Professor Narinder Rawal, MD, PhD, FRCA (Hon), EDRA Department of Anaesthesiology and Intensive Care University Hospital Örebro, Sweden

Professor Narinder Rawal, MD, PhD, FRCA (Hon), EDRA Department of Anaesthesiology and Intensive Care University Hospital Örebro, Sweden

Infiltrative techniques in perioperative pain lecture outline Why use infiltrative techniques? possible benefits Surgical site catheter techniques (not just wound catheters) Role of appropriate catheter placement Current indications Is the technique evidence-based? Technical issues Summary

Infiltrative techniques for perioperative pain possibilities Infiltration, instillation(carl Koller 1884),tumescent anaesthesia For surgery and postoperative analgesia (inpatient,outpatient) Alone or as component of multimodal analgesia technique Single injection or catheter technique ( bolus, infusion, PCA) Drugs: many l.a, adjuvants (opioids,non-opioids)

Advantages of incisional catheter techniques (versus perineural catheter techniques) Simple, safe, inexpensive Can be placed under direct vision by surgeon (no failure rate) Affects only the surgical area, thereby allowing normal use of extremity and early rehabilitation Eliminates unpleasant numbness of entire extremity due to sensory block Eliminates risk of damage to extremity due to motor block Eliminates risks due to vascular, neural, or pleural (interscalene block) placement of needle

Wound catheters in perioperative pain - not just catheters in wound Incisional catheters (variety of procedures, ambulatory surgery) Pre-peritoneal catheters (colorectal surgery) Intraarticular catheters as part of LIA technique (THA, TKA) Subacromial catheters (shoulder surgery, ambulatory surgery) Intraperitoneal catheters (cholecystectomy, hysterectomy, prostatectomy) Periosteal catheters (iliac crest bone harvesting) Subfascial catheters ( C.section, abdominal surgery)

LIA technique (knee, hip replacement) Intraoperative infiltration of surgical area ropivacaine 0.2 % 150 ml (300 mg) ketolorac 30 mg adrenaline 0.5 mg Intraarticular catheter (withdrawn morning after surgery) Pressure bandage + icepack for 4-6 h (to prolong analgesia) Anaesthesia: spinal with high GA Surgical technique: conventional Early mobilization within 3-5 h 50 % discharged day after surgery (almost all others on day 2) Pain management: paracetamol, NSAID s, weak opioids Antithrombotic treatment: only aspirin!

RCT, TKA, n=102, surgery under spinal anaesthesia EDA group: bupi 0.1% + fentanyl + epinephrine for 48h vs LIA group: ropi 150mg + epinephrine 0.5mg (150ml), intraarticular catheter (lateral side, epidural 18G) - LIA group: intraarticular ketolorac 30mg + morphine 5mg - LIAiv group: intravenous ketorolac 30mg + morphine 5mg LIA group: injections repeated at 22-24h, rescue PCA, oxycodone after PCA stopped LIA with intraarticular ketorolac and morphine (vs EDA) associated with: - lower pain scores at rest from 24h after surgery until discharge - lower cumulated morphine consumption (80mg vs 101mg) - superior knee function - faster mobilization - earlier discharge (3.5 vs 5.5 days) LIA with local adjuvants compared with epidural analgesia results in reduced opioid consumption, faster mobilization, and earlier readiness for hospital discharge. Ketolorac and morphine are more efficient when given locally than systemically.

Elective, open surgery, GA, n=42 20 G multiple hole cath under transversalis fascia, ropivacaine 0.2% or placebo, 10 ml bolus + 10 ml/h. Rescue: i.v. PCA Ropivacaine group - pain scores significantly better at rest (up to 12 h) and movement (up to 72 h) - reduced morphine consumption during 72 h - better sleep quality for 2 nights - early recovery of bowel function (74 vs 105 h) - shorter hospital stay (115 vs 147 h) - plasma concentration below toxic levels Continuous preperitoneal administration of 0.2% ropivacaine at 10 ml/h during 48 h after open colorectal resection reduced morphine consumption, improved pain relief and accelerated postoperative recovery.

Open colorectal surgery, n=106, GA, 72h study Preperitoneal CWI: 19G multiholed cath, 3-5 cm from lower end of incision,above the peritoneum within musculofascial layer CEI: T8-L1, ropi 0.2% 10ml bolus+10ml/h Rescue: i.v PCA morphine Early mobilization started day after, oral fluids after 12h CWI (vs CEI) associated with: Bertoglio S et al Anesth Analg 2012;115:1442-50 - Similar analgesia at rest and movement (pain scores, rescue analgesia) - Shorter time to first flatus and first stool - Shorter LOS (7.4 vs 8.0 days) - Better quality of analgesia and sleep at 72h - Less PONV at 24,48h Preperitoneal CWI analgesia with ropivacaine 0.2% continuous infusion at 10ml/h during 48h after open CRC surgery provided effective postoperative pain relief not inferior to CEI analgesia

Surgical procedures using postoperative surgical site catheter analgesia Inguinal herniotomy Median sternotomy Thoracotomy Major spine surgery Hepatic surgery Appendectomy Gynaecological surgery Caesarean section Total hysterectomy + bilateral salpingooophorectomy Shoulder surgery Arthroscopic procedures Open shoulder surgery Breast and axillary surgery Total hip arthroplasty Abdominal surgery Subcostal incisions Open laparotomy Laparoscopy Prostatectomy Knee surgery Anterior cruciate ligament reconstruction Total knee arthroplasty

Rawal et al Anesth Analg 1998;86:86-9

J Am Coll Surg 2006;203:914-932 39 RCT s (n = 1761) qualitative analysis, 45 RCT s (n = 2031), qualitative analysis Surgical subgroups (abdominal, cardiothoracic, gynecologic, orthopedic, minor) Benefits of wound catheters: decreased pain scores at rest and activity (32 % reduction) decreased need for opioids (25 % reduction) decreased risk of PONV (16 % reduction) increased patient satisfaction (30 % increase) decreased LOS in hospitalized patients (limited data, 1 day, p = 0.01) No increase in adverse effects Qualititative systematic review supported same benefits Continuous wound catheters appear to be an effective modality for management of postoperative pain

J Am Coll Surg 2006;203:914-932 Abdominal surgery (upper abdominal, vascular, others) decreased opioid use 5/6 RCT s reduced pain scores 2/5 RCT s Cardio-thoracic surgery (thoracotomy for lung resection (11 RCT s), esophagectomy (1 RCT), sternotomy (2 RCT s) all RCT s reported analgesic efficacy (reduced pain scores and opioid use (12/13 RCT s) some reduction in LOS (5/6 RCT s) Gynecologic surgery (C. section, abdominal hysterectomy) reduced pain scores (5/7 RCT s), reduced opioid use (6/7 RCT s) reduced AE, better patient satisfaction Orthopaedic surgery (open, arthroscopic, upper, lower extremities, spine surgery) reduced pain scores (12/14 RCT s), opioid use (11/14 RCT s) Minor surgery (ambulatory inguinal hernia repair) reduced pain scores (5/5 RCT s) and opioid use (2/5 RCT s)

20 studies, n=1150 C. section under RA+ wound infiltration - decrease in 24h morphine consumption C.section under GA+ wound infiltration + peritoneal spray - reduced need for opioid rescue LA+NSAID infiltration better than LA alone. Addition of NSAID (but not ketamine) to LA for infiltration better than RA alone Local analgesia infiltration and abdominal nerve blocks as adjuvants to regional analgesia and general anaesthesia are of benefit in Caesaraen section by reducing opioid consumption. Nonsteroidal anti-inflammatory drugs as an adjuvant may confer additional pain relief

Wound catheter infusions - the evidence* Continuous local anaesthetic infusions lead to reductions in pain scores (at rest and activity), opioid consumption, postoperative nausea and vomiting, and length of hospital stay; patient satisfaction is higher and there is no difference in the incidence of wound infections (S) (level 1) * Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine.3rd edition 2010. www.anzca.edu.au <http://www.anzca.edu.au>

Anesthesiology Research Practice 2012; article ID 709531,9 pages 10 studies (8 RCTs, 2case series), n= 893 L.a doses 200mg, 300mg, 400 mg Optimal catheter site? Role of adjuvants? Risk of infection, local anesthetic toxicity no problem so far The LIA technique can be regarded as an effective analgesic method following THA, and consideration should be given to its use by the surgeon and the anaesthetist in the planning of the analgesic management strategy for this surgical procedure

Anesth Analg 2011;113:684-686 In conclusion, the LIA method seems promising as a routine tool for analgesia after knee replacement. Still, we need more clinical research.. In summary, LIA is a relatively simple technique that has shown early promise as a method of pain relief after TKA..Current evidence suggests that we should not abandon the use of the continuous FNB until further data become available

CWI vs other regional techniques 1. CWI vs Neuraxial techniques - vs epidural c.section equally effective Ranta PO Int J Obstet Anesth 2006 - vs epidural THA CWI better, LOS Andersen KV Acta Orthop 2007 - vs epidural TKA CWI better Andersen KV Acta Orthop 2010 - vs epidural TKA CWI better, LOS Spreng KJ Br J Anaesth 2010 - vs i.t morphine TKA CWI better Essving P Anesth Analg 2011 - vs i.t morphine THA CWI better Rikalanen-Salmi R Acta Anaesth Scand 2012 - vs epidural prostatectomy epidural better Fant F Br J Anaesth 2011 - vs epidural for c.section CWI better, LOS O Neill P Anesth Analg 2012 - vs epidural open colorectal CWI better, LOS Bertoglio S Anesth Analg 2012 - vs epidural open colorectal EDA better, LOS Jouve P Anesthesiology 2013 2. CWI vs Femoral nerve block - TKA CWI better Toftdahl K Acta Orthop 2007 - ACLR femoral better Dauri M RAPM 2009 - TKA equally effective Affas F Acta Orthop 2011 3. CWI vs paravertebral block - radical mastectomy CWI better Sidiropoulou T Anesth Analg 2008 4. CWI vs interscalene block for arthroscopic shoulder surgery - 4/6 studies- interscalene better (in 1 study analgesia lasted 6h)

9 RCTs, n= 529 3/10 comparions showed reduction in pain scores 6/12 comparisons showed reduced supplemental opioids Differences in surgical techniques (microdiscectomy and laminectomy are different types of surgery therefore pain scores difficult to compare) Differences in doses, volumes of local anaesthetics It may therefore be argued that this review reveals a relatively(sic) lack of evidence rather than evidence at all. At the best,there seems to be a tendency toward an only modest, clinically questionable and transient effect of wound infiltration with local anaesthetics in lumbar spine surgery

Resource use and costs evaluated from medical records and published data Decision analytic model (clinical trials and observational cohort, n= 85) Total costs: medical devices, drugs, time (medical, nursing) for postoperative pain management CWI EDA PCA Cost of devices, drug, staff time 181 158 44 Total costs (mgmt of AE, hospitalization) 6460 7500 7273 Successful pain relief 77.4% 72.9% 53.9% In conclusion, when compared with i.v-pca and EDA, the global reduction in resource consumption outweighed the additional cost of using CWI devices.cwi was less costly than EDA but with almost equivalent efficacy, offering an alternative for pain management after abdominal surgery.

Plastic Reconstructive Surg 2003;III:2090-2096

Wound catheters for postoperative analgesia - concerns and possible risks Poor wound healing Risk of wound infection Risk of local anesthetic toxicity Catheter removal by patient at home

J AM Coll Surg 2008;203:914-932 Technical failure 1% Local anesthetic toxicity 0% Wound infection - active (WCI) group 0.7% - control group 1.2%

Wound catheters for postoperative analgesia - unanswered questions Best position for catheter placement? Dose (conc.) vs volume relationship? Role of adjuvants? PCRA or continuous infusion or both? Are multiple-hole catheters better? Reliability of elastomeric pumps? Can persistent postoperative pain be prevented? How does it compare to other (more invasive) regional techniques?

To summarize...

PONV PAIN

Why wound catheter techniques for postoperative analgesia - Summary Simple, safe, effective and inexpensive(?) Evidence-based data (Grade scoring) shows efficacy in following surgeries: - Orthopedic (shoulder, knee, hip, iliac crest bone harvesting) - Abdominal (colorectal, hernia, hysterectomy, C.Section) - Breast surgery - Sternotomy - Other surgeries (limited data) Recommended by societies (ANZCA,ASA,PROSPECT,French,German) Important component of multimodal analgesia Routine method for pain management after ambulatory surgery in many institutions Several questions unanswered - further studies necessary

Do not waste any more time on clinical trials (or meta-analysis) of wound infiltration with local anaesthetics after in particular major surgical procedures be it with or without catheters the analgesic effect, if any, is not clinically relevant.

THA: Little evidence for intraoperative use or WCI postoperatively (if non-opioid multimodal analgesia given) TKA: Intraoperative infiltration useful but not WCI Intraarticular NSAIDs or adrenaline: limited supportive data Data on LOS conflicting

Top-up doses (WCI) do have analgesic effect Very little data on LIA being inferior to even the most efficient alternative methods of systemic analgesia If new method equally effective, does it mean it is of no value. For LIA it means: - less need for patient compliance - less total dose of NSAIDs - no need for gabapentinoids (side effects?)

Wound catheters for postoperative analgesia - Summary Emerging technique, well-established internationally Evidence-based data (Grade scoring) shows efficacy in following surgeries: - Orthopedic (shoulder, knee, hip, iliac crest bone harvesting) - Abdominal (colorectal, hernia, hysterectomy, C.Section) - Breast surgery - Sternotomy - Other surgeries (limited data) No major problems so far (nearly 2 million pumps sold by one company) Routine method for pain management after ambulatory surgery in many institutions Several questions unanswered - further studies necessary