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4/16/2014
1
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
4/16/2014
2
• 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:
4/16/2014
3
• 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
Success for any block
• 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
Success for any block
– Site(s) marking—VISIBLE during block
– Patient participation (counsel)
– Prone and re-positioning
4/16/2014
4
• Positioning
• Positioning
• Positioning
Success for any block
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
Success for any block
• 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
4/16/2014
5
• Sono-anatomy
– (Femoral)
Femoral
• Sono-anatomy
– (Femoral)
Femoral
Iliopsoas
• Sonoanatomy– (Adductor)
Femoral
4/16/2014
6
• Sonoanatomy– (Adductor)
Femoral
Sartorius
Vastus M. Adductor L.
• Positioning– Femoral
– Adductor
Femoral
• The block– (Adductor)
Femoral
4/16/2014
7
• The block– (Adductor)
Femoral
• The block– (Adductor)
Femoral
• The block– (Adductor)
Femoral
4/16/2014
8
• The block– (Adductor)
Femoral
• The block– (Adductor)
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
4/16/2014
9
• 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
4/16/2014
10
• 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
4/16/2014
11
• Positioning
Sciatic
• The
block
Sciatic
• The
block
Sciatic
4/16/2014
12
• 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)
4/16/2014
13
• 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
4/16/2014
14
• Sono-anatomy
Interscalene
• Sono-anatomy
Interscalene
SCMTrap
AS MS
Transverse Process
• Positioning
Interscalene
4/16/2014
15
• The
block
Interscalene
• The
block
Interscalene
• The
block
Interscalene
4/16/2014
16
• The
block
Interscalene
• The
block
Interscalene
• The
block
Interscalene
4/16/2014
17
• 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
4/16/2014
18
• Sono-anatomy
Infraclavicular
• Sono-anatomy
Infraclavicular
Pec Maj
Pec Min
cephaladcaudad
MMPP
LLM
• Positioning
Infraclavicular
4/16/2014
19
• 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)
4/16/2014
20
• 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.
4/16/2014
1
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
4/16/2014
2
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
4/16/2014
3
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)
Ramo K. Naidu, [email protected]
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
4/16/2014
4
Prasugrel (Effient)
P2Y12 antagonists
Ticagrelor (Brilinta)
Ramo K. Naidu, [email protected]
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.
Ramo K. Naidu, [email protected]
4/16/2014
5
FDA Alert regarding Low-Molecular Weight Heparin
Prophylactic
Therapeutic
Ramo K. Naidu, [email protected]
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
Ramo K. Naidu, [email protected]
4/16/2014
6
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?
Ramo K. Naidu, [email protected]
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
Ramo K. Naidu, [email protected]
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
4/16/2014
7
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
ResidentsResidentsResidentsResidents
RegionalRegional TeamTeamRegionalRegional TeamTeam
AttendingAttendingAttendingAttending
ResidentsResidentsResidentsResidents
NursesNursesNursesNurses
PharmacistsPharmacistsPharmacistsPharmacists
ResidentsResidentsResidentsResidents
InternInternInternIntern
Service BService BService BService B
AttendingAttendingAttendingAttending
FellowFellowFellowFellow
ResidentsResidentsResidentsResidents
InternInternInternIntern
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
Ramo K. Naidu, [email protected]
4/16/2014
8
The Idea
HEMATOLOGYHEMATOLOGYHEMATOLOGYHEMATOLOGY
CARDIOLOGYCARDIOLOGYCARDIOLOGYCARDIOLOGY
ANESTHESIAANESTHESIAANESTHESIAANESTHESIA
PHARMACYPHARMACYPHARMACYPHARMACY
RADIOLOGYRADIOLOGYRADIOLOGYRADIOLOGY
ORTHOORTHOORTHOORTHORamo K. Naidu, MD
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
48 hoursCONTRAINDICATED while catheter in place
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
72 hoursCONTRAINDICATED while catheter in place
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
24 hoursCONTRAINDICATED while catheter in place
4 hours
CATHETERCATHETERCATHETERCATHETERCATHETERCATHETERCATHETERCATHETER
TIMELINETIMELINETIMELINETIMELINE
DRUGDRUGDRUGDRUG DRUGDRUGDRUGDRUG
TIMELINETIMELINETIMELINETIMELINE
DRUGDRUGDRUGDRUG DRUGDRUGDRUGDRUG
Single ShotSingle ShotSingle ShotSingle ShotU/kg SQ q12h
enoxaparin (Lovenox) 1mg/kg SQ bid; 1.5mg/kg SQ qday
24 hoursCONTRAINDICATED while catheter in place
4 hours
fondaparinux (Arixtra) 5‐10mg SQ qday
72 hoursCONTRAINDICATED while catheter in place
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
48 hoursCONTRAINDICATED while catheter in place
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
TIMELINETIMELINETIMELINETIMELINE
DRUGDRUGDRUGDRUG DRUGDRUGDRUGDRUG DRUGDRUGDRUGDRUG
TIMELINETIMELINETIMELINETIMELINE
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
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
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
4/16/2014
9
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 AT THERAPEUTIC DOSES apixaban (Eliquis)2.5 ‐ 5mg PO bid
72 hoursCONTRAINDICATED while catheter in place
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
24 hoursCONTRAINDICATED while catheter in place
4 hours
enoxaparin (Lovenox) 1mg/kg SQ bid; 1.5mg/kg SQ qday
24 hoursCONTRAINDICATED while catheter in place
4 hours
fondaparinux (Arixtra) 5‐10mg SQ qday
72 hoursCONTRAINDICATED while catheter in place
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
48 hoursCONTRAINDICATED while catheter in place
6 hours
warfarin (Coumadin) 5 days or INR < 1.5CONTRAINDICATED while catheter in place
2 hours(no consensus)
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
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
THROMBOTIC THROMBOTIC COMPLICATIONCOMPLICATIONTHROMBOTIC THROMBOTIC COMPLICATIONCOMPLICATION
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.
Ramo K. Naidu, [email protected]
4/16/2014
10
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
Ramo K. Naidu, [email protected]
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.
Ramo K. Naidu, [email protected]
Bleeding Clotting
4/16/2014
11
Systems-Based Practice
Acute Pain ServiceAcute Pain ServiceAcute Pain ServiceAcute Pain ServiceService AService AService AService A
AttendingAttendingAttendingAttending
FellowFellowFellowFellow
ResidentsResidentsResidentsResidents
NPNPNPNPAttendingAttendingAttendingAttending
ResidentsResidentsResidentsResidents
Regional TeamRegional TeamRegional TeamRegional Team
AttendingAttendingAttendingAttending
ResidentsResidentsResidentsResidents
NursesNursesNursesNurses
PharmacistsPharmacistsPharmacistsPharmacists
ResidentsResidentsResidentsResidents
InternInternInternIntern
Service BService BService BService B
AttendingAttendingAttendingAttending
FellowFellowFellowFellow
ResidentsResidentsResidentsResidents
InternInternInternIntern
NPNPNPNP
EPIDURAL EPIDURAL HEMATOMAHEMATOMAEPIDURAL EPIDURAL HEMATOMAHEMATOMA
THROMBOTIC THROMBOTIC COMPLICATIONCOMPLICATIONTHROMBOTIC THROMBOTIC COMPLICATIONCOMPLICATION
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
Ramo K. Naidu, [email protected]
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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.
•
Ramo K. Naidu, [email protected]
• 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.
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
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
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
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
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
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
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
Data on the home pump program
The plan for Stanford
Conclusions
4/16/2014
23
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
1
29 31
3
52
2 3
49
1
22
44
0
20
40
60
Fem
ora
l w
ith
Cat
h w
ith
U/S
Fem
ora
l w
ith
Cat
h,
U/S
, N
erve
S
tim
ula
tio
n
Infr
acla
vicu
lar
Bra
chia
l P
lexu
s w
ith
C
ath
, N
erve
Sti
m
Infr
acla
vicu
lar
Bra
chia
l P
lexu
s w
ith
C
ath
, U
/S
Infr
acla
vicu
lar
Bra
chia
l P
lexu
s w
ith
C
ath
, U
/S,
Ner
ve S
tim
Inte
rsca
len
e B
rach
ial
Ple
xus
wit
h
Cat
h,
Ner
ve S
tim
Inte
rsca
len
e B
rach
ial
Ple
xus
wit
h
Cat
h,
U/S
, N
erve
Sti
m
Inte
rsca
len
e B
rach
ial
Ple
xus
wit
h
Cat
h,
U/S
Lu
mb
ar P
lexu
s w
ith
Cat
h,
Ner
ve
Sti
mu
lati
on
Lu
mb
ar P
lexu
s w
ith
Cat
h,
U/S
Lu
mb
ar P
lexu
s w
ith
Cat
h,
U/S
, N
erve
Sti
mu
lati
on
Sci
atic
wit
h C
ath
, N
erve
S
tim
ula
tio
n
Sci
atic
wit
h C
ath
, U
/S
Sci
atic
wit
h C
ath
, U
/S,
Ner
ve
Sti
mu
lati
on
Su
pra
clav
icu
lar
Bra
chia
l P
lexu
s w
ith
Cat
h,
Ner
ve S
tim
Su
pra
clav
icu
lar
Bra
chia
l P
lexu
s w
ith
Cat
h,
U/S
Su
pra
clav
icu
lar
Bra
chia
l P
lexu
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
4/16/2014
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
4/16/2014
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?
4/16/2014
26
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
4/16/2014
27
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
4/16/2014
28
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.