Transcript Document

Regional Blocks in Outpatient
Surgery
Roy Greengrass M.D. F.R.C.P.
Professor of Anesthesiology
Mayo Clinic Jacksonville
Your Personal Case Scenario
• Your only son graduates from MIT in 2 days. In
your excitement getting everything ready to travel
for this important event you trip on a rug and
fracture your arm requiring surgery. Dr. Evans
recommends interscalene catheter and propofol
sedation for the procedure with interscalene
analgesia postoperatively. Unfortunately your
hospital has no one with expertise in this
procedure. What do you do?
Disclosure
• I have no relevant financial relationships
with any commercial interests related to the
content of this activity.
Learning Objective
• List the different kinds of peripheral nerve
blocks, the choice of local anesthetics, and
their role in outpatient surgery and post op
pain management.
Why not Gas and Opioids for
Everyone?
General Anesthesia for Ambulatory
Surgery - Advantages
• Easy to initiate
• Minimal assistance required
General Anesthesia for Ambulatory
Surgery - Disadvantages
• Ubiquitous nausea, vomiting
• Postoperative pain usually mandates opioids
which have well documented side effects
Regional Anesthesia-Advantages
• Evidence-based medicine suggests that
multimodal anesthesia with regional
anesthesia as the primary modality results in
advantages of superior analgesia,earlier
discharge,enhanced convalescence and
better patient satisfaction compared with
more traditional approaches.
Regional Anesthesia for Ambulatory
Surgery -Disadvantages
• Skill level required to perform efficiently
• Often requires assistance
• Concern for side effects
Regional Block-Methods to
Enhance Efficacy
• A dedicated pre-operative area with
appropriate equipment is essential for
performance of blocks –do not perform
blocks in the OR under “surgical” time.
• Early performance of blocks allows for
assessment of efficacy with the opportunity
to redo/rescue block if necessary.
Ambulatory Surgery-Nausea and
Vomiting
• By far the most important determinant of
prolonged PACU stay
• More debilitating than pain-patient surveys
• Polypharmacy with antiemetics often
ineffective
• Recurrence of symptoms after discharge
Nausea and Vomiting
• 60% of all breast procedures- even “minor”
(includes plastics)
• Multifactorial
– General anesthetics
– Opioids
– ?reflexes
Paravertebral Block
• A somatic block of the mixed nerve soon
after exiting the intervertebral foramina
• Allows profound anesthesia/analgesia
without the associated effects of
centralneuraxial anesthesia
Fast Tracking with Nerve Blocks
for Breast and Hernia Surgery
Roy A. Greengrass, M.D.
Associate Professor of Anesthesiology
Mayo Clinic, Jacksonville, FL
Does Regional Anesthesia Impact
Pain?
Does Continuous Peripheral Nerve
Block Provide Superior Pain Control to
Opioids? A Meta-Analysis
Richman Anes Analg Jan/06
• 19 randomized clinical trials enrolling 603
patients
• At all times and for all catheter locations
CRA provided superior analgesia
• Opioid related side effects were
significantly reduced using CRA techniques
“Almost all cases of hernia, with the
possible exception of those in young
children, could undoubtedly be
subjected to the radical operation
under local anesthesia”
H. Cushing Annals of Surgery 1900
Postherniorrhaphy Urinary Retention-Effect
of Local,Regional,and General Anesthesia
Jensen Reg Anes Pain Manag Nov/Dec 2002
• Medline search 1996-2001 “Urinary Retention” not delay
in passing urine
• 70 non-randomized,2 randomized studies
• “Regional”=central neuraxial
• General = 3%(11471 pt), Central =2.42%(6191),Local =
0.37%(8991)
• Dispels the myth of less UR with GA (GA interferes with
the Autonomic Nervous System)
• Opioids cause urinary retention ( eg morphine relaxes the
detrusor while maintaining normal sphincter tone)
C.R.A. Applications: Orthopaedic
Surgery
Upper Extremity
• Total elbows- CPM
• Total shoulders
• Trauma
Popliteal Block
Hadžić A, Vloka JD: Peripheral Nerve Blocks. Principles and Practice.
McGraw-Hill, New York, 2004, Figure 22-19, p 296.
Continuous Interscalene Analgesia
• How many of you routinely send patients
home with interscalene catheters?
• How many of you routinely insert IS
catheters?
• Why not single shot blocks?
Continuous Interscalene AnalgesiaIndications
• Surgical procedures involving the shoulder,
arm, lateral forearm and lateral hand
Palliative analgesia in patients with
metastatic disease
• Sympathectomy for vascular reconstructive
surgery
Ambulatory Continuous Interscalene
Nerve Blocks Decrease the Time to
Discharge Readiness after Total
Shoulder Arthroplasty
Ilfeld
Anesthesiology Nov/06
• Discharge criteria ( adequate analgesia,
independence from intravenous analgesics,
tolerance to 50% of shoulder motion targets)
achieved significantly earlier in patients receiving
continuous perineural 0.2% ropivacaine vs saline
controls
• Essentially impossible to allow 23 hour discharge
unless CRA is present ( Duke and Mayo
experience)
Analgesic Effectiveness of a
Continuous Versus Single Injection
Interscalene Block for Minor
Arthroscopic Shoulder Surgery
Fredrickson Reg Anes Pain Management Jan-Feb/10
• Procedures including subacromial decompression,
excision lateral clavicle, stabilization procedures
• Significantly less pain and enhanced range of
motion versus single shot blocks
• Ubiquitous use of opioids in patients with chronic
pain makes “minor” surgery a misnomer
Interscalene Block
Applications C.R.A: Orthopaedic
Surgery
Lower Extremity
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ACL reconstructions
Total ankles, triple arthrodesis
Extensive tumor surgery
Total knees
Popliteal Block
Hadžić A, Vloka JD: Peripheral Nerve Blocks. Principles and Practice.
McGraw-Hill, New York, 2004, Figure 22-19, p 296.
Caveats to Safe Practice of Regional
Anesthesia
• Don’t do blocks with patients under general
anesthesia
• Inject 1ml test dose – if patient complains of
severe pain don’t “reposition” the needle-remove
it-and abandon the block
• Author avoids epinephrine
• CRA may be through needle or catheter-if via
catheter dilate space first (DW-can still stimulate)
CRA-Home Catheter Service
• Disposable Pump
• Removal by patient/care giver
• Anesthesiology consultation available 24/7
Are There Other Benefits Using
Regional Anesthesia?
Preincisional Paravertebral Block
Reduces the Prevalence of Chronic
Pain After Breast Surgery
Kairaluoma Anes Analg Sept 2006
• PVB vs GA 1 year followup: Prevalence
of pain PVB<< GA ( P= 0.003)
• Dynamic pain PVB<< GA ( P= 0.003)
• Pain at Rest PVB<<GA (P= 0.01)
• ? Deafferentiation + enhanced blood flow
• (seen also with post-thoracotomy pain)
Can Anesthetic Technique for
Primary Breast Cancer Affect
Recurrence or Metastasis?
Aristomenis Anesthesiology Oct 2006
• GA vs PVB
• 32 month followup
• Recurrence and met free survival 1 year
94% PVB vs 82% GA/opioid
CRA-Significant Cost Savings
• Duke – TSA-formerly 3 days-23 hour with
IS catheter
• Mayo – TAA –formerly 3 days – 23 hour
with Pop catheter
Your Case Scenarios
• You choose the “gas and oid” approach,
experience severe post-op pain needing excessive
doses of PCA analgesics, and have nausea and
vomiting related to the opioids. You are advised
not to travel due to your problems and cancel your
flight
• You choose the block approach, are discharged
from PACU with a CRA device , and fly out to
enjoy your son’s honor