New Kids on the Block: Advances in Regional Anesthesia Practice. Melissa Byrne DO,

Transcription

1 New Kids on the Block: Advances in Regional Anesthesia Practice Melissa Byrne DO,

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9 Precision Acute Care Medicine

10 Chronic Pain

11 Nurse, get on the internet, go to NYSORA.COM, scroll down and click on the Are you totally lost? icon.

12 Roadmap for Discussion Take Home Points Novel Local Anesthetics Lower Extremity Blocks Fascial Plane Blocks

13 Overview Who can do it? What do you need? Where should you place them? Why bother?

14 Who Can Do It?

15 What Do You Need? Catheters / Needles Single- or multi-orifice catheters Stimulating or nonstimulating Flexible springwound or rigid plastic Through or over the needle

16 Overview Who can do it? What do you need? Where should you place them? Why bother?

17 Truncal Fascial Plane Blocks Tactile pops and clicks + ultrasound fascial plane blocks Fastest growing subset of blocks If we can see it, we can now block it. (Elsharkawy et al., RAPM 2018)

18 The Rise of the Fascial Plane Block TAP Serratus Anterior QLB PECS El-Boghdadly & Pawa (Anaesthesia, 2017)

19 Transversus Abdominis Plane (TAP) Blocks

20 TAP Blocks Why Bother? Recent meta-analysis of US-guided TAP blocks Baeriswyl et al, Anesth Analg 2015 Statistically significant but clinically modest analgesic benefit in adult patient undergoing abdominal laparotomy, laparoscopy or cesarean delivery 6 and 11 mg IV morphine at 6 and 24 hours, respectively

21 Beneficial Upper Abdominal Surgery: Subcostal TAP block is a useful alternative when epidural analgesia is contraindicated with fewer side effects such as hypotension Colorectal Surgery: open and laparoscopic Open appendectomy Abdominoplasty

22 The Data is Out Major open gynecological surgery including total abdominal hysterectomy Laparoscopic total hysterectomy Open inguinal hernia surgery Laparoscopic donor nephrectomy Cesarean delivery

23 No Benefit Laparoscopic cholecystectomy Laparoscopic Roux-en-Y bypass surgery Laparoscopic appendectomy Open radical retropubic prostatectomy Reconstructive abdominal surgery Renal transplantation

24 Quadratus Lumborum (QL)

25 Quadratus Lumborum (QL)

26 QL Block Why Bother? Sparse literature; most only case reports

27 PECs Blocks

28 PECS Blocks PECS I - Lateral and medial pectoral nerves blocked - Suitable for surgeries involving pecs major muscle (e.g., breast expanders, traumatic chest injuries, Portocath, pacemaker insertion)

29 PECS Blocks PECS II - T2-4 spinal nerves (including intercostobrachial) and long thoracic nerve may be blocked - Suitable for more extensive excisions (e.g., tumor resections, mastectomy, axillary clearance, sentinel node excision, tissue expanders)

30 PECS Blocks Why Bother? RCTs for mastectomy Decreased opioid consumption and pain scores in first 24 hours compared to paravertebral (PVB) blocks (Wahba and Kamal, 2014) Lower pain scores and opioid use (Bashandy and Abbas, 2015) Increased duration of analgesia compared to PVB (Kulhari, 2016)

31 PECS Blocks Why Bother? Case Reports Insertion of cardiac resynchronization device with block and dexmedetomidine Mastectomy under PECS II with supplemental infiltration Alternative to brachial plexus blockade for axilla, proximal medial upper arm and posterior shoulder

32 Serratus Anterior - Thoracodorsal, thoracic intercostal nerves may be blocked - Suitable for latissimus dorsi flap reconstruction

33 Serratus Anterior Why Bother? Early data Duration of paresthesia in intercostal nerve distribution T2-9 was 752 minutes Case reports Rib fracture: enabled PT and ambulation Thoracotomy: pain and ventilation improvement RCTs Increased opioid consumption during radical mastectomy compared to PVB Less hemodynamic change compared to thoracic epidural in thoracotomy

34 Erector Spinae (ESP) Blocks

35 ESP Is this a paravertebral block by proxy???

36 ESP Why Bother? Early data Case reports/series Rib fractures (single shot and catheters employed) Pleuroscopy: minimized procedural sedation (T5 level) Bariatric surgery Thoracotomy (as rescue analgesic) Pilot study Laparoscopic ventral hernia repair (T7 level)

37 Roadmap for Discussion Take Home Points Novel Local Anesthetics Lower Extremity Blocks Fascial Plane Blocks

38 Adductor Canal Indications: saphenous vein stripping, supplementation for medial foot/ankle surgery, analgesia for knee surgery

39 Adductor Canal Why Bother? TKA Similar pain scores to femoral nerve block Quad strength preserved and ambulation retained (several studies) compared to FNB Analgesic and opioid-sparing benefits in TKA KEY COMPONENT OF MULTIMODAL ANALGESIC PLAN

40 Adductor Canal Why Bother? Minor knee arthroscopies Little benefit (i.e., multimodal with NSAIDs + APAP = ACB) ACL reconstruction mixed data

41 ipack Blocks ipack = interspace between the popliteal artery and capsule of the posterior knee

42 ipack Why Bother? Early data ipack + ACB equivalent analgesia + improved PT + earlier hospital discharge post-tka (Thobhani et al, Ochsner Journal 2017) ipack + ACB better analgesia + improved ROM and number of steps walked post-tka than ACB alone (Reddy et al, Int J Orthop Sci 2017)

43 Roadmap for Discussion Take Home Points Novel Local Anesthetics Lower Extremity Blocks Fascial Plane Blocks

44 Liposomal Bupivacaine (Exparel )

45 Liposomal Bupivacaine Why Bother? Many efficacy studies in surgical infiltration but compare only to placebo Hemorrhoidectomy Mammoplasty Bunionectomy Forefoot surgery TKA

46 Liposomal Bupivacaine Why Bother? Single-injection PNB NOTE: only FDA-approved for interscalene & TAP blocks Femoral blocks: dose-response study (Ilfeld et al, Anesth Analg 2013) High degree of intersubject variability Peak effect at 24 hours in 75% of subjects MUCH less than predicted 72 hours by manufacturer

47 Liposomal Bupivacaine Why Bother? Robotic-assisted hysterectomy Decrease in LOS with TAP blocks Potentially long-term opioid-sparing benefit Laparoscopic prostatectomy No difference in median time to opioid use, pain scores comparing 20 ml vs 40 ml No placebo group included Open abdominal umbilical hernia repair Pain severity, opioid-related adverse events recorded No placebo group included

48 Liposomal Bupivacaine Why Bother?

49 Liposomal Bupivacaine Why Bother?

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51 Final Words on Liposomal Bupivacaine

52 SABER

53 SABER Why Bother? Laparoscopic cholecystectomy Did not meet its primary efficacy for Phase 3 trial with 380 patients No statistical difference in pain reduction with movement over first 48 hours post surgery compared to bupivacaine HCl Open hernia repair Significantly lower AUC for mean pain intensity from 1-72 hours compared to placebo Abdominal surgery Decreased pain for 3 days

54 Roadmap for Discussion Take Home Points Novel Local Anesthetics Lower Extremity Blocks Fascial Plane Blocks

55 Take Home Points Continued emphasis on precision acute care medicine and avoiding persistent postoperative pain Multiple newer fascial plane blocks can be employed in the perioperative period Research regarding outcomes demands further investigation Novel long-acting formulations may provide additional benefit

56 References H. Elsharkawy, A. Pawa, E.R. Mariano. Interfascial Plane Blocks: Back to Basics. Regional Anesthesia and Pain Medicine 43(4): , May El-Boghdadly K, Pawa A. The erector spinae plane block: plane and simple. Anaesthesia. 2017: 72;4: K.J. Chin, J.G. McDonnell, B. Carvalho, A. Sharkey, A. Pawa, J. Gadsden. Essentials of our current understanding: abdominal wall blocks. Reg Anesth Pain Med. 2017; 42: Baeriswyl M, Kirkham KR, Kern C, Albrecht E. The analgesic efficacy of ultrasound-guided transversus abdominis plane block in adult patients: a meta-analysis. Anesth Analg. 2015;121: Ganapathy S, Sondekoppam RV, Terlecki M, et al. Comparison of efficacy and safety of lateral-to-medial continuous transversus abdominis plane block with thoracic epidural analgesia in patients undergoing abdominal surgery: a randomised, open-label feasibility study. Eur J Anaesthesiol. 2015;32: Niraj G, Kelkar A, Jeyapalan I, et al. Comparison of analgesic efficacy of subcostal transversus abdominis plane blocks with epidural analgesia following upper abdominal surgery. Anaesthesia. 2011;66: Wahba SS, Kamal SM. Analgesic efficacy and outcome of transversus-abdominis plane block versus low thoracic-epidural analgesia after laparotomy in ischemic heart disease patients. J Anesth. 2014;28: Wu Y, Liu F, Tang H, et al. The analgesic efficacy of subcostal transversus abdominis plane block compared with thoracic epidural analgesia and intravenous opioid analgesia after radical gastrectomy. Anesth Analg. 2013;117: Blanco R, Ansari T, Girgis E. Quadratus lumborum block for postoperative pain after caesarean section: a randomised controlled trial. Eur J Anaesthesiol. 2015;32: Murouchi T, Iwasaki S, Yamakage M. Quadratus lumborum block: analgesic effects and chronological ropivacaine concentrations after laparoscopic surgery. Reg Anesth Pain Med. 2016;41: Parras T, Blanco R. Randomised trial comparing the transversus abdominis plane block posterior approach or quadratus lumborum block type I with femoral block for postoperative analgesia in femoral neck fracture, both ultrasound-guided. Rev Esp Anestesiol Reanim. 2016;63: McCrum CL, Ben-David B, Shin JJ, Wright VJ. Quadratus lumborum block provdes improved immediate postoperative analgesia and decreased opioid use compared with a multimodal pain regimen following hip arthroscopy. J Hip Preservation Surg. 2018; 5:3: Chin KJ, Adhikary S, Sarwani N, Forero M. The analgesic efficacy of pre operative bilateral erector spinae plane (ESP) blocks in patients having ventral hernia repair. Anaesthesia 2017; 72: Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain. RAPM 2016;41: Forero M, Rajarathinam M, Adhikary S, Chin KJ. Continuous erector spinae plane block for rescue analgesia in thoracotomy after epidural failure: a case report. AA Case Rep 2017;8: Chin KJ, Adhikary S, Sarwani N, Forero M. The analgesic efficacy of pre-operative bilateral erector spinae plane (ESP) blocks in patients having ventral hernia repair. Anaesthesia 2017;72: Chin KJ, Malhas L, Perlas A. The erector spinae plane block provides visceral abdominal analgesia in bariatric surgery: a report of 3 cases. RAPM 2017;42: Accessed 11/25/2018.

57 References Jenstrup, MT, Jæger, P, Lund, J, Fomsgaard, JS, Bache, S, Mathiesen, O, Larsen, TK, Dahl, JB Effects of adductor-canal-blockade on pain and ambulation after total knee arthroplasty: A randomized study.. Acta Anaesthesiol Scand. (2012) A.V. Gururva Reddy, A. Jangale, R.C. Reddy, M. Sagi, A. Gaikwad, A. Reddy. To compare effect of combined block of ACB with IPACK and ACB alone on total knee replacement in immediate postoperative rehabilitation. Int J Orthop Sci, 3 (2017), pp Thobhani S, Scalercio L, Elliott CE, Nossaman BD, Thomas LC, Yuratich D, Bland K, Osteen K, Patterson M. Novel regional techniques for total knee arthroplasty promote reduced hospital length of stay: an analysis of 106 patients. Ochsner Journal 2017; 17: M.A. Mont, W.B. Beaver, S.H. Dysart, J.W. Barrington, D.J. Del Gaizo. Local infiltration analgesia with liposomal bupivacaine improves pain scores and reduces opioid use after total knee arthroplasty: results of a randomized controlled trial. J Arthroplasty, 33 (2018), pp Hadzic s Textbook of Regional Anesthesia and Acute Pain Management. Chapter 8: Controlled-Release Local Anesthetics. Accessed 11/25/2018.

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