new kids on the block: advances in regional anesthesia practice … · 2019-02-21 · new kids on...
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New Kids on the Block:
Advances in Regional Anesthesia Practice
Melissa Byrne DO, MPH@dr_melissabyrne
“Precision” Acute Care Medicine
Chronic Pain
“Nurse, get on the internet, go to NYSORA.COM, scroll down and click on the ‘Are you totally lost?’ icon.”
Roadmap for Discussion
Fascial Plane Blocks
Lower Extremity
Blocks
NovelLocal
Anesthetics
Take Home Points
• Who can do it?
• What do you need?
• Where should you place them?
• Why bother?
Overview
Who Can Do It?
• Catheters / Needles– Single- or multi-orifice
catheters
– Stimulating or non-
stimulating
– Flexible springwound or
rigid plastic
– Through or over the
needle
What Do You Need?
• Who can do it?
• What do you need?
• Where should you place them?
• Why bother?
Overview
• Tactile “pops” and “clicks” + ultrasound fascial
plane blocks
• Fastest growing subset of blocks
Truncal Fascial Plane Blocks
“If we can see it, we can now block it.” (Elsharkawy et al., RAPM 2018)
The Rise of the Fascial Plane Block
El-Boghdadly & Pawa (Anaesthesia, 2017)
TAP
QLB
PECS
Serratus Anterior
Transversus Abdominis Plane (TAP) Blocks
• Recent meta-analysis of US-guided TAP blocks
– Baeriswyl et al, Anesth Analg 2015
– Statistically significant but clinically modest
analgesic benefit in adult patient undergoing
abdominal laparotomy, laparoscopy or
cesarean delivery
– 6 and 11 mg IV morphine at 6 and 24 hours,
respectively
TAP Blocks…Why Bother?
• Upper Abdominal Surgery: Subcostal TAP
block is a useful alternative when epidural
analgesia is contraindicated with fewer side
effects such as hypotension
• Colorectal Surgery: open and laparoscopic
• Open appendectomy
• Abdominoplasty
Beneficial
• Major open gynecological surgery including total
abdominal hysterectomy
• Laparoscopic total hysterectomy
• Open inguinal hernia surgery
• Laparoscopic donor nephrectomy
• Cesarean delivery
The Data is Out…
• Laparoscopic cholecystectomy
• Laparoscopic Roux-en-Y bypass surgery
• Laparoscopic appendectomy
• Open radical retropubic prostatectomy
• Reconstructive abdominal surgery
• Renal transplantation
No Benefit
Quadratus Lumborum (QL)
Quadratus Lumborum (QL)
• Sparse literature; most only case reports
QL Block – Why Bother?
PECs Blocks
PECS Blocks – PECS I
- Lateral and medial pectoral nerves blocked
- Suitable for surgeries involving pecs major muscle (e.g., breast expanders, traumatic chest injuries, Portocath, pacemaker insertion)
PECS Blocks – PECS II
- T2-4 spinal nerves (including intercostobrachial) and long thoracic nerve may be blocked
- Suitable for more extensive excisions (e.g., tumor resections, mastectomy, axillary clearance, sentinel node excision, tissue expanders)
• RCTs for mastectomy
– Decreased opioid consumption and pain
scores in first 24 hours compared to
paravertebral (PVB) blocks (Wahba and
Kamal, 2014)
– Lower pain scores and opioid use
(Bashandy and Abbas, 2015)
– Increased duration of analgesia compared
to PVB (Kulhari, 2016)
PECS Blocks – Why Bother?
• Case Reports
– Insertion of cardiac resynchronization device with
block and dexmedetomidine
– Mastectomy under PECS II with supplemental
infiltration
– Alternative to brachial plexus blockade for axilla,
proximal medial upper arm and posterior
shoulder
PECS Blocks – Why Bother?
Serratus Anterior
- Thoracodorsal, thoracic intercostal nerves may be blocked
- Suitable for latissimus dorsi flap reconstruction
• Early data
– Duration of paresthesia in intercostal nerve
distribution T2-9 was 752 minutes
• Case reports
– Rib fracture: enabled PT and ambulation
– Thoracotomy: pain and ventilation improvement
• RCTs
– Increased opioid consumption during radical
mastectomy compared to PVB
– Less hemodynamic change compared to
thoracic epidural in thoracotomy
Serratus Anterior – Why Bother?
Erector Spinae (ESP) Blocks
ESP
Is this a paravertebral block by proxy???
• Early data
– Case reports/series
• Rib fractures (single shot and catheters
employed)
• Pleuroscopy: minimized procedural
sedation (T5 level)
• Bariatric surgery
• Thoracotomy (as rescue analgesic)
– Pilot study
• Laparoscopic ventral hernia repair (T7
level)
ESP – Why Bother?
Roadmap for Discussion
Fascial Plane Blocks
Lower Extremity
Blocks
NovelLocal
Anesthetics
Take Home Points
• Indications: saphenous vein stripping,
supplementation for medial foot/ankle surgery,
analgesia for knee surgery
Adductor Canal
• TKA
– Similar pain scores to femoral nerve block
– Quad strength preserved and ambulation
retained (several studies) compared to FNB
– Analgesic and opioid-sparing benefits in TKA
– KEY COMPONENT OF MULTIMODAL
ANALGESIC PLAN
Adductor Canal – Why Bother?
• Minor knee arthroscopies
– Little benefit (i.e., multimodal with NSAIDs +
APAP = ACB)
– ACL reconstruction mixed data
Adductor Canal – Why Bother?
• iPACK = interspace between the popliteal artery
and capsule of the posterior knee
iPACK Blocks
• Early data
– iPACK + ACB equivalent analgesia +
improved PT + earlier hospital discharge
post-TKA (Thobhani et al, Ochsner Journal
2017)
– iPACK + ACB better analgesia + improved
ROM and number of steps walked post-TKA
than ACB alone (Reddy et al, Int J Orthop Sci
2017)
iPACK – Why Bother?
Roadmap for Discussion
Fascial Plane Blocks
Lower Extremity
Blocks
NovelLocal
Anesthetics
Take Home Points
Liposomal Bupivacaine (Exparel ®)
• Many efficacy studies in surgical infiltration
but compare only to placebo
– Hemorrhoidectomy
– Mammoplasty
– Bunionectomy
– Forefoot surgery
– TKA
Liposomal Bupivacaine – Why Bother?
• Single-injection PNB
– NOTE: only FDA-approved for interscalene &
TAP blocks
– Femoral blocks: dose-response study (Ilfeld
et al, Anesth Analg 2013)
• High degree of intersubject variability
• Peak effect at 24 hours in 75% of subjects
• MUCH less than predicted 72 hours by
manufacturer
Liposomal Bupivacaine – Why Bother?
• Robotic-assisted hysterectomy
– Decrease in LOS with TAP blocks
– Potentially long-term opioid-sparing benefit
• Laparoscopic prostatectomy
– No difference in median time to opioid use, pain
scores comparing 20 mL vs 40 mL
– No placebo group included
• Open abdominal umbilical hernia repair
– Pain severity, opioid-related adverse events
recorded
– No placebo group included
Liposomal Bupivacaine – Why Bother?
Liposomal Bupivacaine – Why Bother?
Liposomal Bupivacaine – Why Bother?
Final Words on Liposomal Bupivacaine…
SABER®
• Laparoscopic cholecystectomy
– Did not meet its primary efficacy for Phase 3
trial with 380 patients
– No statistical difference in pain reduction with
movement over first 48 hours post surgery
compared to bupivacaine HCl
• Open hernia repair
– Significantly lower AUC for mean pain intensity
from 1-72 hours compared to placebo
• Abdominal surgery
– Decreased pain for 3 days
SABER – Why Bother?
Roadmap for Discussion
Fascial Plane Blocks
Lower Extremity
Blocks
NovelLocal
Anesthetics
Take Home Points
• Continued emphasis on precision acute care
medicine and avoiding persistent postoperative
pain
• Multiple newer fascial plane blocks can be
employed in the perioperative period
• Research regarding outcomes demands further
investigation
• Novel long-acting formulations may provide
additional benefit
Take Home Points
References
• H. Elsharkawy, A. Pawa, E.R. Mariano. Interfascial Plane Blocks: Back to Basics. Regional Anesthesia and Pain Medicine 43(4):341-346, May
2018.
• El-Boghdadly K, Pawa A. The erector spinae plane block: plane and simple. Anaesthesia. 2017: 72;4:434-438.
• K.J. Chin, J.G. McDonnell, B. Carvalho, A. Sharkey, A. Pawa, J. Gadsden. Essentials of our current understanding: abdominal wall blocks. Reg
Anesth Pain Med. 2017; 42:133-183.
• Baeriswyl M, Kirkham KR, Kern C, Albrecht E. The analgesic efficacy of ultrasound-guided transversus abdominis plane block in adult patients: a
meta-analysis. Anesth Analg. 2015;121:1640–1654.
• Ganapathy S, Sondekoppam RV, Terlecki M, et al. Comparison of efficacy and safety of lateral-to-medial continuous transversus abdominis plane
block with thoracic epidural analgesia in patients undergoing abdominal surgery: a randomised, open-label feasibility study. Eur J Anaesthesiol.
2015;32:797–804.
• Niraj G, Kelkar A, Jeyapalan I, et al. Comparison of analgesic efficacy of subcostal transversus abdominis plane blocks with epidural analgesia
following upper abdominal surgery. Anaesthesia. 2011;66:465–471.
• Wahba SS, Kamal SM. Analgesic efficacy and outcome of transversus-abdominis plane block versus low thoracic-epidural analgesia after
laparotomy in ischemic heart disease patients. J Anesth. 2014;28:517–523.
• Wu Y, Liu F, Tang H, et al. The analgesic efficacy of subcostal transversus abdominis plane block compared with thoracic epidural analgesia and
intravenous opioid analgesia after radical gastrectomy. Anesth Analg. 2013;117:507–513.
• Blanco R, Ansari T, Girgis E. Quadratus lumborum block for postoperative pain after caesarean section: a randomised controlled trial. Eur J
Anaesthesiol. 2015;32:812–818.
• Murouchi T, Iwasaki S, Yamakage M. Quadratus lumborum block: analgesic effects and chronological ropivacaine concentrations after
laparoscopic surgery. Reg Anesth Pain Med. 2016;41:146–150.
• Parras T, Blanco R. Randomised trial comparing the transversus abdominis plane block posterior approach or quadratus lumborum block type I
with femoral block for postoperative analgesia in femoral neck fracture, both ultrasound-guided. Rev Esp Anestesiol Reanim. 2016;63:141–148.
• McCrum CL, Ben-David B, Shin JJ, Wright VJ. Quadratus lumborum block provdes improved immediate postoperative analgesia and decreased
opioid use compared with a multimodal pain regimen following hip arthroscopy. J Hip Preservation Surg. 2018; 5:3: 233-239.
• Chin KJ, Adhikary S, Sarwani N, Forero M. The analgesic efficacy of pre‐operative bilateral erector spinae plane (ESP) blocks in patients having
ventral hernia repair. Anaesthesia 2017; 72: 452–60.
• Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain.
RAPM 2016;41:621-627.
• Forero M, Rajarathinam M, Adhikary S, Chin KJ. Continuous erector spinae plane block for rescue analgesia in thoracotomy after epidural failure:
a case report. AA Case Rep 2017;8:254-256.
• Chin KJ, Adhikary S, Sarwani N, Forero M. The analgesic efficacy of pre-operative bilateral erector spinae plane (ESP) blocks in patients having
ventral hernia repair. Anaesthesia 2017;72:452-460.
• Chin KJ, Malhas L, Perlas A. The erector spinae plane block provides visceral abdominal analgesia in bariatric surgery: a report of 3 cases. RAPM
2017;42:372-376.
• https://www.asra.com/asra-news/article/39/how-i-do-it-erector-spinae-block-for-rib Accessed 11/25/2018.
References
• Jenstrup, MT, Jæger, P, Lund, J, Fomsgaard, JS, Bache, S, Mathiesen, O, Larsen, TK, Dahl, JB Effects of adductor-canal-blockade on pain and
ambulation after total knee arthroplasty: A randomized study.. Acta Anaesthesiol Scand. (2012). 56 357–64.
• A.V. Gururva Reddy, A. Jangale, R.C. Reddy, M. Sagi, A. Gaikwad, A. Reddy. To compare effect of combined block of ACB with IPACK and ACB
alone on total knee replacement in immediate postoperative rehabilitation. Int J Orthop Sci, 3 (2017), pp. 141-145.
• Thobhani S, Scalercio L, Elliott CE, Nossaman BD, Thomas LC, Yuratich D, Bland K, Osteen K, Patterson M. Novel regional techniques for total
knee arthroplasty promote reduced hospital length of stay: an analysis of 106 patients. Ochsner Journal 2017; 17:233-238.
• M.A. Mont, W.B. Beaver, S.H. Dysart, J.W. Barrington, D.J. Del Gaizo. Local infiltration analgesia with liposomal bupivacaine improves pain scores
and reduces opioid use after total knee arthroplasty: results of a randomized controlled trial. J Arthroplasty, 33 (2018), pp. 90-96.
• Hadzic’s Textbook of Regional Anesthesia and Acute Pain Management. Chapter 8: Controlled-Release Local Anesthetics.
https://accessanesthesiology.mhmedical.com/content.aspx?bookid=2070§ionid=157599103#1141731079 Accessed 11/25/2018.
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