Regional Anestesi

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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


• Stakeholder communication– Room team, surgeon, PACU RN

• Patient counseling– Follow-up, multimodal analgesia, incidental

blocks, limb protection/fall prevention

• Avoiding laterality errors– Checklist, Time out

– Surgical consent VISIBLE during time out


– Site(s) marking—VISIBLE during block

– Patient participation (counsel)

– Prone and re-positioning

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• Positioning

• Positioning

• Positioning


g

• Sedation choice

• Avoiding infection, leakage, dislodgement

• Standardizing ultrasound screen view

• Pre-sedation final confirmation– “Any blood thinners?” “Any nerve problems?”

• Pre-block neurologic exam for traumas


• Preop block testing

• Postop follow-up

• Indications• TKA, UKA

• Knee MUA, ACL

AKA/BKA

Femoral

• AKA/BKA

• Femur ORIF

• Tibial plateau fracture

• Patella ORIF

• Anterior thigh STSG, tumor excisions

• Free Flaps

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• Sono-anatomy

– (Femoral)

Femoral

• Sono-anatomy

– (Femoral)

Femoral

Iliopsoas

• Sonoanatomy– (Adductor)

Femoral

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• Sonoanatomy– (Adductor)

Femoral

Sartorius

Vastus M. Adductor L.

• Positioning– Femoral

– Adductor

Femoral

• The block– (Adductor)

Femoral

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Femoral


Femoral


Femoral

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Femoral


Femoral

• Common errors– Using ultrasound view below femoral artery

split

Femoral (Traditional)

– Failure to retract pannus skin

– Injection above the fascia iliaca

– Choosing femoral block in ambulatory patient

– Allowing caregivers to expect femoral block to cover posterior knee pain

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• Common errors– Failure to approach at consistent level

– Failure to appreciate tactile ‘pop’ on canal

Femoral (Adductor)

entry

– Accepting local anesthetic spread in/below sartorius (rather than in adductor canal)

• Local anesthesia deposition strategies– Injecting below the femoral nerve

– Injecting between the femoral nerve and

Femoral

fascia iliaca

– Using a ‘hydrodissection’ technique to maneuver within tissue plane

• Testing your block– Ice to kneecap area, medial ankle

– Voluntary contraction of quadriceps

Femoral

• “Make a muscle”

• Follow-up

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• Indications– Distal leg, foot, ankle

• Fracture ORIFs, diabetic ulcers, amputations, plastics gastroc flaps burns/grafts

Sciatic

plastics gastroc flaps, burns/grafts

– BKA, Achilles repair, tibial nails (delayed)

– ACL, Tibial plateau, Total knee

• Sono-anatomy

Sciatic

• Sono-anatomy

Sciatic

CPT

CP

Biceps Femoris

SemitendinosusSemimembranosus

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• Positioning

Sciatic

• The

block

Sciatic

• The

block

Sciatic

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• The

block

Sciatic

• The

block

Sciatic

• Common errors– Failure to elevate ankle with towels

– Failing to identify sciatic nerve split

Sciatic

– Not allowing sufficient time for block setup

– Injection outside the perineurium

– Ignoring the saphenous distribution when planning a surgical block (tourniquet)

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• Local anesthetic deposition strategies– At the common peroneal/tibial split

– Above the sciatic nerve split

Sciatic

– Subperineurial injection

• Testing your block

Sciatic

• Indications– Analgesia of the shoulder and upper arm

– Single shot vs. catheter for shoulder

Interscalene

arthroscopy

– Typically single shot for distal clavicle ORIF

– Typically catheter for shoulder replacement or humerus ORIF

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• Sono-anatomy

Interscalene

• Sono-anatomy

Interscalene

SCMTrap

AS MS

Transverse Process

• Positioning

Interscalene

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• The

block

Interscalene

• The

block

Interscalene

• The

block

Interscalene

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• The

block

Interscalene

• The

block

Interscalene

• The

block

Interscalene

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• Common errors– Incomplete chart review– Inadequate patient counseling regarding

incidental/accessory blocks

Interscalene

incidental/accessory blocks– Supine positioning– Not using a systematic scanning method– Excessive LA volume deposition, especially

into anterior scalene muscle– Catheter dislodgement/leakage

• Local anesthetic deposition strategies– Avoiding excessive volume

– Entering interscalene fascia space between

Interscalene

upper and middle trunks

– Avoiding excessive injection into ASM

– Color doppler to check for vertebral artery

• Indications– Procedures from mid-humerus to finger

– Finger/forearm reimplantation

Infraclavicular

– Why preferable to axillary or supraclav

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• Sono-anatomy

Infraclavicular

• Sono-anatomy

Infraclavicular

Pec Maj

Pec Min

cephaladcaudad

MMPP

LLM

• Positioning

Infraclavicular

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• The

block

Infraclavicular

• The

block

Infraclavicular

• Common errors– Failure to use systematic scanning

– Failure to adjust plan for veins

Infraclavicular

– Failure to adjust transducer pressure

– Extremely lateral approach, after splitting of cords

– (AVF re-do patients)

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• Local anesthetic deposition strategies– Multi-injection

– Single injection

Infraclavicular

– Approach from 12 o’clock

– Approach from 7 o’clock

• Testing your block

Infraclavicular

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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Current Guidelines for the use of Antithrombotics

& N i l P d

2014 Winter Anesthesia Seminar

& Neuraxial ProceduresRamo K. Naidu, MD

UC – San Francisco Dept of Anesthesiology Division of Pain Medicine

Director of Acute Pain Services at Moffitt-Long and Mount Zion HospitalsIntegrated Pediatric Pain & Palliative Care (IP3)

San Francisco, California. April 26, 2014

• Nothing to disclose regarding this lecture.

• Received stipends for educational courses related to spinal cord stimulation from

Disclosures

Boston Scientific and Medtronic

• Understand the growing number of patients on TSOAs and the implications on regional anesthesia

• Have a new perspective on the risk of neuraxial hematoma associated with neuraxial anesthesia

Learning Objectives

hematoma associated with neuraxial anesthesia• Understand the potential differences in risk among

procedures (Regional Anesthesia & Interventional Pain) and the challenge in assessing individual risk

• Understand the potential consequences of ceasing antithrombotic therapy for an intervention

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American Society European Society Scandinavian

The Guidelines

American Society of Regional

Anesthesia & Pain Medicine

European Society of Regional

Anaesthesia & Pain Therapy

Scandinavian Society of

Anaesthesiology and Intensive Care

Medicine

Jan-Feb 2010RAPM

Oct 2010EJA

2010AAS

US Introduction of Antithrombotics

2012

2011

2010

1993

1994

2001

1997

FDA Approval Dates

2009

Ramo K. Naidu, [email protected]

The New Drugs

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Target-Specific Oral Anticoagulants (TSOACs)

Dabigatran (Pradaxa™)FDA approval 2010.Oral direct thrombin inhibitor indicated for stroke prevention in non-valvular atrial fibrillation.Elimination Half-life: 12-17 hours. Onset: 1-2 hours. Renal elimination: 80%

Rivaroxaban (Xarelto™)FDA approval 2011.ppOral factor Xa Inhibitor indicated for stroke prevention in non-valvular atrial fibrillation AND DVT prophylaxis and treatment.Elimination Half-life: 7-11 hours. Onset: 2-3 hours. Renal elimination: 30%. 3A4 metabolism

Apixaban (Eliquis™)FDA-approval in 2012. Oral factor Xa Inhibtor indicated for stroke prevention in non-valvular atrial fibrillation AND DVT prophylaxis and treatment.Elimination Half-life: 8-15 hours. Onset: 3-4 hours. Renal elimination: 25%. 3A4 metabolism

Cove C et al. JAHA. 2013

Target-Specific Oral Anticoagulants (TSOACs)

Dabigatran (Pradaxa)

Rivaroxaban (Xarelto)

Apixaban (Eliquis)


Prophylactic

Therapeutic

P2Y12 antagonists

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

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Prasugrel (Effient)

P2Y12 antagonists

Ticagrelor (Brilinta)


The New Concerns About the Old Drugs

FDA Alert regarding Low-Molecular Weight Heparin

November 6, 2013.Review of data regarding low‐molecular weight heparin from 1992‐2013. 170 cases. 100 cases confirmed with imaging.

FDA Statement:Change the time of LMWH start after neuraxial procedure or catheter removal from 2 to 4 hours.


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FDA Alert regarding Low-Molecular Weight Heparin

Prophylactic

Therapeutic


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

Lumbar Puncture

SS SpinalILESITFESI

ParavertebralLumbar Plexus

EpiduralIntrathecal

Spinal Cord StimulationIntrathecal

Pump

20-24ga 17-25ga 17-20ga 14-17ga


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Neuraxial Hematoma

Exogenous AntithrombosisExogenous AntithrombosisExogenous AntithrombosisExogenous Antithrombosis

Indwelling CatheterIndwelling CatheterIndwelling CatheterIndwelling Catheter

Contributing Factors

Needle PlacementNeedle PlacementNeedle PlacementNeedle Placement

WHATWHAT’’s THE s THE WHATWHAT’’s THE s THE

EPIDURAL HEMATOMAEPIDURAL HEMATOMAEPIDURAL HEMATOMAEPIDURAL HEMATOMA

Mechanical Tissue InjuryMechanical Tissue InjuryMechanical Tissue InjuryMechanical Tissue Injury

Endogenous Coagulable StateEndogenous Coagulable StateEndogenous Coagulable StateEndogenous Coagulable State

AgeAgeAgeAge

Anatomic VarianceAnatomic VarianceAnatomic VarianceAnatomic Variance

INCIDENCE OF INCIDENCE OF NEURAXIAL NEURAXIAL

HEMATOMA?HEMATOMA?

INCIDENCE OF INCIDENCE OF NEURAXIAL NEURAXIAL

HEMATOMA?HEMATOMA?


U.S. Introduction of Antithrombotics

SpinalAnesthetic

2012

2010

1930

1940

2000

1990

1980

1970

1960

1950

1920

1910

1900

NeuraxialHematomaParalysis

Horlocker T, RAPM, 1998FDA Approval Dates


History

Tryba. 13 clinically‐relevant epidural hematomata / 850,000 neuraxial anesthetics = 1/150,000 Epidurals 1/220,000 SAB

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.

Horlocker T, A&A, 2013

2013

Systems-Based Practice

Acute Pain ServiceAcute Pain ServiceAcute Pain ServiceAcute Pain ServiceService AService AService AService A

AttendingAttendingAttendingAttending

FellowFellowFellowFellow

ResidentsResidentsResidentsResidents

NPNPNPNPAttendingAttendingAttendingAttending


RegionalRegional TeamTeamRegionalRegional TeamTeam



NursesNursesNursesNurses

PharmacistsPharmacistsPharmacistsPharmacists


InternInternInternIntern

Service BService BService BService B





NPNPNPNP

EPIDURAL EPIDURAL HEMATOMAHEMATOMAEPIDURAL EPIDURAL HEMATOMAHEMATOMA

THROMBOTIC THROMBOTIC COMPLICATIONCOMPLICATIONTHROMBOTIC THROMBOTIC COMPLICATIONCOMPLICATION

The Idea

• Patient Safety.

• It is a launchpoint, a communication piece.

• It does not replace individual decisions• It does not replace individual decisions.

• It is evidence-based, with the data we have.

• It is adaptable based on data received globally and locally.

• Rare, High Consequence Events are challenging to study, data are disparate. e.g. POVL


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The Idea

HEMATOLOGYHEMATOLOGYHEMATOLOGYHEMATOLOGY

CARDIOLOGYCARDIOLOGYCARDIOLOGYCARDIOLOGY

ANESTHESIAANESTHESIAANESTHESIAANESTHESIA

PHARMACYPHARMACYPHARMACYPHARMACY

RADIOLOGYRADIOLOGYRADIOLOGYRADIOLOGY

ORTHOORTHOORTHOORTHORamo K. Naidu, MD

[email protected]

Minimum time between the last dose and when neuraxial shot/ catheter placement can occur

Minimum time after catheter placement to drug start.

Minimum time between last dose of drug and catheter removal

Minimum time between neuraxial shot/ catheter removal and when next dose can be given

ANTICOAGULANTS FOR VENOUS THROMBOEMBOLISM PROPHYLAXIS

dalteparin (Fragmin)5000 units SQ qday 12 hours ADVISE CAUTION. May be given.Wait 6 hrs after catheter placement before next dose.

12 hours 4 hours

enoxaparin (Lovenox)40mg SQ qday

12 hours ADVISE CAUTION. May be given. Wait 6 hrs after catheter placement before next dose.

12 hours 4 hours

enoxaparin (Lovenox)30mg SQ bid or 40mg SQ bid

12 hoursCONTRAINDICATED while catheter in place

4 hours

fondaparinux (Arixtra) <2.5mg SQ qday


2 hours

heparin 5000 Units SQ bid May be given; No time restrictions for catheter placement or removal

heparin 5000 Units SQ tid 4 hours 2 hours 4 hours 2 hours

rivaroxaban (Xarelto)10mg PO qday

48 hours 6 hours 24 hours 6 hours

ANTICOAGULANTS AT THERAPEUTIC DOSES

apixaban (Eliquis)2.5 ‐ 5mg PO bid


6 hours

warfarin (Coumadin) 5 days or INR < 1.5CONTRAINDICATED while catheter in place

2 hours(no consensus)

dabigatran (Pradaxa) 4 days or when TT is normal CONTRAINDICATED while catheter in place

6 hours

dalteparin (Fragmin) 200 U/kg SQ qday; 100 U/kg SQ q12h


4 hours

CATHETERCATHETERCATHETERCATHETERCATHETERCATHETERCATHETERCATHETER

TIMELINETIMELINETIMELINETIMELINE

DRUGDRUGDRUGDRUG DRUGDRUGDRUGDRUG


DRUGDRUGDRUGDRUG DRUGDRUGDRUGDRUG

Single ShotSingle ShotSingle ShotSingle ShotU/kg SQ q12h

enoxaparin (Lovenox) 1mg/kg SQ bid; 1.5mg/kg SQ qday


4 hours

fondaparinux (Arixtra) 5‐10mg SQ qday


2 hours

heparin full dose IV(In emergent situations, may have to be used. Recommend neuro checks q2h)

when aPTT < 40 CONTRAINDICATED while catheter in place. In emergent situation, start at least 1 hour after.

CONTRAINDICATED while catheter in place.

In emergent situation, 4 hours and check aPTT<40

2 hours

rivaroxaban (Xarelto)20‐30mg PO qday


6 hours

ORAL ANTIPLATELET AGENTS

aspirin/NSAIDS/COX inhibitors/dipyridamole May be given; No time restrictions for catheter placement or removal

clopidogrel (Plavix)/ prasugrel (Effient)/ ticagrelor (Brilinta)

7 daysCONTRAINDICATED while catheter in place

2 hours

ticlopidine (Ticlid) 14 daysCONTRAINDICATED while catheter in place

2 hours

DIRECT THROMBIN INHIBITORS

argatroban / bivalirudin (Angiomax) When TT is normalCONTRAINDICATED while catheter in place

2 hours

G IIB/IIIA INHIBITORS

abciximab (Reopro) 48 hoursCONTRAINDICATED while catheter in place

2 hours (ACS)

eptifibatide (Integrilin) / tirofiban (Aggrastat) 8 hoursCONTRAINDICATED while catheter in place

2 hours (ACS)

THROMBOLYTIC AGENTS

alteplase (TPA)Full dose for stroke, MI, etc 10 daysCONTRAINDICATED while catheter in place

10 days

alteplase (TPA)2mg dose for catheter clearanceMay be given; No time restrictions for catheter placement or removal


DRUGDRUGDRUGDRUG DRUGDRUGDRUGDRUG DRUGDRUGDRUGDRUG


DRUGDRUGDRUGDRUG DRUGDRUGDRUGDRUG DRUGDRUGDRUGDRUG

The risk of epidural hematoma is equal for both catheter placement, and

catheter removal

Vandermeulen, A&A. 1994

Single ShotSingle ShotSingle ShotSingle Shot





ANTICOAGULANTS FOR VENOUS THROMBOEMBOLISM PROPHYLAXIS

dalteparin (Fragmin)5000 units SQ qday 12 hours ADVISE CAUTION. May be given.Wait 6 hrs after catheter placement before next dose.

12 hours 4 hours

enoxaparin (Lovenox)40mg SQ qday

12 hours ADVISE CAUTION. May be given. Wait 6 hrs after catheter placement

12 hours 4 hours

before next dose.

enoxaparin (Lovenox)30mg SQ bid or 40mg SQ bid

12 hours

CONTRAINDICATED while catheter in place

4 hours

fondaparinux (Arixtra) <2.5mg SQ qday

48 hours

CONTRAINDICATED while catheter in place

4 hours

heparin 5000 Units SQ bidMay be given; No time restrictions for catheter placement or removal

heparin 5000 Units SQ tid 4 hours 2 hours 4 hours 2 hours

rivaroxaban (Xarelto)10mg PO qday

48 hours 6 hours 24 hours 6 hours

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ANTICOAGULANTS AT THERAPEUTIC DOSES apixaban (Eliquis)2.5 ‐ 5mg PO bid


6 hours

dabigatran (Pradaxa) 4 days or when TT is normal CONTRAINDICATED while catheter in place

6 hours

dalteparin (Fragmin) 200 U/kg SQ qday; 100 U/kg SQ q12h


4 hours

enoxaparin (Lovenox) 1mg/kg SQ bid; 1.5mg/kg SQ qday


4 hours

fondaparinux (Arixtra) 5‐10mg SQ qday


4 hours

heparin full dose IV(In emergent situations, may have to be used. Recommend neuro checks q2h)

when aPTT < 40 CONTRAINDICATED while catheter in place. In emergent situation, start at least 1 hour after.

CONTRAINDICATED while catheter in place.

In emergent situation, 4 hours and check aPTT<40

2 hours

rivaroxaban (Xarelto)20‐30mg PO qday


6 hours

warfarin (Coumadin) 5 days or INR < 1.5CONTRAINDICATED while catheter in place

2 hours(no consensus)





ORAL ANTIPLATELET AGENTSaspirin/NSAIDS/COX inhibitors/dipyridamole

May be given; No time restrictions for catheter placement or removal

clopidogrel (Plavix)/ prasugrel (Effient)/ ticagrelor (Brilinta)

7 daysCONTRAINDICATED while catheter in place

2 hours

ticlopidine (Ticlid) 14 daysCONTRAINDICATED while catheter in place

2 hours

DIRECT THROMBIN INHIBITORSDIRECT THROMBIN INHIBITORSargatroban / bivalirudin (Angiomax) When TT is normal

CONTRAINDICATED while catheter in place2 hours

G IIB/IIIA INHIBITORSabciximab (Reopro) 48 hours

CONTRAINDICATED while catheter in place2 hours (ACS)

eptifibatide (Integrilin) / tirofiban (Aggrastat) 8 hoursCONTRAINDICATED while catheter in place

2 hours (ACS)

THROMBOLYTIC AGENTSalteplase (TPA)Full dose for stroke, MI, etc 10 days

CONTRAINDICATED while catheter in place10 days

alteplase (TPA)2mg dose for catheter clearance May be given; No time restrictions for catheter placement or removal

Risks of Ceasing Antithrombotic Therapy & The Role of BridgingYou may need to consult with cardiology or hematology based


on the concern for the risk for thrombosis.

Peripheral Regional Anesthesia & AntithromboticsA standardized set of recommendations for all peripheral regional anesthetics cannot be made at this time.


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Hepatic & Renal Impairment

If unclear about the pharmacokinetics in impaired metabolism and excretion, refer to the package insert of a medication.

Cytochrome P450 Metabolism

Be aware of interactions with other substances (grapefruit juice, herbals, drugs). If unclear, please refer to the package insert of a medication.

Protein Binding


Combinations of Factors

This table does not identify the risk associated with combinations of antithrombotic etiologies.

Examples include combinations of drugs with herbal supplements, von Willebrand disease, etc.

Traumatic or “Bloody” Tap

There is a ~10‐fold increased risk of epidural hematoma with traumatic placement.


Bleeding Clotting

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Systems-Based Practice

Acute Pain ServiceAcute Pain ServiceAcute Pain ServiceAcute Pain ServiceService AService AService AService A




NPNPNPNPAttendingAttendingAttendingAttending


Regional TeamRegional TeamRegional TeamRegional Team



NursesNursesNursesNurses

PharmacistsPharmacistsPharmacistsPharmacists



Service BService BService BService B





NPNPNPNP

EPIDURAL EPIDURAL HEMATOMAHEMATOMAEPIDURAL EPIDURAL HEMATOMAHEMATOMA


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

PREPRE‐‐OPOPPREPRE‐‐OPOP POSTPOST‐‐OPOPPOSTPOST‐‐OPOPINTRAINTRA‐‐OPOP

INTRAINTRA‐‐OPOP


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The Future

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.

http://www.asahq.org/For‐Members/Standards‐Guidelines‐and‐Statements.aspx

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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Upcoming Events


Fairmont Kea Lani


4/16/2014

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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




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

Decreased use of pain medication, NV, pruritus

Decreased N/V (6% vs 30%)

Improved sleep pattern, delirium, urinary retention, patient satisfaction (significant) / humanitarian benefit (PR)

Liu SS, et al. Anesth Analg 2005;101:1634-42

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


Results

Subjects who received ropivacaine suffered fewer sleep disturbances and consumed less oral opioid medication

Subjects who received ropivacaine reported higher satisfaction with recovery


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

with RA / induction room P<0.05

Anesthesiology 93(2):529-538, 2000n=127 n=83 n=159

RA and Rehabilitation

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

Complication Hip KneePulmonary embolism NS NSCerebrovascular event P=0.0271 NSPulmonary compromise P<0.0001 P<0.0001y pPneumonia P=0.0029 P=0.0083All infections P<0.0001 P<0.0001Acute renal failure P<0.0001 P<0.0001Mechanical ventilation P=0.0085 P<0.0001Transfusion P<0.0001 P<0.000130-day mortality NS P=0.0211

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




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

Decreased use of pain medication, NV, pruritus

Decreased N/V (6% vs 30%)

Improved sleep pattern, delirium, urinary retention, patient satisfaction (significant) / humanitarian benefit (PR)

Liu SS, et al. Anesth Analg 2005;101:1634-42

Evans H, et al. Anesth Clin North Am 2005;23(1):141-62

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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

#1 Is this going to affect turn over?

0

5

10

15

20

25

GA GA/RA RA

ACTTOTTotal

RA: lowest ACT and total time (ACT + TOT) 9-minute OR time savings

with RA / induction room P<0.05

Anesthesiology 93(2):529-538, 2000n=127 n=83 n=159

Orthopedic question #3What’s in it for me?

- A little work up front

- A lot of satisfaction later

Less ER visits less resident pager calls

What’s In It for Me (Surgeon)?

- Less ER visits, less resident pager calls, less refill of oral analgesics

- Reduced ER bounce backs 62%

- Patient receiving one-shot blocks and not continuous infusions, have complained that their pain came on severely and acutely (rebound)

-Williams BA, et al. Anesthesiology 2004; 100:697–706

-Coldstein RY et al: (rebound pain). J Orth Tr 2012;26(10):557-62

- Spend some time to explain the process…

- Patients often ask:

- “You are still going to put me to sleep aren’t you?”

Frequent Asked Questions?

- “Is that going to hurt?”

- “You are still going to give me drugs right?”

- “I have a high tolerance for pain…Is it necessary?”

- “How do I take it out at home?”

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Goal:Balance between good pain relief

and mobility

• Concern on the impact of nerve blocks on motor function

• Particularly the impact of weakness on patients’ ability to participate in active physiotherapy block (Ilfeld, et al)

W k i h i k f f ll (F ib l l) ?• Weakness increases the risk of falls (Feibel, et al) or not?

• Multlimodal analgesia may facilitate this goal

-Ilfeld BM, et al. Anesthesiology 2008;108(4):703-13-Ilfeld BM, Anesthesiology 2004; 101(4):970-7-Feibel RJ, et al. Abstract, AOA/COA Annual Meeting 2008-Ilfeld BM, et al. Anesth Analg 2005;100:1172–8

Pre-op Identification of Block Patients

As surgeons initiate the process a pre-op evaluation including his/her preference for RA will be schedule to trigger an EPIC identifier

HMR icon, and specific status board for regional

During the pre-op visit:

Confirm appropriateness of a RA (inclusion/exclusion criteria)

Educate the patient about RA and choices especially for home pump(computer presentation + pamphlet)

Questions be answered

Schedule an early arrival on surgery day

Inform patients about expectations and other oral medications to take with the CPNB

www.happypatient.org

EPIC Status Board for RA

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Pamphlet withGeneral Information

on Nerve Blocks

Education Pamphletfor Home Pumps

The RA Team

Block team available 24/7 for hip fracture protocol and follow-up

Providers with interest and expertise in regional anesthesia

Assistants: fellows, residents, nurse and/or techs

Bl k / di t ith d di t bl k Block nurse/coordinator with dedicate block area

Good patient education system (preop clinic, web based,…)

Life HMR identifier to schedule, track and follow patients

In and outpatients with single shot and continuous nerve blocks

Rapid response and treatment for complication/neuropathy

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The Mission of the RA Team

The mission of the RA division is to provide best patient care to facilitate OR flow, patient outcome and satisfaction

Zero delay Proper patient selection and efficient flow

Improved turnover Improved turnover

Early discharge from PACU, floor

Decrease delirium

Decrease long term pain

Improve long term recovery

GOOD COMMUNICATION

Happy Patients, Surgeons and Anesthesiologistswww.happypatient.org

Patients’ Selection and Education

• Pamphlet, Web info, preop education

• Consented: adequate information concerning risks/benefits

• Proper expectations

• Signs of LAST, specific block side effects (IS)

• Ambulation precaution/fall prevention

• Pressure injuring prevention

Optimal Infusion Regimen

• Multi-center RCT

• 83 subjects comparing morphine IV PCA and 2 regimens for CPNB

Capdevila X, et al. Anesth 2006;105:566 Capdevila X, et al. Anesth 2006;105:566

• VAS scores and analgesic consumption highest in control group

• Early activity greatest in basal-bolus CPNB

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Multimodal Pain Management

Medications NSAIDs Acetaminophen Anti-epileptics

-2 agonists Ketamine Opioids

Menigaux et al. Anesth Analg 2005;100:1394-9

Peng et al Pain Res Manag 2007 Summer; 12(2): 85–92Peng et al. Pain Res Manag. 2007 Summer; 12(2): 85 92

Adjunct relaxation, ice, acupuncture

Sun et al. BJA, 2008;149:1-10

Securing the Catheter

Drying agent

Surgical tape

(T li ) (Tunneling)

Glue

(Suture)

Clear dressing

Anchoring device

Unplanned catheter disconnection

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Prevent that black thing from sliding loose

“Tape is good,fold and tape”

“More tape is good,fold and tape”

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“BAM!!- Solid, you can pull that thing

27

Problems, Risks and Complications

• Serious problems are rare

• Minors issues are common and easy to

manage, but often resulted from

poor understanding/education

-Wiegel M, et al.. Anesth Analg 2007; 104:1578–1582. -Swenson JD, et al. Anesth Analg 2006; 103:1436–1443

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Minor and Preventable Issues

Leak (reassure, instruction, reinforcing the dressing)

Ambulation difficulties, falls (immobilizers, crushes, slings, education)

Numbness (instructions, proper expectation)

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

Block Technique:

Direct Needle Trauma

High Pressure, intra-fascicular injection

Neuronal ischemia (Pressure, epinephrine)

LA/additives Neurotoxicity

Surgical Factors:

Stretch/Retractor Injury/duration/positioning

Hematoma

Tourniquet

Overview

Rationale and benefits of regional anesthesia?

Effective regional anesthesia program and risks


The plan for Stanford

Conclusions

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OHSU Ambulatory CPNB Experience

Over 6 years, > 5000 patients went home with a

perineural infusion

Potentially Serious Complications:

1 pneumothorax

5 cut catheters

1 possible LA toxicity

6 retained catheters (2 surgically removed)

OHSU Ambulatory CPNB Experience :768 Catheters

180

161

58 5265

4965

60

80

100

120

140

160

180

200

Type of Catheters

32

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29 31

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52

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s w

ith

Cat

h,

U/S

, N

erve

Femoral Infraclavicular Interscalene Lumbar Sciatic Supraclavicular

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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24

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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25

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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26

Overview


Selling it to our Surgeons and Administrator



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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27

Overview


Selling it to our Surgeons and Administrator



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

4/16/2014

28

Thank You



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