Transcript C19_Michael Barrington

Regional Anaesthesia
Techniques for DaySurgery
CSM 2011
Dr Michael Barrington
Department of Anaesthesia
St Vincent’s Hospital, Melbourne
Attributes of the ideal
anaesthetic for day-surgery
High quality analgesia
low pain score
low incidence of side-effects
long duration
Efficient
Patient acceptance
Range of techniques
available
Central neural blockade (CNB)
Peripheral nerve blockade (PNB)
Local infiltration analgesia (LIA)
CNB and PNB result in:
decreased pain scores in PACU
decreased requirement for PACU analgesia
CNB was not associated
with decreased PACU time
with reduced nausea
Ambulatory Surgical Unit (ASU) discharge was
increased by 35 mins
Peripheral Nerve Blockade
increased ability to bypass PACU (OR14)
decreased PACU time (24 mins)
decreased risk of nausea (OR 0.17)
increased patient satisfaction
not associated with decreased discharge ASU
Entire diamond lies to the right of line, RR = 1, indicating that
ultrasound guided blocks are more likely to be successful
Shoulder surgery
Ambulatory shoulder surgery
Ultrasound-guided techniques:
interscalene (n = 515)
supraclavicular (n = 654) blocks
Pain score (VAS) in PACU 0/10
Need for IV analgesia in PACU 0.6%
Time in PACU 168 mins
Body mass index 22 kg/m2
Volume of local anaesthetic 50 mls
Hospital for Special Surgery
Side-effects/complications
Hoarseness 26%
Dyspnoea 8%
Pneumothorax 0%
LA toxicity 0%
The role of Ultrasound
Low dose efficacy studies (both single shot and
continuous infusions)
Dose reduction
Severe hypotension following interscalene
block
Bilateral upper limb block in PACU
Differential diagnosis:
Bezold-Jarisch reflex
Anaphylaxis
Intrathecal spread
Epidural spread
Hand surgery
Infraclavicular block (ICB), chloroprocaine
compared with GA (LMA, desflurane) and
wound infiltration in RCT
PACU nurses “blinded” to technique scored
patients for readyness for PACU discharge
76% of patients who received ICB met criteria
for PACU bypass compared to 25% in the GA
group
None of the patients in the ICB group requested
pain medication in hospital compared to 48% in
the GA group
Patients receiving ICB were able to ambulate
earlier 82 min vs 145 min with GA
Results from St Vincent’s
Hospital, Melbourne
Data obtained from 933 patients (received 1216 PNBs)
Median (worst) pain score 1.1
Most common pain score 0
757 (81%) required no analgesia in PACU
Average time to readiness for discharge 25 mins
464 (50%) achieved discharge criteria on PACU arrival
Breast surgery
Unilateral breast surgery without reconstruction
Randomised to single-shot paravertebral block (PVB)
or continuous (PVB)
0.1 %, 0.2% or saline infusion for 48 hrs
Validated pain assessment instruments including
McGill Pain Questionnaire
No clinically significant difference in:
degree of postoperative pain
Nausea
Mood state
Level of symptom distress
Return to normal activity
Patients having unilateral breast surgery without
reconstruction were randomised to receive
either GA alone or combined GA and PVB
Multilevel blocks T1 - T6 PVB
Ropivacaine 5mg/kg + Adrenaline (350mg
maximum) was used
Pain was study endpoint
Pain scores were lower following PVB at one
hour and at three hours, but not at later time
points
Pain scores were higher in PVB at 24 hrs
compared to GA alone
Hernea surgery
Inguinal hernea repair
Randomised to GA or paravertebral blockade
Patients randomised to paravertebral blockade had
improved outcomes including analgesia and recovery
Inguinal hernea repair
Randomised to transversus abdominis plane block or
conventional ilioinguinal/ileohypogastric nerve blocks
(n= 273)
Ultrasound techniques:
Reduced pain scores at 4, 12 and 24 hours
No difference in PACU, Postoperative day 1 or
thereafter
Wound infiltration
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1. Single injection wound
2. Continuous local anaesthetic wound infusions
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3. High volume local anaesthetic wound
infiltration
Need for procedure specific randomised controlled
trials
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1. Single injection wound
2. Continuous local anaesthetic wound infusions
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3. High volume local anaesthetic wound
infiltration
Need for procedure specific randomised
controlled trials
Wound infiltration
Efficacy should be procedure specific
Single injection of local anaesthetic at
completion of surgery reduce analgesia - short
duration only
Choice of local anaesthetic important
Catheter type
Adjuvants
Note anatomical location of infiltration
Sites of wound catheter
placement
Intraperitoneal
Intraarticular
Subfascial
Subcutaneous
Intrapleural
Substernal
Knee Arthroscopy
One of the most common lower limb ambulatory
surgical procedures
Multitude of intraarticular agents used for
postoperative analgesia (opiates, NSAID, local
anaesthetics)
Peripheral blocks
Four groups: 0.9 % saline, bupivacaine 0.25%, ropivacaine
0.2%, ropivacaine 0.75%
No difference within LA groups
40% of patients receiving placebo had motor block
Low dose (4 - 5 mg) compared with intermediate
dose and high dose (10 - 15mg)
Low dose requires unilateral positioning of
patient
Associated with reduced discharge times
Ambulatory arthroscopic surgery of the knee
Spinal anaesthesia
Randomised to prilocaine 20 mg or
plain bupivacaine 7.5 mg
In summary
Wide range of regional techniques available for
ambulatory techniques
Large number of studies supporting these
techniques for various surgical procedures
Efficacy vs effectiveness vs cost-effectiveness in
our own practice is important
In summary
Evidence supports PNB upper limb surgery
Choice of ideal regional anaesthesia technique
for ambulatory trunk surgery unclear
RA for ambulatory lower limb surgery is a
challenge - motor block
Thank you for your
attention