.COM -

Regional Anesthesia in Trauma

The Newest Subspecialty

Regional Anesthesia in Trauma

The Newest Subspecialty

DON’T BE A

Acute Pain Medicine = not just blocks

Regional Anesthesia in Trauma

Overview Benefits of regional anesthesia Risks of regional anesthesia Review of the evidence Training in regional anesthesia The bottom line—yes (with caveats)

Regional Anesthesia in Trauma

Develop a System Discuss with trauma surgeons in

advance regarding appropriate patients and types of blocks

Who will be performing blocks?– Dedicated regional anesthesia providers

vs.– All practitioners equally trained

Use consistent practices and equipment

Communication is key!

Regional Anesthesia in Trauma

Perform Blocks in a Safe Place

Standard ASA monitors available

Oxygen source Resuscitation

equipment available

Skilled assistants nearby

Mariano ER. Anesth Clin 2008;28:681

Regional Anesthesia in Trauma

Education and Follow-Up Coordinate postop care with primary

team Careful neurovascular assessment

(be on the look-out for compartment syndrome)

Provide contact info for regional anesthesia service available 24/7

Clear instructions for infusion device Routine daily follow-up (esp if

catheter)–Caretaker for first 24 hours if

discharged

Ilfeld BM, et al. RAPM 2003;28:418

Regional Anesthesia in Trauma

Take Home Message

Gadsden & Warlick. Loc Reg Anes 2015;8:45

Regional Anesthesia in Trauma

Summary We discussed:

– Benefits of regional anesthesia– Risks of regional anesthesia– Review of the evidence– Training in regional anesthesia– The bottom line—yes (with caveats)