Role of PNB in Postoperative Pain Management

Transcription

1 27th ESRA Regional Anaesthesia Cadaver Workshop Innsbruck, Austria, February 23 24, 2018 Role of PNB in Postoperative Pain Management Paul Kessler Department of Anaesthesiology and Intensive Care Medicine Orthopaedic University of Frankfurt

2 Faculty Disclosure X No, nothing to disclose Yes, please specify: Company Name Honoraria/ Expenses Consulting/ Advisory Board Funded Research Royalties/ Patent Example: company XYZ x x x Stock Options Ownership/ Equity Position Employee Other (please specify)

3 Postoperative Pain after Major Surgery in Patients With Optimized Parenteral Opioid Analgesia Brennan TJ et al, Pain 1996; 64:

4 Stressresponse Haemodynamic Instability Immuno modulation PAIN Morbidity Chronic Pain Mortality

5 Postoperative Pain Therapy Multimodal Approach Non-Opioids Regional anästhesie Techniques Opioids ASA NSAID s Metamizole Paracetamol COX-2-Inhibitors Rückenmarknahe Neuraxial, + Periphere peripheral, Verfahren truncal, local infiltration Morphine iv, oral, transdermal

6 Epidural (1.5%) and Peripheral Nerve Blocks (4.7%) were underused Fletcher D et al, Pain 2008; 137:

7 Multifactorial Causes of Undermanaged Postoperative Pain Paucity of pain assessment and documentation Heightened awareness and increased number of audits or surveys increased identification of undertreatment of pain Absence of specific written postoperative pain protocols Deficiencies in educational pain management programmes for health care workers Poor adherence to available guidelines Underuse of effective analgesic techniques (eg, epidural analgesia and peripheral nerve catheters) Wu CL et al, Lancet 2011; 377:

8 Regional Techniques for Postoperative Pain Management Neuraxial Techniques Peripheral Regional Analgesia Techniques Upper, lower limb blocks Truncal blocks Infiltration Techniques Wound Infiltration Topical Application Local Infiltration Analgesia Other Nonpharmacological Techniques

9 Evolution of Pain Control after Major Knee Surgery Intravenous Analgetics Neuraxial Blockade Peripheral Blocks Local Infiltration Analgesia

10 Epidurals and Postoperative Analgesia Meta Analysis, , TEA vs syst. opiods Block BM et al, JAMA 2003; 290:

11 Major Knee Surgery: Pain during Mobilisation Comparison of Systemic and Regional Analgesia Hours Hours Hours after the procedure Hours after the procedure Capdevila, X et al. Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after the major knee surgery Anesthesiology 1999; 91:8-15

12 Total Knee Replacement: Meta Analysis Epidural Analgesia Peripheral Nerve block 8 PRCT, 510 pts Femoral, Psoas, sciatic nerve block Summary Peripheral Nerve Blocks: Comparable analgesia to EDA Improved side effect profile (no hypotension, no urinary retention) Less difficult neurological complications (bladder disorder, paresthesia, paraplegia) Fowler SJ et al, Br J Anaesth 2008; 100:

13 Pain Management after Thoracotomy Paravertebral Blockade PROSPECT Working Group ( org) Systemic review of 74 randomized studies Recommendations TEA: local anesthetics & opioid via thoracic, started pre or intraoperatively for 2 3 days postoperatively PVB: SS or continuously for 2 3 days, fewer adverse effects compared to TEA, including hypotension, urinary retention and nausea ICB: increased VAS & opioid consumption second line treatment if thoracic epidural or PVB is not feasible Interpleural blocks not recommended Joshi GP et al, Anesth Analg 2008; 107:

14 Epidural Analgesia and Adverse Events Respiratory depression Local anaesthetics: low local anesthetics + opioids: 0.5% 1.1% Hypotension Higher incidence with lumbar (7.7%) compared with thoracic catheters (0.7% 4%) Motor Blockade Increased for lumbar (7% 50%) compared with thoracic catheters (1% 4%) Haematoma Werner MU et al, Anesth Analg 2002;95: Pöpping DM et al, Br J Anaesth 2008; 101: Flisberg P et al, Acta Anaesthesiol Scand 2003; 47:

15 Orthopaedics Peripheral Blocks, whenever possible, neuraxial blockades only, when necessary

16 Conclusions: The use of peripheral nerve blocks in lower extremity surgery is becoming a mainstay of perioperative pain management strategy Stein BE et al, J Bone Joint Surg Am. 2012;94:e167(1-13)

17 18 RCT Improved analgesia laparotomy for colorectal surgery, laparoscopic cholecystectomy, open and laparoscopic appendectomy Opiod saving effect 8 of 9 trials using preincisional TAP block and 4 of 9 with postincisional block revealed better analgesic outcomes trend toward superior analgesic outcomes when 15 ml of local anesthetic or more was used Abdallah Fw et al, Reg Anesth Pain Med 2012;37:

18 Patient Satisfaction as an Outcome of Regional Anesthesia and Analgesia: A Systematic Review Metaanalysis PRCT Result 7 of 10 studies: Regional anesthesia/analgesia results in superior postoperative analgesia, which is responsible for higher levels of patient satisfaction Wu Cl et al, Reg Anesth Pain Med, 26, 2001:

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20 Further Reasons for Regional Analgesia and Lower Limb Surgery Improved mobilisation and early functional recovery (up to 4 6 weeks) Capdevila X, Anesthesiology 1999 Singelyn, J Clin Anesth 1999 Chelly, J Arthroplasty 2001 Earlier rehabilitation and hospital discharge Capdevila X, Anesthesiology 1999 Singelyn, J Clin Anesth 1999 Chelly, J Arthroplasty 2001 Less thromboembolic complikationen Prins, Thromb Haemost 1990 McKenzie, Br J Anaesth 1991 Samama, Ann Fr Anesth Reanim 1992 Dupre, Cah Anesthesiol 1993

21 Impact of Peripheral Nerve Blocks in Hip Arthroplasty Population Based Study retrospective cohort study, data from the National Premier Perspective database ( ) N=1,062,152 total knee/ hip arthroplasty procedures; 17.9% PNB Memtsoudis SG et al, ASRA Meeting, März 2016, Abstrakt-Nr.: 1623

22 (VAS) Single Shot Continuous po Analgesia Total Knee Replacement Single Shot Femoral Catheter 8 h 12 h 1.Day Rest * 2.Day Rest * 1.Day Ex * 2.Day Ex * Salinas, F. V. et al, Anesth Analg 2006, 102(4):

23 32 RCTs Compared with sipnbs, cpnbs were associated with improved pain control decreased need for opioid analgesics less nausea greater patient satisfaction Other clinically relevant outcomes unclear complications long term functional outcomes costs Bingham AE et al, Reg Anesth Pain Med 2012;37:

24 Benefits Following Infusion Improved analgesia a few days post infusion Martin, et al, Anesthesiology 2008; 109: Salinas FV et al, Anesth Analg 2006;102: Improved analgesia 6 months post infusion Blumenthal, et al, Br J Anaesth 2011; 106: Accelerated resumption standing/lavatory use Martin, et al, Anesthesiology 2008; 109: Accelerated tolerance of passive knee flexion earlier rehabiliation center discharge Capdevila X et al, Anesthesiology 91: 8-15, 1999 Williams BA et al, Anesthesiology 2006; 104: Improved quality of life 6 weeks after TKA Carli, et al, Brit J Anaesth 2010; 105: Kadic L et al, Acta Anaesth Scand 2009; 53:

25 Local Anesthetic Delivery Regimens Bolus Supra-Therapeutical Analgesia Therapeutical Sub-Therapeutical

26 Local Anesthetic Delivery Regimens Bolus Continuous Supra-Therapeutical Analgesia Therapeutical Sub-Therapeutical

27 Local Anesthetic Delivery Regimens Bolus Continuous PCA Supra-Therapeutical Analgesia Therapeutical Sub-Therapeutical

28 Bolus Basal PCA Basal infusion maximizes benefits (sleep) Ilfeld BM et al, Anesthesiology 2004;101:970 7 Patient controlled bolus doses (most cases) Improves analgesia and minimizes opioid use Capdevila X et al, Anesthesiology 2006;105: Optimal: Allows block reinforcement (therapy, dressings) Allows decreased basal infusion rate Both basal infusion and Fredrickson MJ et al, Br J Anaesth. 2011;106: patient controlled Decreases limb weakness bolus doses Charou MT et al, Anesthesiology. 2011; 115: Ambulatory: maximizes infusion duration Improves postoperative functioning Capdevila X et al, Anesthesiology 2006;105:566 73

29 Which Regimen, Which Concentration? High concentration: good pain relief, but unwanted motor block No recommendations on the Suggestion for optimal analgesia optimal basal rate, bolus volume, Ropivacaine 0.2% Patient controlled regional anesthesia (PCRA): backgroundor infusion lockout of at least period 3 4 ml/h with a bolus dose of 5 8 ml, lockout time 60 min

30 Most Common Indications for PNBs Superior analgesia Less supplemental analgesics Less opiod effects (opioids) Higher level of satisfaction Better sleep (quality) Faster discharge readiness Shorter hospitalization Passive range of motion Improved rehabilitation Ilfeld BM, Anesth Analg 2011, 113: Liu S et al, Anesth Analg. 2005;101: Richman JM et al, Anesth Analg 2006;102:248 57

31 Advantages of Continuous Peripheral Nerve Blocks Evidence based Advantages improved Analgesia Interscalene Infraclavicular Psoas Femoral block Distal Sciatic at rest movement Ilfeld BM, Anesth Analg 2011, 113:

32 Advantages of Continuous Peripheral Nerve Blocks Evidence based Advantages improved Analgesia Lower opioid consumption Interscalene Infraclavicular Psoas Femoral block Distal Sciatic at rest movement oral opioids iv opioids Ilfeld BM, Anesth Analg 2011, 113:

33 Advantages of Continuous Peripheral Nerve Blocks Evidence based Advantages Interscalene Infraclavicular Psoas Femoral block Distal Sciatic improved Analgesia Lower opioid consumption Less opioid side effects at rest movement oral opioids iv opioids nausea itching sedation Ilfeld BM, Anesth Analg 2011, 113:

34 Advantages of Continuous Peripheral Nerve Blocks Evidence based Advantages Interscalene Infraclavicular Psoas Femoral block Distal Sciatic improved Analgesia Lower opioid consumption at rest movement oral opioids iv opioids nausea Less opioid side effects itching sedation Higher satisfaction Earlier discharge Improved joint function shoulder knee hip foot mod. from Ilfeld BM, Anesth Analg 2011, 113:

35 Infection Higher infection rate after catheter procedure in comparison to single shot procedure La-Wendling L et al, Current Opinion in Anaesthesiology 2008, 21:

36 Infectious Complications associated with CPNB Colonization: 23.7% 57% Local Infection: 0% 13.7% Systemic Infection: 0% 0.9% Capdevila X et al, Anesthesiology 2009; 110:182 8

37 Risk Factors for the Development of Perineural Catheter Inflammation or Infection Catheter use longer > 48h Admission to the ICU No prophylactic antibiotics Axillary and femoral catheter Frequent change of dressing Capdevila X et al, Anesthesiology 2005; 103: Neuburger M et al, Acta Anaesthesiol Scand 2007; 51: Cuvillon P et al, Anesth Analg 2001; 93:

38 Major Components of Aseptic Technique Removal of watches and jewelry Preprocedural hand hygiene with an alcohol based antiseptic solution Protective barriers surgical hat and mask and sterile gloves Appropriate selection and application of skin disinfectant involves use of chlorhexidine gluconate in an alcohol base Proper sterile draping technique(s) Maintenance of a sterile procedural field Appropriate dressing techniques Proper preparation of local anesthetic infusate solutions JR. Hebl, AD. Niesen, Curr Opin Anesthesiol 24: 2011

39 Postoperative Neurologic Symptoms After Regional Anesthesia Transient paresthesia (< 7 days) < 3 : 100 (< 3%) Postoperative neurologic deficit (< 2 months) ~20 : 10,000 (0.2%) Longterm nerve injury (~ 12 months) < 3 : 10,000 (< 0.03%) Brull R et al, Anesth Analg 2007; 104: Auroy Y et al, Anesthesiology. 2002; 97: Neal JM, Reg Anesth Pain Med 2010; 35: S59-S67

40 Ultrasound Nerve Stimulation PNBs Summary 2018 Metaanalysis, RCTs, register analysis US guided peripheral regional anaesthesia Higher success rate Faster block onset Less local anesthetic Less vessel puncture No difference of nerve injury Abrahams MS et al, Br J Anaesth 2009; 103: Neal JM et al, Reg Anesth Pain Med 2010; 35: S1-9 Liu SS et al, Reg Anesth Pain Med 2010;35: S26-S35 Gelfand HJ et al, J Clin Anesth 2011, 23, Munirama S et al, Anaesthesia 2015, 70, Lewis SR et al, Cochrane Database Syst Rev Sep 11;(9):CD006459

41 Massive retro-peritoneal hematoma without neurological deficit after psoas block and concomitant anticoagulation RS Weller, Anesthesiology, 98, 2003:

42 Bleeding Complications after Femoral + Sciatic Nerve-Catheter 3 Cases, TKR Femoral-sciatic nerve catheter Removal 3h after sc LMWH Time interval? Bickler P et al, Anesth Analg 2006; 103:1036 7

43 Preventive Measures Indication, guidlines, atraumatic puncture Intraoperative: short acting LA Immediately postoperative: stopp LA, evaluation of neurology Regular neurologic assessment every 6-8 h Postoperative: low concentrated LA ± opioids Before catheter removal: no LA Acute pain service Logistic requirements: CT, MRI and neurosurgeons

44 Femoral Nerve Block Falls after Major Knee Surgery Single injection does not increase the risk over no block No falls with Single injections: no ambulation within 12h Ilfeld BM, Anesthesiology 2014, 121(3):668-9 Case reports of falls during femoral infusion Kandasami M et al, Knee Mar;16(2): Feibel RJ et al, J Arthroplasty Sep;24(6 Suppl):132-7 Continuous vs single injection: increase RR 4.4 Wasserstein D et al, J Arthroplasty. 28 (2013) Meta analyses RCT: increase RR 3.9 and 5.5 Johnson RL et al, Br J Anaesth 110 (4): (2013) Ilfeld BM et al, Anesth Analg Dec;111(6): Causal association with perineural infusion and falls

45 Knee Arthroplasty Preoperative quadriceps Weakness 58,34 cm 2 40,23 cm 2 Petterson SC et al, Med Sci Sports Exerc 2011, 43,

46 Alternatives to PNB in Postoperative Pain Management Motor sparing blocks? Local infiltration analgesia? Additives to local anaesthetics?

47 VAS Extend the knee Koh HJ et al, J Arthroplasty Jun;32(6):

48 Limitations of Continuous Peripheral Nerve Block Catheter associated block failure Incidence 10% 40% Salinas FV. Reg Anesth Pain Med 2003; 28: Marhofer D et al, Brit J Anaesth 111 (5): (2013)

49 Successfully Working Peripheral Catheter Requirements 1. Nerve/Plexus localization 2. Needle Placement 3. Catheter placement 4. Distribution of local anesthetic 5. Catheter fixation 6. Equipment Primary Block Failure Secundary Block Failure

50 Catheter Insertion Techniques 1. Usual practice: Blind catheter insertion after correct needle placement 2. Stimulation catheters 3. Ultrasound guided catheter insertion Key question: where is the catheter tip?

51 Catheter Tip and Local Anesthetic? mod. from Mariano ER et al, Can J Anesth (2010) 57:

52 1. Ultrasound guided Catheter Insertion Needle in plane, Nerve in Short Axis Catheter tip near the nerve Catheter bypassing the nerve mod. from Mariano ER et al, Can J Anesth (2010) 57:

53 Nerve in short axis, in plane Puncture Femoral Nerve Block

54 and Assistance Required: 3. Hand

55 2. Ultrasound guided Catheter Insertion Needle in plane, Nerve in long axis Catheter tip near the nerve Catheter far off the nerve mod. from Ilfeld BM et al, Reg Anesth Pain Med 2010

56 3. Ultrasound guided Catheter Insertion Needle out of plane, Nerve in short axis Method of choice for cpnb, familiar, parallel needle to nerve insertion Disadvantages Visualisation of the needle tip combina on of ssue movement hydrodissection and hydrolocation mod. from Ilfeld BM et al, Reg Anesth Pain Med 2010

57 Nerve in Short Axis, out of plane Puncture Interscalene Nerve Block

58 Limitations of Continuous Peripheral Nerve Block Catheter associated block failure Incidence 10% 40% Salinas FV. Reg Anesth Pain Med 2003; 28: Marhofer D et al, Brit J Anaesth 111 (5): (2013) Complications

59 Complications of Malposition of Catheter Tip Epidural, intrathecal, intravascular, interpleural placement Tuominen MK et al, Anesthesiology Aug;75(2): Souron V et al, Anesth Analg Oct;97(4): Litz RJ et al, Reg Anesth Pain Med Jan-Feb;29(1):60-4 Cook LB, Br J Anaesth Oct;67(4):473-5 Walter M et al, Anaesthesist 2005, 54: Gaus P et al, Anaesthesist 2011, 60: Yanovski B et al, Anaesthesia 2012, 67,

60 Epidural Malposition of an Interscalene Catheter Gaus P et al, Anaesthesist 2011, 60:

61 Intrathecal Misplacement of an Interscalene Catheter Walter M et al, Anaesthesist 2005, 54:

62 Catheter near the intervertebral foramina at C5 6 Contrast dye in the intrathecal space at C6 Blind and deep insertion increases the risk of an abnormal catheter position Anaesthesia 2012, 67,

63 Complications of Malposition of Catheter Tip Epidural, intrathecal, intravascular, interpleural placement Tuominen MK et al, Anesthesiology Aug;75(2): Souron V et al, Anesth Analg Oct;97(4): Litz RJ et al, Reg Anesth Pain Med Jan-Feb;29(1):60-4 Cook LB, Br J Anaesth Oct;67(4):473-5 Walter M et al, Anaesthesist 2005, 54: Gaus P et al, Anaesthesist 2011, 60: Yanovski B et al, Anaesthesia 2012, 67, Avoidance Insert catheter only 3 5 cm past needle tip Test dose including local anaesthetic and epinephrine? Catheter: bolus anesthetic via catheter?

64 Catheter Dislodgement Preventing?, securing catheters Dressing Suture Tunneling? Rate of dislodgement : Tunneling < Suture < Dressing Compere V et al, Acta Anaesthesiol Scand 2009; 53: Cuvillon P et al, Anesth Analg 2001; 93:

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66 Other Catheter associated Failures Leakage at catheter site (0 40%) Catheter in the needle technique: Puncture hole > catheter diameter Superficial > deeper blocks Avoidance Inpatients: dermabond Future patients: proactive dermabond, tunnel? New catheter: catheter over the needle technique

67 Catheter over the needle Technique

68 Other Rare Catheter associated Failures Catheter knotting Offerdahl MR et al, Anesth Analg 2004;99: Motamed C et al, Reg Anesth 1997;22:486 7 Bures E et al, Ann Fr Anesth Reanim. 2009;28: Insert catheter minimum distance past needle tip Optimal insertion distance? No knot reported < 5 cm < 2 cm may dislodge Removal, extraction, shearing Vary positioning Offerdahl MR et al, Anesth Analg 2004;99: Interventional radiology Burgher AH et al, Reg Anesth Pain Med 2007;32:162 6 Surgical removal

69 Other Rare Catheter associated Failures Catheter shearing Do not pull catheter back into needle Bergman BD et al, Anesth Analg 2003;96: Lee BH et al, Anesth Analg 2002;95:760 1 Neuburger M et al, Anaesthesist : Catheter breakage Chin KJ et al, Reg Anesth Pain Med 2006;31:

70 Catheter Shearing 3D CT Reconstruction of a cut axillary catheter Neuburger et al, Anaesthesist, 2011