The lecturer has no financial interests and does not receive salary from any pharmaceutical company.

Transcription

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2 The lecturer has no financial interests and does not receive salary from any pharmaceutical company. 2

3 Some of the key questions of this presentation. 3

4 We are not talking about Africa or South America, these are data from Europe and USA. 4

5 Acute pain is one of the most important factors influencing chronic postsurgical pain. 5

6 Acute postoperative pain is followed by persistent pain in 10-50% of individuals after common operations, such as groin hernia repair, breast and thoracic surgery, leg amputation, and coronary artery bypass surgery. Since chronic pain can be severe in about 2-10% of these patients, persistent postsurgical pain represents a major, largely unrecognised clinical problem. Iatrogenic neuropathic pain is probably the most important cause of long-term postsurgical pain. Consequently, surgical techniques that avoid nerve damage should be applied whenever possible. Also, the effect of aggressive, early therapy for postoperative pain should be investigated, since the intensity of acute postoperative pain correlates with the risk of developing a persistent pain state. Finally, the role of genetic factors should be studied, since only a proportion of patients with intraoperative nerve damage develop chronic pain. Based on information about the molecular mechanisms that affect changes to the peripheral and central nervous system in neuropathic pain, several opportunities exist for multimodal pharmacological intervention. Here, we outline strategies for identification of patients at risk and for prevention and possible treatment of this important entity of chronic pain. Kehlet H et al. Lancet 2006; 13: All data in are copied from the original article to describe the slide (mostly explanation of figures or abstracts of articles). 6

7 Acute postoperative pain is followed by persistent pain in 10-50% of individuals after common operations, such as groin hernia repair, breast and thoracic surgery, leg amputation, and coronary artery bypass surgery. Since chronic pain can be severe in about 2-10% of these patients, persistent postsurgical pain represents a major, largely unrecognised clinical problem. Iatrogenic neuropathic pain is probably the most important cause of long-term postsurgical pain. Consequently, surgical techniques that avoid nerve damage should be applied whenever possible. Also, the effect of aggressive, early therapy for postoperative pain should be investigated, since the intensity of acute postoperative pain correlates with the risk of developing a persistent pain state. Finally, the role of genetic factors should be studied, since only a proportion of patients with intraoperative nerve damage develop chronic pain. Based on information about the molecular mechanisms that affect changes to the peripheral and central nervous system in neuropathic pain, several opportunities exist for multimodal pharmacological intervention. Here, we outline strategies for identification of patients at risk and for prevention and possible treatment of this important entity of chronic pain. Kehlet H et al. Lancet 2006; 13:

8 Sites and mechanisms responsible for chronic postsurgical neuropathic pain (1) Denervated Schwann cells and infiltrating macrophages distal to nerve injury produce local and systemic chemicals that drive pain signalling. (2) Neuroma at site of injury is source of ectopic spontaneous excitability in sensory fibres. (3) Changes in gene expression in dorsal root ganglion alter excitability, responsiveness, transmission, and survival of sensory neurons. (4) Dorsal horn is site of altered activity and gene expression, producing central sensitisation, loss of inhibitory interneurons, and microglial activation, which together amplify sensory flow. (5) Brainstem descending controls modulate transmission in spinal cord. (6) Limbic system and hypothalamus contribute to altered mood, behaviour, and autonomic reflexes. (7) Sensation of pain generated in cortex (past experiences, cultural inputs, and expectations converge to determine what patient feels). (8) Genomic DNA predispose (or not) patient to chronic pain and affect their reaction to treatment. Kehlet H et al. 2006, 367:

9 Patient questionnaires reflect another reality compared to what surgeons tell us about postsurgical pain after major joint arthroplasty. 9

10 Patient questionnaires reflect another reality compared to what surgeons tell us about postsurgical pain after major joint arthroplasty. 10

11 Chronic pain after hip and knee replacement is a prevalent and overlooked issue to be addressed in the health care industry. Patients seek out joint replacements to relieve their chronic pain and restore their functional activities because of arthritis and injury. The intensity and duration of postsurgical pain vary, but with uncomplicated wound healing, the pain typically shows progressive attenuation. Chronic pain after surgery occurs after the normal time for tissue to heal and can be detrimental for the patient. It is possible that certain nerve damage or irritation during surgery plays a role in development of persistent pain after joint replacement. The nature and properties of persistent postsurgical pain are poorly characterized. Risk factors for persistent postsurgical pain after these surgeries are vast and inclusive of preoperative, intraoperative, and postoperative factors in relation to pain catastrophizing, surgical approach, nerve injury, and acute pain management. Pain catastrophizing is conceptualized as a negative cognitive affective response to anticipated or actual pain and has been associated with many important pain-related outcomes. The majority of the times the views of medical and surgical interventions differ from the surgeons and the patients, especially in respect to the assessment of function and pain. Patient-reported outcome tools and assessment of satisfaction are included to ensure the patient's perception of the end results is included in the evaluation of total knee replacement. Vilardo L et al. Tech in Reg Anesth and Pain Mag 2011; 15:

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13 The impact of acute pain services on health costs must be further evaluated to assure that the efforts of these services will not be rationalized due to financial pressure. 13

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15 This is a letter to the editor by an orthopedic surgeon as reaction to the editorial by Fredrickson. Obviously, this colleague has a) very bad anesthesiologists or b) a different point of view. Important is not if he is right or not. When a surgeon accuses you of wasting money then the financial department will tell you to prove that you are not! The question is: do we have enough data to state, that continuous perineural catheters are cost-effective? And if we have, what are our arguments. The following slides shall give you an overview of the different positive issues and the issues, where our arguments are not based on good research. 15

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22 BACKGROUND: This study investigated the cost-effectiveness of ultrasonographic-guided interscalene brachial plexus blockade (ISB) in comparison with general anaesthesia (GA) for arthroscopic shoulder surgery. METHODS: Forty patients undergoing arthroscopic shoulder surgery received either an ultrasonographicguided ISB or GA. ISB was performed outside the operation room (OR) and patients were transferred in the OR at the earliest 20 min after block performance. All drugs and disposables were recorded to evaluate the costs for both techniques. The following anaesthesia-related times were defined: ready for surgical preparation (from arrival in the OR until end of anaesthesia induction), OR emergence time (from end of dressing until leaving the OR), anaesthesia control time (from patient's arrival in the OR until readiness for positioning plus time from the end of surgery to patient's discharge from the OR), and post-anaesthesia care unit (PACU) time (from patient's arrival in the PACU to the eligibility for discharge to normal ward). Personnel costs were excluded from statistical analysis. RESULTS: The total costs were [mean (sd)] 33 (9)euro for patients with ISB and 41 (7)euro for those who received GA (P<0.01). The anaesthesia-related workflow was improved in the ISB group when compared with the GA group [ready for surgical preparation 8 (3) vs 13 (5) min, P<0.001; OR emergence time 4 (3) vs 10 (5), P<0.001; anaesthesia control time 12 (4) vs 23 (6), P<0.001; and PACU time 45 (17) vs 70 (20), P<0.001]. CONCLUSIONS: Ultrasonographic-guided ISB is a cost-effective method for arthroscopic shoulder surgery. Gonano C et al. BJA 2009; 103:

23 Figure (right): Economical aspects and time analysis. ISB group, interscalene group; GA group, general anaesthesia group. Data are presented as mean (SD). ISB time: from sterile preparation of the skin until withdrawing of the needle; Sensory onset time of ISB: time from administration of the local anaesthetic until pinprick 0; Ready for surgical preparation: time from arrival in the OR until end of anaesthesia induction; Surgical time: from incision to skin closure; OR emergence time: from end of dressing until leaving the OR; Anaesthesia control time: from patient s arrival in the OR until readiness for positioning plus time from the end of surgery to patient s discharge from the OR; Total anaesthesia time: ISB time plus anaesthesia control time; PACU time: from patient s arrival in the PACU to the eligibility for discharge to normal ward. Gonano C et al. BJA 2009; 103:

24 Figure: Summary of costs per minute for one OR at the Medical University of Vienna. The total costs are 14.89E. *Costs for 1 min GA.1 Costs for installation of surgical and anaesthesia equipment, respirator, monitoring, X-ray, electric cauter, etc. Information technology, administration, laundry, accounting, billing, maintenance, safety, procurement, and storage costs. }Includes cleaning and energy costs. Gonano C et al. BJA 2009; 103:

25 Abstract: Although most randomized clinical trials conclude that the addition of continuous peripheral nerve blockade (CPNB) decreases postoperative pain and opioid-related side effects when compared with opioids, studies have included relatively small numbers of patients and the majority failed to show statistical significance during all time periods for reduced pain or side effects. We identified studies primarily by searching Ovid Medline (1966-May 21, 2004) for terms related to postoperative analgesia with CPNB and opioids. Each article from the final search was reviewed and data were extracted from tables, text, or extrapolated from figures as needed. Nineteen articles, enrolling 603 patients, met all inclusion criteria. Inclusion criteria were a clearly defined anesthetic technique (combined general/regional anesthesia, general anesthesia alone, peripheral nerve block), randomized trial, adult patient population (> or =18 yr old), CPNB (or analgesia) used postoperatively (intrapleural catheters were deemed not to be classified as a peripheral nerve catheter), and opioids administered for postoperative analgesia in groups not receiving peripheral nerve block. Perineural analgesia provided better postoperative analgesia compared with opioids (P < 0.001). This effect was seen for all time periods measured for both mean visual analog scale and maximum visual analog scale at 24 h (P < 0.001), 48 h (P < 0.001), and 72 h (mean visual analog scale only) (P < 0.001) postoperatively. Perineural catheters provided superior analgesia to opioids for all catheter locations and time periods (P < 0.05). Nausea/vomiting, sedation, and pruritus all occurred more commonly with opioid analgesia (P < 0.001). A reduction in opioid use was noted with perineural analgesia (P < 0.001). CPNB analgesia, regardless of catheter location, provided superior postoperative analgesia and fewer opioid-related side effects when compared with opioid analgesia. Figure: Mean visual analog scale (VAS) pain scores for each treatment group are shown at 24, 48, and 72 h postoperatively. P < for all days after surgery. Number of patient observations n = 278, 217, and 30 respectively at 24, 48, and 72 h for continuous catheters (e.g., the number of patients with recorded mean VAS pain scores receiving perineural catheters at 24 h from the combined studies was 278). Number of patient observations n = 286, 227, and 30 respectively at 24, 48, and 72 h for opioids. Numbers in parenthesis represent 95% confidence intervals. Richman JM et al. A&A 2006; 102:

26 Figure: Maximum visual analog scale (VAS) pain scores for each treatment group are shown at 24 and 48 h postoperatively. (P < 0.001) Number of patient observations n = 86 at 24 and 48 h for continuous catheters (e.g., the number of patients with recorded maximum VAS pain scores receiving perineural catheters at 24 h from the combined studies was 86). Number of patient observations n = 97 at 24 and 48 h for opioids. Numbers in parenthesis represent 95% confidence intervals. Richman JM et al. A&A 2006; 102:

27 Figure: In results, numerator represents total number of patients noted to have side effect. Denominator represents total number of patients in group from studies that listed complications in the given category. Results weighted by subject number; e.g. 38/182 indicates that studies documenting nausea and vomiting as a side effect had 182 patients randomized to the catheter group and reported 38 of those patients having either nausea or vomiting. Number in parenthesis represents percentage of patients reported to have side effects. NNT number needed to treat. NNT was not calculated for motor block since it is not a treatable event. Richman JM et al. A&A 2006; 102:

28 Abstract: Background: The aim of the study was to compare the efficacy of either ropivacaine or placebo through an iliac crest (IC) catheter after Bankart repair with IC bone grafting. Methods: With approval of the local ethics committee and after written informed consent was obtained, 36 patients had an interscalene catheter placed preoperatively. Intraoperatively, the surgeon placed a catheter at the IC donor site. At the end of surgery, 30 ml ropivacaine, 0.5% (ropivacaine group), or 30 ml NaCl, 0.9% (placebo group), was administered. Ropivacaine, 0.2%, was started 6 h after the initial block through the interscalene catheter for 48 h (t48) in all patients. At t0, the patient received either 5 ml/h ropivacaine, 0.2% (ropivacaine group), or 5 ml/h NaCl, 0.9% (placebo group), for 48 h through the IC catheter. All patients received an intravenous morphine patient-controlled analgesia device. Pain scores at the shoulder and at the IC donor site were assessed at rest and during motion every 8 h for 48 h and after 3 months. Plasma concentrations of total and unbound ropivacaine, morphine consumption, and patient satisfaction were assessed.results: At the IC donor site, pain was significantly lower in the ropivacaine group compared with the placebo group at rest and during motion at any time. Total and unbound plasma concentrations of ropivacaine were below the toxic threshold in both groups. Morphine consumption was significantly lower in the ropivacaine group after 24 and 48 h. Patient satisfaction was significantly higher in the ropivacaine group. At 3 months, pain at the IC during motion was significantly lower in the ropivacaine group.conclusions: Continuous application of 0.2% ropivacaine through an IC catheter after Bankart repair with IC bone grafting is an effective method for pain relief for the first 48 h, with few adverse effects and high patient satisfaction. The benefit of this technique is still present after 3 months. Blumenthal S et al. Anesthesiology 2005; 102:

29 Figures : Pain at the iliac crest at rest (A) and during motion (B) in patients receiving 0.2% ropivacaine (open bars) or saline (closed bars) through the iliac crest catheter. Measurements were made postoperatively ( t0) and then every 8 h until t48. VAS visual analog scale from 0 no pain to 100 worst pain imaginable. Values are presented as mean SD. * Significant differences between the two groups (P < 0.05). Blumenthal S et al. Anesthesiology 2005; 102:

30 Figures : Pain at the iliac crest at rest (A) and during motion (B) after 3 months in patients who received 0.2% ropivacaine or saline through the iliac crest catheter. VAS visual analog scale from 0 no pain to 100 worst pain imaginable. Values are presented as mean SD. * Significant difference between the two groups (P < 0.05). Blumenthal S et al. Anesthesiology 2005; 102:

31 Figures : Plasma concentration of total (A) and unbound (B) ropivacaine in patients receiving 0.2% ropivacaine (open bars) or saline (closed bars) through the iliac crest catheter. Measurements were made 24 and 48 h postoperatively. Values are presented as mean SD. * Significant differences between the two groups (P < 0.05). Blumenthal S et al. Anesthesiology 2005; 102:

32 ABSTRACT BACKGROUND: The contribution of the saphenous nerve in pain after major ankle surgery is unknown. The aim of this study was to evaluate its contribution in this context. METHODS: Fifty patients were included in this prospective, randomized, controlled study. In all patients [Group P (popliteal) and Group F (popliteal+femoral)], a popliteal catheter was placed before operation and ropivacaine 0.5% (30 ml) administered via this catheter; major ankle surgery was then performed under spinal anaesthesia. In Group PF patients, an additional femoral catheter was sited before operation and ropivacaine 0.5% (10 ml) administered. Six hours after spinal anaesthesia (defined as T(0)), a continuous infusion of ropivacaine 0.3% (14 ml h(-1)) was started through the popliteal catheter until T(24). Then, the concentration was reduced to 0.2% until T(48). Patients in Group PF received continuous ropivacaine 0.2% (5 ml h(-1)) through the femoral catheter from T(0) to T(48). I.V. morphine patient-controlled analgesia was used as a rescue analgesia. Pain at rest, pain with movement, adverse effects, and i.v. morphine consumption were assessed. Pain at rest and on movement was evaluated 6 months after operation. RESULTS: Pain at rest was comparable in the two groups. In Group PF, patients had significantly reduced pain during movement in the postoperative period (P=0.01) and 6 months after operation (P=0.03). Morphine consumption was significantly reduced in Group PF at T(0)-T(24) and T(24)- T(48) (P=0.01). Adverse effects were comparable in both groups. CONCLUSIONS: The addition of continuous femoral catheter infusion of ropivacaine to a continuous popliteal catheter infusion improved postoperative analgesia during movement after major ankle surgery. This effect was still present 6 months after surgery. Blumenthal S et al. BJA 2010; 106:

33 BACKGROUND: Continuous femoral or lumbar plexus blocks have been demonstrated to provide effective postoperative analgesia of the lower extremity following total joint arthroplasty. The purpose of this study was to compare these two techniques when used with intravenous patient-controlled analgesia and the use of patient-controlled analgesia alone for postoperative pain management following unilateral primary hip arthroplasty. METHODS: Two hundred and twenty-five patients undergoing unilateral total hip arthroplasty for a diagnosis of osteoarthritis were randomly allocated into one of three postoperative treatment groups: continuous lumbar plexus block with patient-controlled analgesia, continuous femoral block with patient-controlled analgesia, and patient-controlled analgesia alone. Scores on a visual analog pain scale administered during physiotherapy twenty-four hours postoperatively were used as the primary outcome measured. Secondary outcomes included scores on a visual analog pain scale at rest, hydromorphone consumption, opioid-related side effects, complications, sensory and motor blockade, and patient satisfaction. RESULTS: Continuous lumbar plexus block significantly reduced pain scores during physiotherapy on postoperative day 1 (p < ) and day 2 (p < ) compared with either continuous femoral block or patient-controlled analgesia alone. There were no significant differences for pain at rest between the two regional analgesic techniques. Both regional anesthesia techniques significantly reduced total hydromorphone consumption (p < 0.05) and delirium (disorientation to time and/or place) compared with patient-controlled analgesia alone (p < 0.023). In addition, the use of continuous lumbar plexus block was associated with fewer patients with opioid-related side effects (p < 0.05), greater distances walked (p < 0.05), and enhanced patient satisfaction (p < 0.05) compared with the use of a continuous femoral nerve block with patient-controlled analgesia or with patient-controlled analgesia alone. CONCLUSIONS: Continuous lumbar plexus and femoral blocks significantly reduce the need for opioids and decrease related side effects. Continuous lumbar plexus block is a more effective analgesic modality than is a continuous femoral block or patient-controlled intravenous administration of hydromorphone alone during physical therapy following primary unilateral total hip arthroplasty. Marino J et al. J Bone Joint Surg Am 2009; 91:

34 BACKGROUND: Continuous passive motion after major knee surgery optimizes the functional prognosis but causes severe pain. The authors tested the hypothesis that postoperative analgesic techniques influence surgical outcome and the duration of convalescence. METHODS: Before standardized general anesthesia, 56 adult scheduled for major knee surgery were randomly assigned to one of three groups, each to receive a different postoperative analgesic technique for 72 h: continuous epidural infusion, continuous femoral block, or intravenous patientcontrolled morphine (dose, 1 mg; lockout interval, 7 min; maximum dose, 30 mg/4 h). The first two techniques were performed using a solution of 1% lidocaine, 0.03 mg/ml morphine, and 2 microg/ml clonidine administered at 0.1 ml x kg(-1) x h(-1). Pain was assessed at rest and during continuous passive motion using a visual analog scale. The early postoperative maximal amplitude of knee flexion was measured during continuous passive motion at 24 h and 48 h and compared with the target levels prescribed by the surgeon. To evaluate functional outcome, the maximal amplitudes were measured again on postoperative day 5, at hospital discharge (day 7), and at 1- and 3-month follow-up examinations. When the patients left the surgical ward, they were admitted to a rehabilitation center, where their length of stay depended on prospectively determined discharge criteria RESULTS: The continuous epidural infusion and continuous femoral block groups showed significantly lower visual analog scale scores at rest and during continuous passive motion compared with the patient-controlled morphine group. The early postoperative knee mobilization levels in both continuous epidural infusion and continuous femoral block groups were significantly closer to the target levels prescribed by the surgeon than in the patient-controlled morphine group. On postoperative day 7, these values were 90 degrees ( degrees)(median and 25th-75th percentiles) in the continuous epidural infusion group, 90 degrees ( degrees) in the continuous femoral block group, and 80 degrees ( degrees) in the patient-controlled morphine group (P < 0.05). The durations of stay in the rehabilitation center were significantly shorter: 37 days (range, days) in the continuous epidural infusion group, 40 days (range, days) in the continuous femoral block group, and 50 days (range, days) in the patient-controlled morphine group (P < 0.05). Side effects were encountered more frequently in the continuous epidural infusion group. CONCLUSION: Regional analgesic techniques improve early rehabilitation after major knee surgery by effectively controlling pain during continuous passive motion, thereby hastening convalescence. Capdevila X et al. Anesthesiology 1999; 91:

35 What is the clinical impact of these results and what is the socio economical impact? If patients leave the rehabiliation center earlier, money is saved. If patients have a better range of movement at discharge is good, but if the range of movement is equal after 1 and 3 months: where is the socio economic advantage if patients do not go to work (be productive for the community) earlier, the advantage is only personal. We need more studies addressing these questions to further justify perineural catheters. 35

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37 BACKGROUND: Femoral nerve blockade (FNB) is a common method of analgesia for postoperative pain control after total knee arthroplasty. We conducted a systematic review to compare the analgesia outcomes in randomized controlled trials that compared FNB (with and without sciatic nerve block) with epidural and patient-controlled analgesia (PCA). METHODS: We identified 23 randomized controlled trials that compared FNB with PCA or epidural analgesia. These studies included 1,016 patients, 665 with FNB, 161 with epidural, and 190 with PCA alone. RESULTS: All 10 studies of single-shot FNB (SSFNB) used concurrent PCA opioids. SSFNB was found to reduce PCA morphine consumption at 24 h (-19.9 mg, 95% credible interval [CrI]: to -4.6) and 48 h (-38.0 mg, 95% CrI: to -19.7), pain scores with activity (but not at rest) at 24 and 48 h (-1.8 visual analog pain scale, 95% CrI: -3.3 to at 24 h; -1.5 visual analog pain scale, 95% CrI: -2.9 to at 48 h) and reduce the incidence of nausea (0.37 odds ratio, 95% CrI: 0.1 to 0.9) compared with PCA alone. SSFNB had similar morphine consumption and pain scores compared with SSFNB plus sciatic nerve block, and SSFNB plus continuous FNB. CONCLUSIONS: SSFNB or continuous FNB (plus PCA) was found to be superior to PCA alone for postoperative analgesia for patients having total knee arthroplasty. The impact of adding a sciatic block or continuous FNB to a SSFNB needs to be studied further. Paul JE et al. Anesthesiology 2010; 113: According to this review, there is no sufficient evidence, that continuous femoral nerve blocks are superior to single injection nerve blocks for total knee arthroplasty. This is a drawback, as clinically it seems that CFNB offer some advantages. More data are needed to evaluate this important issue. Also the role of the sciatic nerve block must be further evaluated. The editorial by Ilfeld et al. and the article by Wegener et al. offer some new issues. 37

38 BACKGROUND: A continuous interscalene nerve block (CISB) may be used to provide analgesia after shoulder arthroplasty. Therefore, inpatient stays may be shortened if CISB (1) provides adequate analgesia without intravenous opioids and (2) improves shoulder mobilization. This study investigated the relationship between ambulatory CISB and the time to reach three discharge criteria after shoulder arthroplasty. METHODS: Preoperatively, patients received a CISB. All patients received a perineural 0.2% ropivacaine infusion from surgery until 06:00 the following morning, at which time they were randomly assigned either to continue perineural ropivacaine or to switch to normal saline. The primary endpoint was the time from the end of surgery until three discharge criteria were attained (adequate analgesia, independence from intravenous analgesics, and tolerance to 50% of shoulder motion targets). Patients were discharged home as early as the afternoon after surgery with their CISB using a portable infusion pump. RESULTS: Patients receiving perineural ropivacaine (n = 16) attained all three discharge criteria in a median (10th-90th percentiles) of 21 (16-41) h, compared with 51 (37-90) h for those receiving perineural normal saline (n = 13, P < 0.001). Unlike patients receiving perineural ropivacaine, patients receiving perineural normal saline often required intravenous morphine, but still experienced a higher degree of pain and tolerated less external rotation. CONCLUSIONS: An ambulatory CISB considerably decreases the time until readiness for discharge after shoulder arthroplasty, primarily by providing potent analgesia that permits greater passive shoulder movement and the avoidance of intravenous opioids. Additional research is required to define the appropriate subset of patients and assess the incidence of complications associated with earlier discharge. Ilfeld et al. Anesthesiology 2006; 105:

39 Figure: Effects of interscalene perineuralropivacaine infusion on passive shoulderelevation (this slide) and external rotation (next slide) )the day after total shoulder arthroplasty.range of motion is analyzed as the percentageof the surgeon-defined target thepatient achieved. Data are expressed asmedian (horizontal bar) with 25th 75th(box) and 10th 90th (whiskers) percentilesfor patients randomly assigned tothe ropivacaine group (perineural ropivacainefrom surgery through postoperativeday 4) or the placebo group (perineuralropivacaine from surgery through06:00 postoperative day 1 followed byperineural normal saline through postoperativeday 4). For tightly clustereddata (e.g., B, 08:00 and 13:00, ropivacainegroup), the median approximated the10th, 25th, 75th, and 90th percentile valuesbecause all subjects achieved 100% oftheir target angle. Ilfeld et al. Anesthesiology 2006; 105:

40 What is the clinical impact of these results and what is the socio economical impact? There was no follow up after 3 / 6 and 12 months, so no conclusions can be made about the range of motion of these patients at these timepoints If patients rotate earlier, is good, but if the range of movement is equal after 1 and 3 months: where is the socio economic advantage if patients do not go to work (be productive for the community) earlier, the advantage is only personal. To send the patient home after 1 or 2 days is common practice in the US, independently of the range of motion. To justify the costs of elastomeric pumps with all the included risks of therapy at home more clinical data including longterm outcome are needed. 40

41 Continuous wound infusion is a promising technique. This slide was included for completeness. CWI is not inferior for lower extremity and promising for upper extremity. The economical advantages must be evaluated against the clinical standard and not only against opioid-pca. 41

42 Compared to neurologic complications after surgery without regional anesthesia (as reported in orthopedic literature), the neurologic complications of regional anesthesia are lower. We could even argue, that regional anesthesia could have a protective effect on nerves (kind of preconditioning ). 42

43 Infection of regional anesthesia catheters is seldom. Compared with the costs caused by surgery they are of minor importance. Data concerning the protective effects of regional anesthesia are available. 43

44 Many anti-regionalists state, that there is no influence in the anesthesia regimen on the blood transfusion management. This is simply not true. Certainly, multicenter RCTs are lacking but the actual data clearly suggest, there is an impact wich favors the use of regional anesthesia (and to avoid gas anesthesia) for this endpoint. Further research should address this question, as blood management is an important cost factor. 44

45 It is usually expressed by patients in terms of failure to perform simple cognitive tasks, for example to move to another room and, on arrival, to have forgotten the reason for the move, or to be unable to complete mental tasks, such as crosswords, that were previously easily attainable. Clearly, patients who are still under the influence of anesthetic or analgesic drugs may have impaired cognitive performance. This is of significance if they are expected to remember instructions or carry out complex tasks, such as driving a motor vehicle but, in the author s view, this does not constitute POCD. The earliest test point should be about 1 week after surgery once centrally acting analgesics are no longer required and any active metabolites have been eliminated. 45

46 Evidence suggests, that gas anesthesia and opioids should be avoided. This suggests, that regional anesthesia offers clear advantages. However, comparative studies are needed to clarify this point. 46

47 BACKGROUND: Postoperative cognitive dysfunction (POCD) has been documented after cardiac and noncardiac surgery. The type of surgery and anesthetic has been assumed to be associated with the incidence but there are few prospective data comparing the incidence after different procedures. In this study, we sought to determine the association of the type of surgical procedure and anesthesia on the incidence of POCD after procedures involving light sedation, general anesthesia for noncardiac surgery, and general anesthesia for cardiac surgery involving cardiopulmonary bypass. METHODS: Eight neuropsychological tests were administered at baseline and at 7 days and 3 months postoperatively to subjects from 3 procedure groups and a nonoperative control group. Reliable change index was used to calculate POCD. The study sample consisted of subjects involved in 3 separate trials investigating coronary angiography (CA) (percutaneous diagnostic procedure) under sedation, major noncardiac surgery (total hip joint replacement [THJR] surgery) under general anesthesia, and coronary artery bypass graft (CABG) surgery under general anesthesia.results: Data were collected from 644 patients in the patient groups and 34 subjects in the control group. Neuropsychological results were available for POCD at day 7 for THJR surgery (n 162) and CABG surgery (n 281). The incidence of POCD at day 7 was 17% for THJR surgery and 43% for CABG surgery (adjusted odds ratio 0.2, 95% confidence interval [CI]: 0.1, 0.4; P 0.01). At 3 months, the incidence of POCD for all groups combined (n 636) was 17% (21% for CA under sedation, 16% for THJR surgery, and 16% for CABG surgery). The mean (95% CI) for the difference in proportions of POCD among groups was 0.00 (0.07, 0.07) (P 0.91) for CABG versus THJR; 0.05 (0.12, 0.03) (P 0.21) for CABG versus CA; and 0.05 (0.13, 0.03) (P 0.24) for THJR versus CA. There were no significant differences among groups (adjusted odds ratio 1.21, 95% CI: 0.94, 1.55; P 0.13). Evered L. et al. A&A 2011; 112:

48 CONCLUSIONS: The incidence of POCD in old and elderly patients at day 7 was higher after CABG surgery than THJR surgery, but POCD at 3 months was independent of the nature or the type of procedure or anesthetic when comparing CA, THJR, and CABG surgery groups. Cardiovascular risk factors were not predictive of POCD after any procedure. A strength of this investigation is the testing methodology.one difficulty with comparing POCD incidence across procedural groups is the possibility of heterogeneity with testing and analytic methods, not assessing patients contemporaneously,and using different control groups. A limitation of this study is not having day 7 testing for the CA patients, which was a logistic issue related to study design. Another limitation is that the RCI method relies on an appropriate control group, and although the controls we have used have differing baseline means for 2 (of 8) neuropsychological tests, the calculation of POCD relies on change from baseline rather than raw test results; as such,the baseline raw score does not affect attribution of POCD except as a factor of change. Evered L. et al. A&A 2011; 112: This study does not show, that regional anesthesia and general anesthesia do not differ in the incidence of POCD. If you read the text in the slide here above, which is a copy of the methodology section, you see, that spinal anesthesia was supplemented with heavy sedation or even general anesthesia (BIS< 60!!) additionally to the premedication, the midazolam and the morphine PCA. Such study design does not allow to answer the question, if regional anesthesia offers advantages concerning the incidence of POCD compared to general anesthesia. More and far better designed studies are needed. 48

49 This is an overview about the different additional actions of local anesthetics, which could potentially be of interest when possible advantages of regional anesthesia have to be discussed. 49

50 FIGURE Kaplan-Meier plot of percentage of subjects without tumor recurrence. Mean (95% CI) time to reoccurrence for the no-epidural (38 [30-47] months) was not different from epidural analgesia postoperative (33 [21-45] months) (P = 0.92). Epidural anesthesia intraoperative and postoperative epidural analgesia had a mean (95% CI) time to recurrence of 73 (56-91) months, which was longer than either epidural analgesia postoperative (P = 0.002) or the no-epidural (P = 0.001). Where records did not extend to the end of the study period, X denotes time of last recurrence-free follow-up. De Oliveira GS et al. RAPM 2011; 36: Regional anesthesia seems to have an impact on cancer recurrence. Even the time point of application is relevant. Actually, only retrospective studies including central regional anesthesia are available. The question, if also peripheral regional anesthesia offers some kind of protection has to be addressed in clinical studies. If the impact of regional anesthesia is clinically relevant, this anesthesia regimen must be introduced for all tumor surgeries as costs derived from cancer are enormous and every effort must be undertaken to improve the outcome. 50

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54 I hope I could offer you an useful overview and give you some ideas to argue with your surgeons and financial directors. 54