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I have no financial or research affiliations with any product or pharmaceutical
manufacturer displayed in this presentation
-Shafonya Turner, M.D.
Objectives Summarize the basics of choosing regional
anesthesia as a perioperative anesthetic options Describe the arbitration of various technique
appropriateness in diverse perioperative clinical scenarios
Recognize the appropriateness of single-shot block vs catheter placement in regional anesthesia
Discuss expectations in PACU Discuss drawbacks, risks, complications,
concerns of regional anesthesia techniques
Clark Kent : Superman :: Bruce Wayne :
A. Hulk
B. Batman
C. Spiderman
D. Wolverine
Hulk
Batman
Spiderman
Wolverin
e
0% 0%0%0%
A 91yo male presents for RUE AVF for future hemodialysis access. PMHs includes HTN and osteoarthritis. Candidate for regional anesthesia?
A. Yes
B. No
YesNo
0%0%
Objectives Summarize the basics of choosing regional
anesthesia as a perioperative anesthetic options Describe the arbitration of various technique
appropriateness in diverse perioperative clinical scenarios
Recognize the appropriateness of single-shock block vs catheter placement in regional anesthesia
Identify expectation in PACU List options for comprehensive pain management Discuss drawbacks, risks, complications, concerns
of regional anesthesia techniques
Patient selection…
• Everyone is a potential candidate• Infants/neonates• Incapacitated, intubated• Ongoing infection, heart failure, acute psychological or
neurological derailment1
• If the site is blockable, we can block it!! Risk vs. benefit
• Contraindications • PATIENT REFUSAL• Infection at site of needle/catheter placement• Coagulopathy ( i.e. neuraxial and deeper compartmental block
techniques)• Allergy to anesthetizing medications
Patient Selection… Great alternative for:
Higher risk GA patients Chronic pain disorders (Decrease incidence of chronic pain
syndromes)6
Same day procedures High incidence of PONV with
○ GA○ Narcotics
High risk pulmonary patients○ Obesity○ COPD○ Rib fracture○ Elderly
Initiation of post-operative rehabilitation (orthopedic, thoracic)
Pamela is scheduled for a partial vulvectomy for vulvar cancer. Is there a regional anesthesia option for her?
A. Yes
B. No
C. Maybe
YesNo
Mayb
e
0% 0%0%
Buying a new house when the sink is stopped up is a plausible option.
A. True
B. False
True
False
0%0%
Patient selection…
Timing always a consideration Surgeon preference and discussion Follow-up capabilities
Objectives Summarize the basics of choosing regional
anesthesia as a perioperative anesthetic options Describe the arbitration of various technique
appropriateness in diverse perioperative clinical scenarios
Recognize the appropriateness of single-shock block vs catheter placement in regional anesthesia
Identify expectation in PACU Discuss drawbacks, risks, complications,
concerns of regional anesthesia techniques
Which technique? Upper extremity
Brachial plexus (interscale, supraclavicular, infraclavicular, axillary, elbow, wrist, digital block)
Bier block Lower extremity
Lumbar plexus, femoral, 3-in1, sciatic (infragluteal, popliteal fossa), ankle block
Bier block Lumbar epidural
Thoracic Intercostal, paravertebral, thoracic epidural
Abdominal Thoracic epidural, TAP (transversus abdominis plane), rectus sheath
Cervical Cervical plexus, occipital nerve
Tim is having a nail removed from his ankle several months after an ORIF of a fracture. Which block would be appropriate?
A. Ankle block
B. Femoral block
C. Sciatic block (popliteal or infragluteal)
D. It depends
E. A combination of two of the above
Ankle block
Femora
l block
Sciatic b
lock (p
opliteal o
r...
It depends
A combination of t
wo of...
0% 0% 0%0%0%
What technique?Lower Extremity Surgery and Pain
Usually orthopedic proce-
dures
Vascular (e.g. vein Sclerosing)
What technique?
How long will the procedure take?Question in neuraxial anesthesia
○ Spinal anesthesia is finite in duration unless a catheter left in intrathecal space
○ Epidural anesthesia is more long term (up to 5-7 days)
○ Narcotics in solution also an important point
What technique?
PNB decrease3 duration of hospital stayTotal narcotic useTime to rehabilitation and through rehab
(economic benefit??)5
Other serious complications○ Hypoxia, hypotension, ?DVT?, MI, CVA, GI
distress
Objectives Summarize the basics of choosing regional
anesthesia as a perioperative anesthetic options Describe the arbitration of various technique
appropriateness in diverse perioperative clinical scenarios
Recognize the appropriateness of single-shock block vs catheter placement in regional anesthesia
Identify expectation in PACU Discuss drawbacks, risks, complications,
concerns of regional anesthesia techniques
Dwight presents for R TKA. He refused neuraxial anesthesia options and ops for a peripheral technique. The block team decides to do a femoral and sciatic nerve block. Which one, if any, should get a catheter?
A. Femoral
B. Sciatic
C. Neither
D. Both
Femora
l
Sciatic
Neither
Both
0% 0%0%0%
Single-shot vs Catheters
Decrease narcotic use in catheter patients Decrease LA toxicity and complication due to decrease
rate of injection of LA (local anesthetic )2
In neuraxial anesthesia, possible higher dermatomal spread of LA in combined spinal/epidural vs spinal alone4
Prolonged blockade in catheter
Single Shot vs Catheter
Increase is catheter dislodgement (moisture, friction) and subsequent patient dissatisfaction
Catheter site infection or bacteremic seeding8
Increased technical difficulty in placement with larger needles and longer procedure time
Logistics of catheter management services and staff
Objectives Summarize the basics of choosing regional
anesthesia as a perioperative anesthetic options Describe the arbitration of various technique
appropriateness in diverse perioperative clinical scenarios
Recognize the appropriateness of single-shock block vs catheter placement in regional anesthesia
Identify expectations in PACU Discuss drawbacks, risks, complications,
concerns of regional anesthesia techniques
Martha has just come out of R rotator cuff surgery. The surgeons wanted to wait to dose her interscalene catheter until after motor function of her extremity had been confirmed. 10 minutes before arrival to the PACU, she receives 30mL 0.5% Ropivacaine in her catheter. What can you expect?
A. Inability to squeeze your finger with her R hand
B. Incomplete pain relief with no motor function below the elbow
C. Martha will be writhing in pain
D. Little response when you draw blood from her AC fossa
Inability t
o squeeze
your ...
Incomplete pain
relie
f wi..
Marth
a will
be writ
hing i...
Little re
sponse
when you...
0% 0%0%0%
Great Expectations
Failure of epidural analgesia after initial success was observed in 6.8%7
Efficacy of RA ranges 75-85%, depending on block, technical expertise
Failure rates of up to 30% with come brachial plexus techniques.
Great Expectations Comes down to experience
Some outpatient centers do 75% of their anesthetics with RA
Quicker recovery, better infrastructure to facilitate the initiative
Prepare patients for the experience/expectation Comes down to commitment
Facility commitment to staffing, space, time, and money
Providers commitment to safe, good care, education, leadership
Objectives Summarize the basics of choosing regional
anesthesia as a perioperative anesthetic options Describe the arbitration of various technique
appropriateness in diverse perioperative clinical scenarios
Recognize the appropriateness of single-shock block vs catheter placement in regional anesthesia
Identify expectations in PACU Discuss drawbacks, risks, complications,
concerns of regional anesthesia techniques
The good, now the bad
Everything has risk and benefitsThese are different for each patient even
with similar co-morbidities and deficits The informed consent Even done perfectly, complications arise All that glitters is not gold
How long does the ASRA say we should wait to place an epidural in a patient in ASA?A. 7 days
B. 5 days
C. 2 days
D. No days
7 days
5 days
2 days
No days
0% 0%0%0%
• Antiplatelet medications (ASA, Plavix, NSAIDs)• Oral anticoagulants (Warfarin)• Standard heparin • LMWH (Lovenox, Aggranox)• Thrombolytic and fibrinolytic therapy (tPA)• Herbal preparations ( Garlic, ginger, feverfew, Ginseng,
Alfalfa, chamomile, horse chestnut, ginseng, Vitamin E, Ginko)
• New anticoagulants
Risks Patient safety
Prolonged blockade patient should have support at home○ Falls○ Medication toxicity○ Injury to the anesthetized limb○ Inablilty to complete ADL
Given through instructions on pain management and duration of blockade
For those with take home catheters, instructions and removing catheter or given options to return for removal
Drawbacks
Hemodynamic instability – neuraxial anesthesia
Headaches Urinary retention Pneumothorax and vascular injury on
placement Pain/discomfort with block placement Follow up Incomplete relief
References1. Barash 7th edition
2. Analgesic Effectiveness of a Continuous Versus Single-Injection Interscalene Block for MinorArthroscopic Shoulder Surgery Michel J. Fredrickson, MD,* Þ Craig M. Ball, MD,* and Adam J. Dalgleish (Reg Anesth Pain Med 2010;35: 28Y33) Regional Anesthesia and Pain Medicine & Volume 35, Number 1, January-February 2010
3. Chelley JE, Continuous femoral blocks improve recovery and outcome of patients undergoing TKA. J arthrophasty 2001
4. Sensorimotor anesthesia and hypotension after subarachnoid block: combined spinal-epidural versus single-shot spinal technique. Goy RW, Sia AT.
5. Capdevila, X. Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery. Anesthesiology 1999;91:8-15
6. Perkins FM. Chronic pain as an outcome of surgery. A review of predictive factors. Anesthesiology 2000;93:11123-1133
7. Pan PH, Bogard TD, Owen MD. Incidence and characteristics of failures in obstetric neuraxial analgesia and anesthesia: a retrospective analysis of 19,259 deliveries. Int J Obstet Anesth 2004;13:227-33.
8. Cuvillon P. The Continuous Femoral Nerve Block Catheter for Postoperative Analgesia: Bacterial Colonization, Infectious Rate and Adverse Effects. Anesth Analg 2001;93:1045–9
9. Finucane B. Complications of Regional Anesthesia. Springer Science. New York. 2007.