MONDAY, JANUARY 29, 2007 ASPECTS OF ACUTE AND CHRONIC PAIN: Practical lectures and case-scenarios, Sweden Postoperative analgesia and outcome: back to square one, Sweden Extending regional techniques at home, Sweden Spinal pain: What is it and where does it come from? How to manage chronic back pain? Case Scenario s TUESDAY, JANUARY 30, 2007 COMPLEX REGIONAL PAIN SYNDROME AND PERIPHERAL NERVE BLOCKS: Practical lectures and workshops Complex Regional Pain Syndrome: Clinical features and diagnostic concerns Nerve Blocks and Other Interventions for Complex Regional Pain Syndrome Interscalene block Modified infraclavicular block Hands-on workshops WEDNESDAY, JANUARY 31, 2007 PERIPHERAL NERVE BLOCKS: Practical lectures and workshops H. Rettig, Interactive Anatomy Session I G. Groen, Posterior brachial plexus block H. Rettig, Axillary block R. Stienstra, Hands-on and ultrasound workshops H. Rettig, R. Stienstra, THURSDAY, FEBRUARY 1, 2007 PERIPHERAL NERVE BLOCKS: Practical lectures and workshops S. Gligorijevic, Switzerland Interactive Anatomy Session II G. Groen, Paravertebral block: When and how? S. Gligorijevic, Switzerland Sciatic nerve block: When and how? B. Fischer, UK Hands-on workshops S. Gligorijevic, Switzerland B. Fischer, UK FRIDAY, FEBRUARY 2, 2007 PAEDIATRIC REGIONAL ANESTHESIA, ADJUVANTS TO LOCAL ANESTHETICS AND IMPROVING SUCCESS RATE OF CNB: Practical lectures R. Stienstra, Regional anesthesia in children: What to do and what to avoid V. Mossetti, Italy Continuous regional anesthesia in children V. Mossetti, Italy Adjuvants to local anesthetics: When and which? S. Gligorijevic, Switzerland How to improve the success rates of central neuraxis blockade R. Stienstra, 1
Ülevaade RCT-st Perioperatiivne epiduraal-spinaalanesteesiaanalgeesia (Rodgers et al., 2000) Postoperatiivse ep.analgeesia toime tulemustele (müokardi isheemia ja MI) (Rolf et al., 1996, Beattie et al., 1997)- oluline torakaalepiduraalanalgeesia Letaalsus % RA grupp 103/4871 2,1 ÜA grupp 144/4688 3,1 Rodgers et al. 2000 Fig 1. Effect of neuraxial blockade (NB) on postoperative mortality within 30 days of randomisation. Diamonds denote 95% confidence intervals for odds ratios of combined trial results. The vertical dashed line represents the overall pooled result. Size of shaded boxes is proportional to number of events. The overall event rates after adjusting for uneven randomisation 193 were 113/5811 (1.9%) versus 158/5667 (2.8%). 2 test for heterogeneity between individual trials P=0.5 Rodgers et al. 2000 Fig 2. Effect of neuraxial blockade (NB) on postoperative mortality, by surgical group, type of neuraxial blockade, and use of general anaesthesia. Obstetrics and gynaecology trials are included with other surgery. One trial with unknown details of anaesthesia was grouped with lumbar epidural and neuraxial blockade plus general anaesthesia versus general anaesthesia comparisons. Diamonds denote 95% confidence intervals for odds ratios of combined trial results. The vertical dashed line represents the overall pooled result. Size of shaded boxes is proportional to number of events. 2 test for heterogeneity between different surgical groups, P=0.9 Rodgers et al. 2000 Uuringu puudus - Metaanalüüs - Erinevad anesteesia meetodid (SA, EA, torakaal- ja lumbaalepiduraalanesteesia ning analgeesia) - Heterogeensed haigete grupid, kus teatud op.-de puhul suremus on langenud Fig 3. Effects of neuraxial blockade (NB) on postoperative complications. Diamonds denote 95% confidence intervals for odds ratios of combined trial results. The vertical dashed line represents the overall pooled result. Size of shaded boxes is proportional to number of events Rodgers et al. 2000 2
Randomiseeritud uuringud Smith GC, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ 2003; 327: 1459-61 Outcome Decrease in mortality Fewer cardiac events Less thrombo embolism Improved graft survival-vascular surgery Reduced blood loss Reduced metabolic stress response Summary of evidence Not supported Note: supported in older studies, but confined to fractured hip and vascular surgery patients, and with high mortality in general anesthesia group Supported for thoracic epidurals in high risk patients Not supported for a wider population Not supported when modern thromboprophylaxis used Note: supported in older studies, but thromboprophylaxis used was non-aggressive Supported Supported Supported Type of evidence Large RCTs and observational studies RCTs and meta-analyses RCTs RCTs, including large RCTs, and meta-analyses RCTs, including large RCTs RCTs, meta-analyses and observational studies RCTs RCTs and meta-analyses RCTs and observational studies Referen ces 3, 4, 5 and 6 1, 2, 7, 8 and 9 3, 2, 10, 11 and 12 3, 4, 5, 13 and 14 3 and 15 1, 7, 8, 9 and 16 14 and 17 1 and 18 2 and 19 Gulur et al. 2006 Teised regionaalanesteesia tehnikad (pleksuse kateeter, haava kateeter isetühjeneva ballooniga (Liu et al., 2006) Multimodaalne analgeesia (MSPVA, paratsetamool, i/v opioid PCA) Nn. Fast- track protokoll (Kehlet, Holte, 2001) Kirurgi roll kui riskifaktor (Carter, 2003) BMJ 2003;326:832-833 ( 19 April ) Editorials Carter D. The surgeon as a risk factor Determinants of outcome include technical skill, volume of work, and case mix Take home message- Use your own effective methods 3
Rawal N. Extending RA techniques at home Rawal N. Extending RA techniques at home Perineuraalne, intraartikulaarne, haavasisene, periossaalne kateeter + LA (Rawal et al., 1997, 1998, 2002) Haavasisene (ühekordse süstena ja/või kateeter)- efektiivne, ohutu, lihtne, odav Probleemid- instruktsioonid ja organisatsioon, LA toksilisus (madal kontsentratsioon- peamiselt ropivakaiin), kateetri koha infektsioon (kolonisatsioon sageli, infektsioon harva), kateetri migreerumine, ühekordse pumba probleemid Juurdepääsutee Winnie j.-klassikaline, paresteesiate j. (Winnie, 1970) Tagumine juurdepääs Pippa j. (Pippa et al., 1990) Tagumine juurdepääs Pippa j. (Pippa et al., 1990) 4
Tagumine juurdepääs Pippa j. (Pippa et al., 1990) Modifitseeritud lateraalne juurdepääs Meier ja Borgeat j. (Meier et al., 1990) Borgeat A. Modified infraclavicular block (Borgeat et al., 2001) Ajalugu (Koller, 1884; Halsted, 1886; Crile, 1897; Hirschel, 1911; Kullenkampff, 1911 Närvitupe teooria (Burnham, 1958; De Jong, 1961; Winnie, 1983) Paresteesia vs närvistimulatsioon (Greenblatt, Denson, 1962)-paresteesiate p. suurem oht permanentseks närvivigastuseks (Selander et al., 1977, 1979) Üks süst või mitu (mitme närvi) süsti - mitme närvi süst efektiivsem (Baranowski et al., 1990; Lavie et al., 1992) Mitme närvi süsti puhul kirurgiline tegevus saab alata varem ja LA kogudoos on väiksem võrreldes ühekordse süstiga (Koscielniak-Nielsen et al., 1997, 1999) Nn. Triple technique (k.a. n. musculocutaneous) efektiivsem võrreldes nn. Double injection technique (Coventry et al., 2001; Sia et al., 2001; Rodriguez et al., 2005, 2006) Nn. Triple technique (Koscielniak-Nielsen et al., 2006) - Pindmine subkutaanne 3-5 ml LA injektsioon a. axillarise kohal - 50% LA kogudoosist n.medianuse juurde - 5-8 ml LA n.musculocutaneuse juurde - Ülejäänud LA kogus n.radialise juurde (motoorne vastus sõrmede/randme sirutus, mitte tricepsi vastus) 5
Nerve imaging with ultrasound Blokaad sonograafi kontrolli all Nerves are not blocked by the needle but by the local anaesthetic (Marhofer et al., 2005) Fig Transverse view of the axillary part of the brachial plexus, using an Aplio system with an 8 14-MHz linear probe. AA=axillary artery; BV=basilic vein. Marhofer et al. 2005 Nerve imaging with ultrasound Sheppard et al. 1998 Fig 2 Longitudinal section of the median nerve below the cubital level, using an Aplio system with an 8 14- MHz linear probe. Marhofer et al. 2005 Local anaesthetic solutions and injection Table 1. Demographic data Tartu, 2006 N=50 Mean age (range) (yr) 48.8 (15-84) Local anaesthetic Ulnar nerve Mean weight (SD) (kg) Mean height (SD) (cm) 71.8±11.5 171±9.2 Male / female 29/21 Mean ASA (SD) 2.1±0.7 Mean duration of surgery (range) (min) 92 (8-480) 6
Drugs used Bubivacaine 3.75 mg/ml (N=41 patients) or Mixture of Bubivacaine 2.5 mg/ml with Lidocaine 5 mg/ml (N=9 patients) Mean (SD) volume of local anaesthetic 31(± 8.7) ml The use of the catheter In 8 cases catheter was used for postoperative pain management with local anaesthetic (incl. 1 catheter for repeated intraoperative use) - In 6 cases the use of interscalene and in 2 cases of axillary catheter 18-gauge x 50 mm 7 o bevel nerve stimulation insulated needle 21-gauge x 1 m catheter (Portex, Inc., USA) Results Results In all cases nerve stimulator was used In 3 cases (6%) no motor response to nerve stimulation was observed Successful block in 41 cases (success rate 82%) Partial block in 2 cases (4%), general anaesthesia was needed Unsuccessful block in 7 cases (14%), general anaesthesia was needed Retzl et al. 2001 Potential References advantages Direct visualization of nerves 13, 17, 21, 26, 27, 37, 39, 40, 52, 54, 62, 66 Direct visualization of anatomical structures (blood vessels, muscles, bones, tendons) facilitating identification of nerves Direct and indirect visualization of the spread of local anaesthetic during injection with the possibility of repositioning the needle in cases of maldistribution of local anaesthetic Avoidance of side-effects (e.g. intraneuronal injection of local anaesthetic, inadvertent intravascular injection) Avoidance of painful muscle contractions during nerve stimulation (e.g. in cases of fractures) 23, 26, 27, 31, 32, 33, 37, 38, 39, 40, 52, 54, 57, 62, 66 26, 27, 37, 38, 39, 40, 54 20, 21, 26, 27, 37, 38, 39, 40, 54 Reduction of the dose of local anaesthetic 38, 39 Faster sensory onset time 37, 39, 40, 54 Longer duration of blocks 40 Improved quality of block 37, 39, 40, 54 40 Marhofer et al. 2005 7