NEW KIDS ON THE BLOCK: THE NEW ERA OF REGIONAL ANESTHESIA PLANE BLOCKS

2017 CSA Fall Anesthesia Conference NEW KIDS ON THE BLOCK: THE NEW ERA OF REGIONAL ANESTHESIA PLANE BLOCKS Michael Barrington, MB BS, FANZCA, PhD Senior Staff Anaesthetist, St Vincent s Hospital, Melbourne. Associate Professor, Faculty of Medicine, Dentistry. and Health Sciences, Melbourne Medical School, University of Melbourne, Australia

2017 CSA Fall Anesthesia Conference No financial disclosures or conflicts of interest I will not be discussing off-label devices or drugs Acknowledge Research Support from the Australian and New Zealand College of Anaesthetists Images: appropriate license, non copyrighted book chapter, Role of Ultrasound in Preventing Complications and Improving Safety of Peripheral Nerve Blocks, Compendium ISSPS 2016 Barrington MJ; Wong D

Overview Factors driving clinical practice Review anatomy relevant to plane blocks Examples of existing and new plane blocks Challenges with evidence-basis for plane blocks Discuss feasibility of research infrastructure

The opioid epidemic and national guidelines for opioid therapy for chronic noncancer pain: a perspective from different continentsw. Hauser, Schug S, Furlan A. 2 (2017) e599. Pain Reports

Factors driving interfascial plane block use Opioid crisis Ambulatory surgery Pressure to reduce the cost of healthcare Morbidly obese, comorbid surgical cohort Ultrasound expertise

Example of plane block: Fascia iliaca Dalens B, Vanneuville G, Tanguy A: Comparison of the fascia iliaca compartment block with the 3-in-1 block in children. Anesth Analg (1989) 69(6):705-713.

Fascia iliaca block: fractures of the proximal femur Pre-hospital transfer Preoperative analgesia Positioning for neuraxial anaesthesia Postoperative analgesia Level II evidence to support the above indications

But does it improve outcome? Desmet M, Vermeylen K, Van Herreweghe I, et al. A Longitudinal Supra-Inguinal Fascia Iliaca Compartment Block Reduces Morphine Consumption After Total Hip Arthroplasty. Reg Anesth Pain Med 2017.

Primary Outcome Control Group Fascia Iliaca Group 24-hour Morphine Mean (SD) mg 19.0 (2.4) 10.25 (1.64)

Acknowledgements Blanco R. The pecs block : a novel technique for providing analgesia after breast surgery. Anaesthesia. 2011;66:847 848 Blanco R. et. al.: Ultrasound description of Pecs II (modified Pecs I): a novel approach to breast surgery. Rev Esp Anestesiol Reanim 2012; 59: 470-475 Blanco R. Serratus plane block: a novel ultrasoundguided thoracic wall nerve block. Anaesthesia 2013; 68: 1107-1113

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Pectoralis major Pectoralis minor Serratus anterior

Pectoralis major Pectoralis minor Serratus anterior

Serratus plane blockade Author, Year Study type Surgery/ indication N Injectate Outcome Blanco, 2013 Volunteer - 4 0.4 ml/kg levobupivacaine 0.125% and gadolinium Paresthesia T2 T9, at 30 minutes, mean duration intercostal block: 386-752 minutes Kunhabdull a, 2014 Case report Rib fractures 2 6 ml bolus 1% lignocaine then infusion of bupivacaine 0.1% at 7 ml/hr Effective analgesia to enable physiotherapy and ambulation Madabushi, 2015 Case report Thoracotomy analgesia 1 6 ml bolus 1% lignocaine then infusion of bupivacaine 0.1% at 7 ml/hr Improvement in pain and ventilation

Author, Year Study type Surgery/ indication PEC s blockade N Injectate Outcome Fujiwara, 2014 Case report Pacemaker 1.375% ropivacaine: 4 ml intercostal block; 10 ml Pecs I block Surgery performed under intercostal/pecs I blocks and dexmedetomidine Murata, 2015 Case report Mastectomy 2 35 ml and 45 ml 0.2 ropivacaine for mastectomy and lumpectomy respectively Mastectomy performed under Pecs II block and supplemental infiltration Ueshima, 2015 Case report Segmental breast resection 1 0.15% levobupivacaine: 15 ml TTP, 10 ml Pecs I, 20 ml Pecs II. Surgery performed under TTP and Pecs II blocks TTP = Transversus thoracic muscle plane block

Pec s blockade Author, Year Study type Surgery/ indication N Injectate Outcome Wahba, 2014 RCT Mastcectomy 60 0.25% levobupivacaine: 15 20 ml (T4 PVB) 10 ml Pecs I block 20 ml Pecs II block Pecs blocks reduced postoperative morphine consumption (first 24 hours) and pain scores (first 12 hours) in comparison with PVB Bashandy, 2015 RCT Mastectomy 120 0.25% bupivacaine: 10 ml Pecs I 20 ml Pecs II Lower visual analog scale pain scores and opioid requirements in the Pecs group compared to control group patients

Radical mastectomy with axillary clearance - randomized controlled trial Pectoralisserratus interfascial plane block n = 32 Thoracic paravertebral n = 32 p 24-hour morphine median (interquartile range), mg 20 (16-23) 12 (10-14) < 0.001 First request for analgesia median (interquartile range), hours 6 (5-7) 11 (9-13) < 0.001 Hetta DF, Rezk KM.. Pectoralis-serratus interfascial plane block vs thoracic paravertebral block for unilateral radical mastectomy with axillary evacuation. J Clin Anesth 2016; 34: 91-7.

Modified radical mastectomy - randomized controlled trial PEC s II n = 20 Thoracic paravertebral n = 20 p Local anesthetic ropivacaine 0.5% 25 ml < 0.0001 Technique over 3rd rib PECs I 10 ml PECs II 15 ml T3 level, ultrasound guided < 0.0001 Kulhari S, Bharti N, Bala I, Arora S, Singh G. Efficacy of pectoral nerve block versus thoracic paravertebral block for postoperative analgesia after radical mastectomy: a randomized controlled trial. Br J Anaesth 2016; 117(3): 382-6.

Radical mastectomy - randomized controlled trial PEC s II n = 20 Thoracic paravertebral n = 20 p Time to first rescue mean (SD), minutes 294 (53) [4.9 hours] 198 (31) [3.3 hours] < 0.0001 24-hour morphine mean (SD), mg 3.9 (0.8) 5.3 (1.0) < 0.0001 Kulhari S, Bharti N, Bala I, Arora S, Singh G. Efficacy of pectoral nerve block versus thoracic paravertebral block for postoperative analgesia after radical mastectomy: a randomized controlled trial. Br J Anaesth 2016; 117(3): 382-6.

Radical mastectomy - randomized controlled trial PEC s II n = 20 Thoracic paravertebral n = 20 p Sensory spread - T2 n 17 4 < 0.0001 Kulhari S, Bharti N, Bala I, Arora S, Singh G. Efficacy of pectoral nerve block versus thoracic paravertebral block for postoperative analgesia after radical mastectomy: a randomized controlled trial. Br J Anaesth 2016; 117(3): 382-6.

http://www.anzctr.org.au/actrn12616000298415.aspx Dr Gloria Seah

Clinical applications Breast surgery Axillary dissection Breast implant Pacemaker insertion Other thoracic applications

Questions Does it work? Push-back from surgeons? Volume required? PECs versus PVB Serratus versus PEC s II injection Challenges - needle inplane, dressings Catheter technique Can I do one injection? Awake versus under general anesthesia Postoperative injection? Complications?

Anatomy and mechanism of action of Pectoralis plane and Serratus plane blocks are reasonably well described Evidence-light zone

Erector spinae block: a paravertebral block variant Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The Erector Spinae Plane Block: A Novel Analgesic Technique in Thoracic Neuropathic Pain. Reg Anesth Pain Med 2016; 41(5): 621-7.

Erector spinae block: a paravertebral block variant Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The Erector Spinae Plane Block: A Novel Analgesic Technique in Thoracic Neuropathic Pain. Reg Anesth Pain Med 2016; 41(5): 621-7.

Initial experience Rib fractures Rescue block Mastectomy Donor site lat. dorsi flap Chest wall mass

More paravertebral block variants: Retrolaminar plane block

More paravertebral block variants: Retrolaminar plane block

More paravertebral block variants: Retrolaminar plane block

More paravertebral block variants: Mid-point transverse process to pleura block

Advantages of TAP block Anatomy - simplicity Ease of performance, distinct sonographic endpoint Rescue block Chronic pain Performed in unresponsive patients

Key Points from Literature TAP block indicated: Caesarian delivery in absence of intrathecal morphine TAP block is of likely value: Transplant surgery TAP block: Not indicated for laparoscopic cholycystectomy

Key Points from Literature Following laparoscopic surgery TAP block reduces: 1. early but not late pain scores at rest (Minimal effect on dynamic pain); 2. opioid requirements but not opioid sideeffects Compared to controls in absence of concurrent multimodal therapy

Posterior approach to TAP Posterior approach

Posterior approach to TAP n = 6 (ultrasound-guided) Upper level of block Lower level of block Pooling of contrast between the transversalis fascia, quadratus lumborum muscle and psoas muscles. Levels reported in 3 patients, T5 - T10 (n= 1); T6 - T10 (n=2) 13 VOLUNTEERS, 22 BLOCKS, 0.3 OR 0.6 ML/KG Carney J, Finnerty O, Rauf J et al. Studies on the spread of local anaesthetic solution in transversus abdominis plane blocks. Anaesthesia 2011; 66:1023-30.

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The patients who received local anaesthetic used significantly less morphine than the control group (P<0.001) at 6 and 12 h, but not at 24 and 48 hours after caesarean section. Bupivacaine 0.1% 0.2 ml/kg Saline 0.2 ml/kg 6 hours 2.0 (0.0 6.5) 7.0 (5.0 19.0) 12 hours 8.0 (2.5 10.5) 14.0 (9.0 25.0) MEDIAN (INTERQUARTILE RANGE)

Case Reports and other literature Colectomy (2), gastrectomy (1), laparotomy (1), total hip arthroplasty (7), appendicectomy, pyeloplasty (1), nephrectomy (1), ORIF femure, amputation (1), femoral-femoral bypass, mastectomy and tissue reconstruction Review articles (3)

Summary Development and clinical use of interfascial plane blocks has significantly exceeded the growth of controlled trials investigating their efficacy