RCOA nov '14 mccartney
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Transcript of RCOA nov '14 mccartney
Regional Anaesthesia Regional Anaesthesia Papers that are Changing My Papers that are Changing My
PracticePractice
Colin J.L. McCartney Colin J.L. McCartney MBChB PhD FCARCSI FRCA FRCPCMBChB PhD FCARCSI FRCA FRCPCProfessor and Chair of AnesthesiologyProfessor and Chair of Anesthesiology
University of Ottawa, ON, CanadaUniversity of Ottawa, ON, Canada@colinjmccartney@colinjmccartney
Conflicts of InterestConflicts of Interest
No education supportNo education support No industry research supportNo industry research support No honorariaNo honoraria No shares in related companiesNo shares in related companies
Overview:Overview:
Big Data: how do we use it?Big Data: how do we use it? US and impact on quality and safety: US and impact on quality and safety:
where are we now?where are we now? Best techniques for pain control after Best techniques for pain control after
TKA?TKA? Liposomal bupivacaine: place in TKALiposomal bupivacaine: place in TKA Adductor Canal Block: Better than FNB?Adductor Canal Block: Better than FNB? Teaching USGRATeaching USGRA
What is the optimal method of What is the optimal method of anesthesia for TKA?anesthesia for TKA?
BMJ 2000
Rodgers A et al BMJ 2000
Why so few patients having Why so few patients having neuraxial block?neuraxial block?
Reduced postoperative pain, opioid Reduced postoperative pain, opioid consumption, adverse effectsconsumption, adverse effects
No difference in blood loss or TE eventsNo difference in blood loss or TE events No difference in mortalityNo difference in mortality
382,000 patients382,000 patients 25% neuraxial25% neuraxial Neuraxial associated with less mortality, Neuraxial associated with less mortality,
length of stay, in-patient morbiditylength of stay, in-patient morbidity
Anesthesiology 2013
Evidence building that neuraxial block is Evidence building that neuraxial block is superior to GA for TKAsuperior to GA for TKA
Improved morbidity and mortalityImproved morbidity and mortality Evidence from RCTs, systematic review Evidence from RCTs, systematic review
and large database studiesand large database studies ? Further large pragmatic studies needed? Further large pragmatic studies needed
Neuman MD and Brummett C Anesthesiology 2013
Overview:Overview:
Big Data: how do we use it?Big Data: how do we use it? US and impact on quality and safety: US and impact on quality and safety:
where are we now?where are we now? Best techniques for pain control after Best techniques for pain control after
TKA?TKA? Liposomal bupivacaine: place in TKALiposomal bupivacaine: place in TKA Adductor Canal Block: Better than FNB?Adductor Canal Block: Better than FNB? Teaching USGRATeaching USGRA
Impact of US on quality and safety?Impact of US on quality and safety?
A&A 2007
McCartney and Choi 2014
SafetySafety
Prospective multicentre clinical registryProspective multicentre clinical registry Quality and safety of PNBsQuality and safety of PNBs 20,000 patients, 20 hospitals over 5 years20,000 patients, 20 hospitals over 5 years 22 episodes LAST: 0.87/1000 PNBs22 episodes LAST: 0.87/1000 PNBs US associated with reduced incidence LASTUS associated with reduced incidence LAST
Barrington MJ et al RAPM 2013
Barrington MJ et al RAPM 2013
Orebaugh SL et al RAPM 2012
Overview:Overview:
Big Data: how do we use it?Big Data: how do we use it? US and impact on quality and safety: US and impact on quality and safety:
where are we now?where are we now? Best techniques for pain control after Best techniques for pain control after
TKA?TKA? Liposomal bupivacaine: place in TKALiposomal bupivacaine: place in TKA Adductor Canal Block: Better than FNB?Adductor Canal Block: Better than FNB? Teaching USGRATeaching USGRA
Optimizing Pain and Function Optimizing Pain and Function after TKAafter TKA
Is Total Knee Replacement Painful?Is Total Knee Replacement Painful?
✓Poulakka P et al EJA 2010
Best technique?Best technique?
LIA vs FNB vs ACB: GA vs Neuraxial
RCT 120 patientsRCT 120 patients IT bupivacaine or TIVA for TKAIT bupivacaine or TIVA for TKA All patients had multimodal analgesiaAll patients had multimodal analgesia All patients had LIAAll patients had LIA No other RA techniques usedNo other RA techniques used No IT or other opioid in IT group No IT or other opioid in IT group
GA shorter LOS and less PONV (46 vs GA shorter LOS and less PONV (46 vs 52h; p<0.001)52h; p<0.001)
Pain significantly greater in spinal group Pain significantly greater in spinal group after 6h (p<0.001)after 6h (p<0.001)
Patients in GA group used less PCA Patients in GA group used less PCA morphine (12 vs 30 doses; p<0.001)morphine (12 vs 30 doses; p<0.001)
Harsten et al BJA 2013
Liposomal Bupivacaine in TKALiposomal Bupivacaine in TKA
Early experience with liposomal Early experience with liposomal bupivacaine: no increased duration of bupivacaine: no increased duration of analgesia compared to plain bupivacaine analgesia compared to plain bupivacaine alonealone
Three negative studies to dateThree negative studies to date Several more studies to comeSeveral more studies to come
Adductor Canal BlockAdductor Canal Block Block of saphenous Block of saphenous
nerve in adductor nerve in adductor canalcanal
Usually single Usually single injection techniqueinjection technique
Less motor block Less motor block than femoral nerve than femoral nerve blockblock
? Facilitates ? Facilitates ambulation with less ambulation with less painpain
Retrospective review of patients having Retrospective review of patients having ACB or cFNB for TKAACB or cFNB for TKA
Primary outcome: distance walked POD1Primary outcome: distance walked POD1 Secondary outcomes: walking POD2,3. Secondary outcomes: walking POD2,3.
Pain, Opioid dose and AEsPain, Opioid dose and AEs
RAPM 2013
Perlas A et al RAPM 2013
RCT 50 patients TKARCT 50 patients TKA Spinal anaesthesia. LIA. MultimodalSpinal anaesthesia. LIA. Multimodal ACB or FNB 30ml 0.2% ropivacaine after ACB or FNB 30ml 0.2% ropivacaine after
surgerysurgery Endpoints: muscle strength (MVIC), TUG Endpoints: muscle strength (MVIC), TUG
test, pain scorestest, pain scores 120 minutes assessment120 minutes assessment
ACB preserves strength more effectively than ACB preserves strength more effectively than ssFNBssFNB
Pain scores equivalentPain scores equivalent Need more data on longer term pain and Need more data on longer term pain and
function outcomesfunction outcomes Study underlines (again) poor pain control with Study underlines (again) poor pain control with
LIA technique alone as mean pain scores in LIA technique alone as mean pain scores in both groups 6/10 at baselineboth groups 6/10 at baseline
Overview:Overview:
Big Data: how do we use it?Big Data: how do we use it? US and impact on quality and safety: US and impact on quality and safety:
where are we now?where are we now? Best techniques for pain control after Best techniques for pain control after
TKA?TKA? Liposomal bupivacaine: place in TKALiposomal bupivacaine: place in TKA Adductor Canal Block: Better than FNB?Adductor Canal Block: Better than FNB? Teaching USGRATeaching USGRA
Teaching USGRATeaching USGRA
Teaching traditionally uses quantitative Teaching traditionally uses quantitative measuresmeasures
Problems include volume of clinical Problems include volume of clinical material and variability in achievement of material and variability in achievement of competence competence
A&A 1998
Konrad C et al 1998
20 residents randomized to two groups20 residents randomized to two groups Group 1: standard trainingGroup 1: standard training Group 2: Extra training in US guided Group 2: Extra training in US guided
needling (phantom)needling (phantom) Success assessed over 3 week regional Success assessed over 3 week regional
rotationrotation RAPM 2012
Niazi A et al RAPM 2012
Summary:Summary:
Big Data: how do we use it?Big Data: how do we use it? US and impact on quality and safety: US and impact on quality and safety:
where are we now?where are we now? Best techniques for pain control after Best techniques for pain control after
TKA?TKA? Liposomal bupivacaine: place in TKA: Liposomal bupivacaine: place in TKA: Adductor Canal Block: Better than FNB?Adductor Canal Block: Better than FNB? Teaching USGRATeaching USGRA
Acknowledgements
University of Ottawa Department of Anesthesiology and Pain Medicine
Key Faculty: Anne Lui, Desiree Persaud, Alan Lane, Jason McVicar, Patrick Wong, Catherine Smyth, Shona Nair, Colin McCartney
Contact [email protected] Twitter: @colinjmccartney