Is There an Ideal Regimen for CPNB?

Transcription

1 Is There an Ideal Regimen for CPNB? Dr Eric Albrecht, MD, DESA Department of Anesthesiology, CHUV 2nd SARA Annual Symposium June 2013

2 Manuel pratique d ALR échoguidé, Elsevier Masson, Paris, 2013 Albrecht E, editor

3 Benefits of CPNB (RCT evidence) Reduction in pain scores (rest / movement) Reduction in opioid consumption on POD Decreased rate of opioid side-effects (PONV / Pruritus) Satisfaction score improvement Quality of sleep improvement Mariano et al, Anesth Analg, 2009 Ilfeld et al, Anesth Analg 2011 Bingham et al, RAPM, 2012

4 Other Benefits of CPNB Improved rehabilitation Shorter hospital stays Chelly et al, J Arthro, 2001 Kadic, Acta Anaesth Scand, 2009 Singelyn et al, Anesth Analg 1998 White et al, Anesth Analg 2003

5 Is There an Ideal Regimen for CPNB?

6 Questions Bolus before or after catheter insertion? What LA? What concentration? What adjunct? What settings? How long?

7 Bolus before/after catheter insertion? Through-the-needle technique => Secondary block failure rate: 37-80% Capdevila et al, Anesth Analg, 2002 Salinas et al, RAPM, 2003 Dhir et al, Acta Anaesth Scand, 2008 Through-the-catheter technique => Secondary block failure rate: 1-8% Borgeat et al, Anesthesiology, 2003 Borgeat et al,rapm, 2004

8 US tricks to localize the tip Direct visualization of LA spread Use of color flow Doppler Injection of agitated microbubbles (hyperechoic spread) Injection of air Swenson et al, Anesth Analg, 2008 Dhir et al, Acta Anaesth Scand, 2008

9 Continuous IS Block

10 Continuous IS Block

11 Continuous IS Block

12 Bolus before/after catheter insertion? Bolus after catheter insertion Visualization of LA spread

13 WHAT LA? Ropivacaine % Levobupivacaine % Bupivacaine %

14 Which one? 60 patients: Ropi 0.2% vs Bupi 0.15% Settings: 5 ml/h; bolus 4 ml/20 min Similar pain outcomes Less hand weakness and fingers paresthesias with Ropi 0.2%

15 Which one? 50 patients: Ropi 0.2% vs L-Bupi 0.125% Settings: 6 ml/h; bolus 2 ml/15 min Similar pain outcomes Smaller volume of LA in group L-Bupi

16 Which one? 60 patients for hand surgery Ropi 0.125% vs Bupi 0.125% Settings: self administered bolus 10 mlbolus/60 min Similar pain outcomes

17

18 Common sense

19 WHAT LA? Ropivacaine 0.2%

20 WHAT ADJUNCT?

21 CLONIDINE? Similar pain scores, bolus doses, oral analgesics intake Similar sleep quality score and patient satisfaction

22 EPINEPHRINE? 40 patients: Ropi 0.2% vs Ropi 0.2% + E Settings: 20 ml/120 min Equivalent duration of analgesia Equivalent LA and rescue analgesics consumption

23 WHAT ADJUNCT? None

24 Mode of administration Basal rate + Bolus doses > Basal rate or Bolus doses only

25 What settings?

26 What is the primary determinant of CPNB effect? Local anesthetic dose (total mass)? Volume (rate)? Concentration?

27 CONTINUOUS FEMORAL NERVE BLOCK

28 Anesth Analg, 2010

29 Optimal balance between analgesia and mobility?

30 Single-shot or continuous infusion femoral nerve blockade after total knee arthroplasty? A randomized, placebo-controlled, double-blind trial E Albrecht, D Morfey, V Chan, R Gandhi, A Koshkin, KJ Chin, S Robinson, Ph Frascarolo, and R Brull Department of Anesthesia University of Toronto Toronto Western Hospital Toronto ON, CANADA

31 Concentration? Volume?

32 99 patients with CFNB / SNB / IT morphine

33 Time to discharge readiness

34 Early functional outcomes

35 Late functional outcomes

36 Settings? Basal rate: 5-10 ml/h Bolus: 2-5 ml Lockout time: min

37 How Long?

38 cfnb / clbb => 1 day vs 4 days Criteria to discharge readiness: Pain score < 4/10 No iv opioids for 12 h Ambulation > 30 m

39

40 CONCLUSION Bolus AFTER catheter insertion ROPIVACAINE 0.2% without adjunct Settings: Basal rate: 5-10 ml/h Bolus: 2-5 ml Lockout-time: 30 min Period of 4 days

41 THANK YOU!