Regional Anestesi

4/16/2014
2014 Winter Anesthesia Seminar
Regional Blocks Every

Anesthesiologist
g Should Know
How to maximize efficacy and minimize failure
Amanda Monahan, MD
Assistant Professor
Division of Regional Anesthesia
UCSD Department of Anesthesiology
Disclosures
Dr. Monahan has no relevant financial
relationship with any commercial interest.
Learning objectives
Identify basic regional blocks and
indications
Recognize techniques to optimize block
efficacy
Review techniques to minimize
complications or laterality errors
4/16/2014
The blocks
Femoral/Adductor
Sciatic
Interscalene
Infraclavicular
(Block) failure is not an option:

61 YOF 81kg with PMH severe COPD on 4L O2,
Chiari malformation, DM, HTN, obesity, chronic
pain and restless leg syndrome presents with a
pulseless open ankle fracture for urgent I&D
ABG: abysmal.
H/O prolonged intubation for COPD
Anxious, unable to lie flat, pursed lip breathing
My doctor told me that I should never have
anesthesia.
I just need to move my legs all the time.
(Block) failure is not an option:
4/16/2014
Success for any block

Goals for the regional block
Intraop anesthesia vs. postop analgesia
Desired onset time
Desired duration time (single vs. catheter)
Nerve distributions to be anesthetized
Ambulatory vs. inpatient and motor block

Patient selection: mental status, language
Expectation management
Surgical anesthesia vs. postop analgesia
Stakeholder communication
Room team, surgeon, PACU RN
Patient counseling
Follow-up, multimodal analgesia, incidental
blocks, limb protection/fall prevention

Avoiding laterality errors
Checklist, Time out
Surgical consent VISIBLE during time out
Site(s) markingVISIBLE during block
Patient participation (counsel)
Prone and re-positioning
4/16/2014
Positioning
Positioning
Positioning
g
Sedation choice
Avoiding infection, leakage, dislodgement
Standardizing ultrasound screen view

Pre-sedation final confirmation
Any blood thinners? Any nerve problems?
Pre-block neurologic exam for traumas

Preop block testing
Postop follow-up
Femoral
Indications
TKA, UKA
Knee MUA, ACL
AKA/BKA
Femur ORIF
Tibial plateau fracture
Patella ORIF
Anterior thigh STSG, tumor excisions
Free Flaps
4/16/2014
Femoral
Sonoanatomy
(Femoral)
Femoral
Sonoanatomy
(Femoral)
Iliopsoas
Femoral
Sonoanatomy
(Adductor)
4/16/2014
Femoral
Sonoanatomy
(Adductor)
Sartorius
Vastus M.
AdductorL.
Femoral
Positioning
Femoral
Adductor
Femoral
The block
(Adductor)
4/16/2014
Femoral
The block
(Adductor)
Femoral
The block
(Adductor)
Femoral
The block
(Adductor)
4/16/2014
Femoral
The block
(Adductor)
Femoral
The block
(Adductor)
Femoral (Traditional)
Common errors
Using ultrasound view below femoral artery
split
Failure to retract pannus skin
Injection above the fascia iliaca
Choosing femoral block in ambulatory patient
Allowing caregivers to expect femoral block to
cover posterior knee pain
4/16/2014
Femoral (Adductor)
Common errors
Failure to approach at consistent level
Failure to appreciate tactile pop on canal
entry
Accepting local anesthetic spread in/below
sartorius (rather than in adductor canal)
Femoral
Local anesthesia deposition strategies
Injecting below the femoral nerve
Injecting between the femoral nerve and
fascia iliaca
Using a hydrodissection technique to
maneuver within tissue plane
Femoral
Testing your block
Ice to kneecap area, medial ankle
Voluntary contraction of quadriceps
Make a muscle
Follow-up
4/16/2014
Sciatic
Indications
Distal leg, foot, ankle
Fracture ORIFs, diabetic ulcers, amputations,
plastics gastroc flaps,
flaps burns/grafts
BKA, Achilles repair, tibial nails (delayed)

ACL, Tibial plateau, Total knee
Sciatic
Sonoanatomy
Sciatic
Sonoanatomy
CP
T
Semitendinosus
Semimembranosus
BicepsFemoris
10
4/16/2014
Sciatic
Positioning
Sciatic
The
block
Sciatic
The
block
11
4/16/2014
Sciatic
The
block
Sciatic
The
block
Sciatic
Common errors
Failure to elevate ankle with towels
Failing to identify sciatic nerve split
Not allowing sufficient time for block setup
Injection outside the perineurium
Ignoring the saphenous distribution when
planning a surgical block (tourniquet)
12
4/16/2014
Sciatic
Local anesthetic deposition strategies
At the common peroneal/tibial split
Above the sciatic nerve split
Subperineurial injection
Sciatic
Testing your block
Interscalene
Indications
Analgesia of the shoulder and upper arm
Single shot vs. catheter for shoulder
arthroscopy
Typically single shot for distal clavicle ORIF
Typically catheter for shoulder replacement or
humerus ORIF
13
4/16/2014
Interscalene
Sonoanatomy
Interscalene
Sonoanatomy
SCM
AS
Trap
MS
TransverseProcess
Interscalene
Positioning
14
4/16/2014
Interscalene
The
block
Interscalene
The
block
Interscalene
The
block
15
4/16/2014
Interscalene
The
block
Interscalene
The
block
Interscalene
The
block
16
4/16/2014
Interscalene
Common errors
Incomplete chart review
Inadequate patient counseling regarding
incidental/accessory blocks
Supine positioning
Not using a systematic scanning method
Excessive LA volume deposition, especially
into anterior scalene muscle
Catheter dislodgement/leakage
Interscalene
Avoiding excessive volume
Entering interscalene fascia space between
upper and middle trunks
Avoiding excessive injection into ASM
Color doppler to check for vertebral artery
Infraclavicular
Indications
Procedures from mid-humerus to finger
Finger/forearm reimplantation
Why preferable to axillary or supraclav
17
4/16/2014
Infraclavicular
Sonoanatomy
Infraclavicular
Sonoanatomy
caudad
Pec Maj
cephalad
Pec Min
M
L
P
Infraclavicular
Positioning
18
4/16/2014
Infraclavicular
The
block
Infraclavicular
The
block
Infraclavicular
Common errors
Failure to use systematic scanning
Failure to adjust plan for veins
Failure to adjust transducer pressure
Extremely lateral approach, after splitting of
cords
(AVF re-do patients)
19
4/16/2014
Infraclavicular
Multi-injection
Single injection
Approach from 12 oclock
Approach from 7 oclock
Infraclavicular
Testing your block
Upcoming Events
CSA Fall Anesthesia Seminar
October 27- 31, 2014 | Kohala Coast, HI
Fairmont Orchid Hawaii
CSA Winter Anesthesia Seminar

January 12-16, 2015 | Wailea Maui, Hawaii
Fairmont Kea Lani
Visit www.csahq.org/CMEevents for more information.
20
4/16/2014
2014 Winter Anesthesia Seminar
Current Guidelines
for the use of Antithrombotics
& Neuraxial
N
i lP
Procedures
d
Ramo K. Naidu, MD
UC San Francisco Dept of Anesthesiology
Division of Pain Medicine
Director of Acute Pain Services at Moffitt-Long and Mount Zion Hospitals
Integrated Pediatric Pain & Palliative Care (IP3)
San Francisco, California. April 26, 2014
Disclosures
Nothing to disclose regarding this lecture.
Received stipends for educational courses
related to spinal cord stimulation from
Boston Scientific and Medtronic
Learning Objectives
Understand the growing number of patients on
TSOAs and the implications on regional
anesthesia
Have a new perspective on the risk of neuraxial
hematoma associated with neuraxial anesthesia
Understand the potential differences in risk among
procedures (Regional Anesthesia & Interventional
Pain) and the challenge in assessing individual
risk
Understand the potential consequences of ceasing
antithrombotic therapy for an intervention
4/16/2014
The Guidelines
American Society European Society

Scandinavian
of Regional
of Regional
Society of
Anesthesia & Pain Anaesthesia & Pain Anaesthesiology
Medicine
Therapy
and Intensive Care
Medicine
Jan-Feb 2010
RAPM
Oct 2010
EJA
2010
AAS
2011
2012
2009
2010
2001
1997
1993
1994
USIntroductionofAntithrombotics
FDA Approval Dates
RamoK.Naidu,MD
naidur@anesthesia.ucsf.edu
The New Drugs
4/16/2014
Target-Specific Oral Anticoagulants

(TSOACs)
Dabigatran (Pradaxa)
FDA approval 2010.
Oral direct thrombin inhibitor indicated for stroke prevention in non-valvular atrial fibrillation.
Elimination Half-life: 12-17 hours. Onset: 1-2 hours. Renal elimination: 80%
Rivaroxaban (Xarelto)
FDA approval
pp
2011.
Oral factor Xa Inhibitor indicated for stroke prevention in non-valvular atrial fibrillation AND DVT
prophylaxis and treatment.
Elimination Half-life: 7-11 hours. Onset: 2-3 hours.
Renal elimination: 30%. 3A4 metabolism
Apixaban (Eliquis)
FDA-approval in 2012.
Oral factor Xa Inhibtor indicated for stroke prevention in non-valvular atrial fibrillation AND DVT
prophylaxis and treatment.
Elimination Half-life: 8-15 hours. Onset: 3-4 hours.
Renal elimination: 25%. 3A4 metabolism
Cove C et al. JAHA. 2013
Target-Specific Oral Anticoagulants (TSOACs)
Dabigatran (Pradaxa)
Rivaroxaban (Xarelto)
Prophylactic
Therapeutic
Apixaban (Eliquis)
RamoK.Naidu,MD
P2Y12antagonists
Prasugrel (Effient)
FDAapproval2009.
Oralplateletaggregationinhibitorforpreventionandtreatmentofthromboticeventsin
patientswithcoronarystents.
EliminationHalflife:7hours.Onset:1hour.
3A4
3A4metabolism
t b li
Ticagrelor (Brilinta)
FDAapproval2011.
Oralplateletaggregationinhibitorindicatedforpreventionandtreatmentofthrombotic
eventsinpatientswithAcuteCoronarySyndromeormyocardialinfarctionwithSTelevation.
EliminationHalflife:7hours.Onset:1.5hours.
3A4metabolism
4/16/2014
P2Y12antagonists
Prasugrel (Effient)
Ticagrelor (Brilinta)
RamoK.Naidu,MD
The New Concerns About the Old Drugs
FDA Alert regarding Low-Molecular Weight Heparin
November6,2013.
Reviewofdataregardinglowmolecular
weightheparinfrom19922013.
170cases.100casesconfirmedwithimaging.
FDA Statement:
Change the time of
LMWH start after
neuraxial procedure or
catheter removal from 2
to 4 hours.
RamoK.Naidu,MD
4/16/2014
FDA Alert regarding Low-Molecular Weight Heparin
Prophylactic
Therapeutic
RamoK.Naidu,MD
Case Reports of Neuraxial Hematoma with

SSRIs, ASA, and Spinal Cord Stimulation
Jan/Feb 2014 Regional Anesthesia & Pain Medicine
73 yo woman with postlaminectomy pain syndrome

and lumbar radiculopathy underwent SCS lead
placement on ASA 81mg/day for several years.
Conclusion: The only variable that could have led to
our patients epidural hematoma is aspirin.
Stratifying Risks By
Procedure.
All that we dont know
DxSingle
TxSingle
IndwellingCatheter
ImplantableDevices
Lumbar
Puncture
SS Spinal
ILESI
TFESI
Paravertebral
Lumbar Plexus
Epidural
Intrathecal
Spinal Cord
Stimulation
Intrathecal
Pump
20-24ga
17-25ga
17-20ga
14-17ga
RamoK.Naidu,MD
4/16/2014
Neuraxial Hematoma
Contributing Factors
NeedlePlacement
ExogenousAntithrombosis
IndwellingCatheter
WHATs THE
WHAT
INCIDENCE OF
NEURAXIAL
HEMATOMA?
EPIDURALHEMATOMA
MechanicalTissueInjury
EndogenousCoagulableState
AnatomicVariance
Age
RamoK.Naidu,MD
U.S. Introduction of
Antithrombotics
Neuraxial
Hematoma
Paralysis
2010
2012
2000
1990
1980
1970
1960
1950
1940
1930
1920
1910
1900
Spinal
Anesthetic
Horlocker T, RAPM, 1998

FDA Approval Dates
RamoK.Naidu,MD
History
1993
Tryba.13clinicallyrelevantepiduralhematomata/850,000neuraxial anesthetics=
1/150,000Epidurals1/220,000SAB
1994
Vandermeulen.AretrospectiveanalysisofcasereportsfromMEDLINE19061994.46cases
ofconsequentialepiduralhematoma.68%hadimpairedcoagulation.
1993 1998
LMWH(MedWatch System)40casesofneuraxial hematoma,1/3000.

DisparitiescomparedtoEuropeattributedtodosing,timing,andpreferenceforCSCin
Europe.
1998
ASRAstatesthattheyareagainst BIDdosingofLMWH
2003
Ratesofneuraxial hematomadeclinedbythetimeofthe2ndASRAConsensusConferenceon
Neuraxial AnesthesiaandAnticoagulation
Horlocker T, A&A, 2013
4/16/2014
History
2004
Moen.Anesthesiology. Retrospectiveanalysisfrom19901999inSweden.
Rate=1/18,000forcontinuousepiduralanalgesia.
2008
Ppping.BJA.
Ppping
BJA Retrospectiveanalysisfrom19982006.
Retrospective analysis from 1998 2006
Rate=1/4741.1/1000forelderlywomenundergoingLEsurgery
2013
Bateman.A&A.MulticenterPerioperativeOutcomesGroup(MPOG).
Consortiumofacademicanesthesiadepartmentsthatpoolsperioddata.
Eleveninstitutionsinvolvingobstetricandperiopanesthesia.
Rate=7/62,450inperiopepiduralplacement.0/79,837inobstetric
4ofthe7detractedfromASRAGuidelines.
Horlocker T, A&A, 2013
Systems-Based Practice
Regional Team
ServiceA
Attending
AcutePainService
Attending
Residents
Attending
NP
Fellow
Residents
Intern
Residents
EPIDURAL
HEMATOMA
THROMBOTIC
COMPLICATION
ServiceB
NP
Nurses
Attending
Fellow
Residents
Pharmacists
Intern
The Idea
Patient Safety.
It is a launchpoint, a communication piece.
It does not replace individual decisions
decisions.
It is evidence-based, with the data we have.
It is adaptable based on data received globally and locally.
Rare, High Consequence Events are challenging to study,
data are disparate. e.g. POVL
RamoK.Naidu,MD
4/16/2014
The Idea
CARDIOLOGY
HEMATOLOGY
ANESTHESIA
PHARMACY
RADIOLOGY
ORTHO
RamoK.Naidu,MD
Minimum time
between the last
dose and when
neuraxial shot/
catheter
placement can Minimum time after catheter
occur
placement to drug start.
Minimum time between

last dose of drug and
catheter removal
Minimum time
between neuraxial
shot/ catheter
removal and when
next dose can be
given
ANTICOAGULANTS FOR VENOUS THROMBOEMBOLISM PROPHYLAXIS
dalteparin(Fragmin)5000unitsSQqday
12hours
ADVISECAUTION.Maybegiven.
12hours
Wait6hrsaftercatheterplacement
beforenextdose.
enoxaparin(Lovenox)
40mgSQqday
12hours
12hours
beforenextdose.
4hours
4hours
enoxaparin(Lovenox)30mgSQbidor40mgSQ 12hours
bid
CONTRAINDICATEDwhilecatheterinplace
fondaparinux(Arixtra)
<2.5mgSQqday
48hours
heparin5000UnitsSQbid
TIMELINE
4hours
2hours
DRUG
DRUG DRUG
Maybegiven;Notimerestrictionsforcatheterplacementorremoval
heparin5000UnitsSQtid
4hours
2hours
4hours
2hours
rivaroxaban(Xarelto)
10mgPOqday
48hours
6hours
24hours
6hours
ANTICOAGULANTS AT THERAPEUTIC DOSES
apixaban(Eliquis)
2.5 5mgPObid
72hours
warfarin(Coumadin)
5daysorINR<1.5
dabigatran(Pradaxa)
4daysorwhenTT
isnormal
dalteparin(Fragmin)200U/kgSQqday;100
U/kg SQ q12h
U/kgSQq12h
24hours
SingleShot
Single Shot
enoxaparin(Lovenox)1mg/kgSQbid;1.5mg/kg 24hours
SQqday
510mgSQqday
72hours
heparinfulldoseIV(Inemergentsituations,
whenaPTT<40
mayhavetobeused.Recommendneurochecks
q2h)
CONTRAINDICATEDwhilecatheter CONTRAINDICATEDwhile
inplace.Inemergentsituation,start catheterinplace.
atleast1hourafter.
CATHETER
6hours
2hours
(noconsensus)
6hours
4hours
4hours
TIMELINE
2hours
2hours
DRUG
DRUG
DRUG
Inemergentsituation,4hours
andcheckaPTT<40
2030mgPOqday
48hours
6hours
ORAL ANTIPLATELET AGENTS
aspirin/NSAIDS/COXinhibitors/dipyridamole
clopidogrel(Plavix)/prasugrel(Effient)/
ticagrelor(Brilinta)
7days
ticlopidine(Ticlid)
14days
2hours
2hours
DIRECT THROMBIN INHIBITORS
argatroban/bivalirudin(Angiomax)
WhenTTisnormal
2hours
G IIB/IIIA INHIBITORS
abciximab(Reopro)
48hours
eptifibatide(Integrilin)/tirofiban(Aggrastat)
8hours
2hours(ACS)
Theriskofepidural
hematomaisequalforboth
catheterplacement,and
catheterremoval
2hours(ACS)
THROMBOLYTIC AGENTS
alteplase(TPA)Fulldoseforstroke,MI,etc
10days
alteplase(TPA)2mgdoseforcatheterclearance
10days
Minimum time
between the last dose
and when neuraxial
shot/ catheter
Minimum time after catheter
placement can occur placement to drug start.
Vandermeulen, A&A. 1994

last dose of drug and
catheter removal
ANTICOAGULANTS FOR VENOUS THROMBOEMBOLISM PROPHYLAXIS

12hours
dalteparin(Fragmin)5000unitsSQqday 12hours
beforenextdose.
enoxaparin(Lovenox)
40mgSQqday
12hours
enoxaparin(Lovenox)30mgSQbidor
40mgSQbid
12hours
<2.5mgSQqday
48hours
ADVISECAUTION.Maybegiven. 12hours
beforenextdose.
Minimum time
between neuraxial
shot/ catheter
removal and when
next dose can be
given
4hours
4hours
4hours
4hours
heparin5000UnitsSQbid
heparin5000UnitsSQtid
4hours
2hours
4hours
2hours
10mgPOqday
48hours
6hours
24hours
6hours
4/16/2014
Minimum time
between the last
dose and when
neuraxial shot/
catheter
placement can Minimum time after catheter last dose of drug and
occur
catheter removal
ANTICOAGULANTS AT THERAPEUTIC DOSES
apixaban(Eliquis)
72hours
2.5 5mgPObid
dabigatran(Pradaxa)
4daysorwhenTT
isnormal
dalteparin(Fragmin)200U/kgSQqday;100
U/kgSQq12h
24hours
enoxaparin(Lovenox)1mg/kgSQbid;
1.5mg/kgSQqday
24hours
510mgSQqday
72hours
Minimum time
between neuraxial
shot/ catheter
removal and when
next dose can be
given
6hours
6hours
4hours
4hours
4hours
whenaPTT<40
heparinfulldoseIV(Inemergentsituations,
mayhavetobeused.Recommendneurochecks
q2h)
2030mgPOqday
48hours
warfarin(Coumadin)
5daysorINR<1.5
CONTRAINDICATEDwhilecatheter CONTRAINDICATEDwhile
2hours
inplace.Inemergentsituation,
catheterinplace.
startatleast1hourafter.
Inemergentsituation,4hours
andcheckaPTT<40
6hours
Minimum time
between the
last dose and
when neuraxial
shot/ catheter
placement can Minimum time after catheter last dose of drug and
occur
catheter removal
ORAL ANTIPLATELET AGENTS
aspirin/NSAIDS/COXinhibitors/dipyridamole
2hours
(noconsensus)
Minimum time
between neuraxial
shot/ catheter
removal and when
next dose can be
given
clopidogrel(Plavix)/prasugrel(Effient)/
ticagrelor(Brilinta)
7days
ticlopidine(Ticlid)
14days
2hours
2hours
DIRECT THROMBIN INHIBITORS

argatroban/bivalirudin(Angiomax)
WhenTTisnormal
2hours
G IIB/IIIA INHIBITORS
abciximab(Reopro)
48hours
2hours(ACS)
eptifibatide(Integrilin)/tirofiban(Aggrastat) 8hours
2hours(ACS)
THROMBOLYTIC AGENTS
alteplase(TPA)Fulldoseforstroke,MI,etc
10days
10days
alteplase(TPA)2mgdoseforcatheter
clearance
THROMBOTIC
COMPLICATION
RisksofCeasingAntithromboticTherapy&TheRoleof
Bridging
Youmayneedtoconsultwithcardiologyorhematologybased
ontheconcernfortheriskforthrombosis.
PeripheralRegionalAnesthesia&Antithrombotics
Astandardizedsetofrecommendationsforallperipheral
regionalanestheticscannotbemadeatthistime.
RamoK.Naidu,MD
4/16/2014
Hepatic&RenalImpairment
Ifunclearaboutthepharmacokineticsinimpairedmetabolism
andexcretion,refertothepackageinsertofamedication.
CytochromeP450Metabolism
Beawareofinteractionswithothersubstances(grapefruitjuice,
herbals,drugs).Ifunclear,pleaserefertothepackageinsertof
amedication.
ProteinBinding
RamoK.Naidu,MD
CombinationsofFactors
Thistabledoesnotidentifytheriskassociatedwith
combinationsofantithromboticetiologies.
Examplesincludecombinationsofdrugswithherbal
supplements,vonWillebranddisease,etc.
TraumaticorBloody Tap
Thereisa~10foldincreasedriskofepiduralhematomawith
traumaticplacement.
RamoK.Naidu,MD
Bleeding
Clotting
10
4/16/2014
Systems-Based Practice
RegionalTeam
ServiceA
Attending
AcutePainService
Attending
Residents
Attending
NP
Fellow
Residents
Residents
EPIDURAL
HEMATOMA
Intern
ServiceB
THROMBOTIC
COMPLICATION
NP
Nurses
Attending
Fellow
Residents
Pharmacists
Intern
No regional anesthesia.
No antithrombotics.
Institute of Medicine 2011 Report
Chronic Pain affects 100 million Americans

25--40% have chronic pain from surgery or trauma
25
IASP
Understandingtherisksandbenefits.
Communicatingtherisksandbenefits.
Medical Costs and Lost Productivity
MakinganinformedANDshareddecisionwithyourpatient
Pain:
$635,000,000,000
Heart Disease:
$309,000,000,000
Gaskin et al.
Cancer:
$243,000,000,000
Appendix C.
Economic Costs of Pain
Diabetes:
$188,000,000,000
Legal
Ramifications?
1)Communication
1)
Communication
2)Communication
3)Communication
PREOP
PRE
INTRA
INTRA
OP
POSTOP
POST
RamoK.Naidu,MD
11
4/16/2014
TheFuture
Increased demand for antithrombotic prophylaxis and
therapy.
The incidence of neuraxial hematoma is higher than
previously
p
y considered
Awareness, statistical methodology, or trend?
New drugs continue to be developed
Without safe reversibility.
The importance of Regional Anesthesia and Interventional
Pain Medicine
Requires education and systems-based safety measures.
ASA Standards, Guidelines, and Statements

Standardsproviderulesorminimumrequirementsforclinicalpractice.Theyareregardedasgenerally
acceptedprinciplesofpatientmanagement.Standardsmaybemodifiedonlyunderunusual
circumstances,e.g.,extremeemergenciesorunavailabilityofequipment.
Guidelinesaresystematicallydevelopedrecommendationsthatassistthepractitionerandpatientin
makingdecisionsabouthealthcare.Theserecommendationsmaybeadopted,modified,orrejected
accordingtoclinicalneedsandconstraintsandarenotintendedtoreplacelocalinstitutionalpolicies.
Inaddition,practiceguidelinesarenotintendedasstandardsorabsoluterequirements,andtheiruse
cannotguaranteeanyspecificoutcome.Practiceguidelinesaresubjecttorevisionaswarrantedbythe
evolutionofmedicalknowledge,technology,andpractice.Theyprovidebasicrecommendationsthat
aresupportedbyasynthesisandanalysisofthecurrentliterature,expertopinion,openforum
commentary,andclinicalfeasibilitydata.
Statementsrepresenttheopinions,beliefs,andbestmedicaljudgmentsoftheHouseofDelegates.As
such,theyarenotnecessarilysubjectedtothesamelevelofformalscientificreviewasASAStandards
orGuidelines.EachASAmember,institutionorpracticeshoulddecideindividuallywhetherto
implementsome,none,oralloftheprinciplesinASAstatementsbasedonthesoundmedical
judgmentofanesthesiologistsparticipatinginthatinstitutionorpractice.
http://www.asahq.org/ForMembers/StandardsGuidelinesandStatements.aspx
References
RamoK.Naidu,MD
CoveCL,HylekEM.AnUpdatedReviewofTargetSpecificOralAnticoagulantsUsedinStrokePreventioninAtrialFibrillation,VenousThromboembolicDisease,and
AcuteCoronarySyndromes.JofAmHeartAssoc.2013Oct23;2(5):e000136.
HorlockerTTetal.Regionalanesthesiainthepatientreceivingantithromboticorthrombolytictherapy.AmericanSocietyofRegionalAnesthesiaandPainMedicine
EvidenceBasedGuidelines(thirdedition).RegAnesthPainMed2010;35:64101.
GogartenWetal.Regionalanaesthesiaandantithromboticagents:recommendationsoftheEuropeanSocietyofAnaesthesiology. EurJofAnaesthesiol2010;27:999
1015ESRA
BreivikHetal.NordicguidelinesforneuraxialblocksindisturbedhaemostasisfromtheScandinavianSocietyofAnaesthesiologyandIntensiveCareMedicine.Acta
AnaesthesiolScand2010;54:1641.
BatemanBTetal.TheRiskandOutcomesofEpiduralHematomasAfterPerioperativeandObstetricEpiduralCatheterization:AReportfromtheMulticenter
PerioperativeOutcomesGroupResearchConsortium.Anesthesia&Analgesia.June2013;116(6):13801385.MPOG
HorlockerT,KoppS.EpiduralhematomaafterepiduralblockadeintheUnitedStates:it'snotjustlowmolecularheparinfollowingorthopedicsurgeryanymore.
AnesthAnalg.2013Jun;116(6):11957.
HorlockerTT,WedelDJ:Spinalandepiduralblockadeandperioperativelowmolecularweightheparin:SmoothsailingontheTitanic.AnesthAnalg1998;86:11536
VandermeulenEP,VanAkenH,VermylenJ:Anticoagulantsandspinalepiduralanesthesia.AnesthAnalg1994;79:116577
DouketisJD,BergerPB,DunnAS,JafferAK,SpyropoulosAC,BeckerRC,AnsellJ,Theperioperativemanagementofantithrombotictherapy:AmericanCollegeofChest
PhysiciansEvidenceBasedClinicalPracticeGuidelines(8thEdition).AmericanCollegeofChestPhysicians.Chest.2008Jun;133(6Suppl):299S339S.
HolbrookA,SchulmanS,WittDM,VandvikPO,FishJ,KovacsMJ,SvenssonPJ,VeenstraDL,CrowtherM,GuyattGH;Evidencebasedmanagementofanticoagulant
therapy:AntithromboticTherapyandPreventionofThrombosis,9thed:AmericanCollegeofChestPhysiciansEvidenceBasedClinicalPracticeGuidelines.Chest.2012
Feb;141(2Suppl):e152S84S.doi:10.1378/chest.112295.
MoenV,DahlgrenN,IrestedtL:SevereneurologicalcomplicationsaftercentralneuraxialblockadesinSweden19901999.Anesthesiology2004;101:9509
HellerAR,LitzRJ.Whydoorthopedicpatientshaveahigherincidenceofseriouscomplicationsaftercentralneuraxialblockade?Anesthesiology.2005Jun;
102(6):1286;authorreply12878.
PppingDM,ZahnPK,VanAkenHK,DaschB,BocheR,PogatzkiZahnEM.Effectivenessandsafetyofpostoperativepainmanagement:asurveyof18925consecutive
patientsbetween1998and2006(2ndrevision):adatabaseanalysisofprospectivelyraiseddata. BrJAnaesth.2008Dec;101(6):83240
12
4/16/2014
Upcoming Events

Fairmont Kea Lani
13
4/16/2014
Continuous Regional Anesthesia: How to Make it

Work?
Jean--Louis Horn, MD
Jean
Professor, Chief
Division of Regional Anesthesia
Department of Anesthesiology, PeriPeri-Operative and Pain Medicine
Stanford University Medical Center
Disclosure
Consultant for I-Flow
Consultant for Arrow
4/16/2014
Overview
Rationale and benefits of regional anesthesia

Effective regional anesthesia program
Data on the home pump program
The future
Conclusions
Overview

The future
Conclusions
Continuous PNB: an Old Story
Dr. Ambros, 1946
4/16/2014
Postoperative Pain:
Myth or Reality ?
Survey of Postoperative Analgesia Following Ambulatory

Surgery (n=1035, 94.1% returned questionnaire)
Inguinal Hernia 62%
Ortho 41%
Severity of pain did NOT decrease over 48 hours
20% difficulty sleeping due to severe pain, 20% N, 20% tiredness, 8%
95% were satisfied with care
Rawal et al. Acta Anaesth Scan, 1997
Systemic Review and Analysis of PostDischarge Symptoms afterOutpatient Surgery
45% pain (25-35% moderate to severe 16% severe after ortho)

42% drowsiness
21% fatigue
17% N
8% V
Wu et al. Anesthesiology 96(4):994-1003, 2002
Pain
Deleterious consequences of poor pain control on pain and recovery
CRPS prevalence following wrist fracture: 8-22%
Poorly controlled acute pain favors the development of chronic pain
condition
Pain is major predictor for poor recovery and increasing medical
cost $
Lancet. 1999;354(9195):2025-8.
Anesthesiology, 2004;101:1215-25
JBJS, 2007;1343-58
Anesth & Analg, 2007;105:228-32
4/16/2014
From Acute Pain to Chronic Pain

56% of surgical patients will develop chronic postsurgical pain
Some studies indicate percentage may be much higher
Complex process involving multiple factors,, social-environmental,
and patient-related factors
Duration
D
i off surgery, llow-versus high-volume
hi h l
surgical
i l unit
i
Psychological and social
Younger age, female sex, increased pain and incidence
Katz J. ASRA News. February, 2009.
Regional Anesthesia and

Reduction of Chronic pain
Continuous PNB reduces the prevalence of chronic pain after
breast cancer surgery
1 month: Intensity of motion-related pain lower in CPNB
group (P = 0.005) vs. control group
6 month: Prevalence of any pain symptoms lower in
CPNB group (P = 0.029) vs. control group
12 month: Prevalence of pain symptoms (P = 0.003),
intensity of motion-related pain (P =0.003), and intensity
of pain at rest (P = 0.011) all lower in CPNB group vs.
control group
Kairaluoma PM, et al. Anesth Analg. 2006;103:703-708.
RA vs. GA in Ambulatory Surgery:

Meta-Analysis
Increased induction time (19.6 min vs 8.8, p<0.001)
bypass of Phase 1 recovery (81% vs 31.5% p<0.001)
Decreased PACU time (9.6 min vs 35.8 min p<0.001)
Decreased PACU pain VAS 9.6 mm vs 35.8 mm, and long term pain
Decreased use of pain medication, NV, pruritus
Decreased N/V (6% vs 30%)
Improved sleep pattern, delirium, urinary retention, patient satisfaction
(significant) / humanitarian benefit (PR)
Liu SS, et al. Anesth Analg 2005;101:1634-42
Evans H, et al. Anesth Clin North Am 2005;23(1):141-62
4/16/2014
Meta-analysis: CPNB vs. Opioids

Mean VAS
24h
48h
Infraclav 1.0
4.3
4.0
1 0 vs.
vs 4
3 p<0.001
p<0 001 0.6
0 6 vs.
vs 4
0 p<0.001
p<0 001
Interscal 1.4 vs. 3.6 p<0.001 0.5 vs. 2.3 p<0.001
Fem/LP
2.1 vs. 4.0 p<0.001 1.6 vs. 3.2 p<0.001
Sciatic
0.9 vs. 4.6 p<0.001 0.9 vs. 3.5 p<0.001
N/V, sedation, pruritus and opioid usage significantly decrease

at all time point and for all block areas
Richman JM, et al. A&A 2006;102:248
Meta--analysis: CPNB vs. Single Shot

Meta
Pain, Opioid Usage, Side Effects and Satisfaction
Meta-analysis CPNB vs. single-injection block: 21 studies (702
subjects) included
Bingham AE, et al. RAPM 2012;37:583
Benefits of CPNB for

Outpatients
RCT: 32 patients scheduled for outpatient shoulder
surgery with an US-guided interscalene nerve block
All subjects received a nerve block catheter and one-time
ropivacaine bolus
After surgery, subjects discharged home with portable
infusion device
Half received ropivacaine infusion for 2 days
Half received saline infusion for 2 days
Mariano ER, et al. A&A 2009;108:1688
4/16/2014
Results
Results
Subjects who received ropivacaine suffered fewer sleep
disturbances and consumed less oral opioid medication
Subjects who received ropivacaine reported higher
satisfaction with recovery
Improving Range of
Motion
25 patients s/p total shoulder arthroplasty with
continuous interscalene block (CISB) compared to
matched controls (PCA) (Retrospective study)
Primary outcome: ability to achieve surgeon-defined
physical therapy goals
Secondary outcome: pain scores
Ilfeld BM, et al. RAPM 2005; 30:42930:429-33
4/16/2014
Improving Range of Motion

150
90
10
-30
30
45
Elevation: 85%(CISB) vs. 33%(PCA), p=.048

Ext Rotation: 100%(CISB) vs. 17%(PCA), p<.001
Worst Pain score: 2.0 (0.0(0.0-8.7) vs. 8.5 (1.8
(1.8--10.0), p<.001
Ilfeld BM, et al. RAPM 2005; 30:42930:429-33
US vs. NS for CPNB

4 IRB-approved
randomized clinical trials
Randomized
(n=160, not blinded)
Nerve Stimulation
Ultrasound
Nonstimulating Catheter
Stimulating Catheter
Primary outcome: catheter placement time (min)

Secondary outcomes: pain during placement,
venous puncture and leakage rates, pain on POD 1
Mariano ER, et al. RAPM 2009;34:480
Mariano ER, et al. JUM 2009;28:1211

Results
Popliteal

4/16/2014
Results
US: less inadvertent vascular punctures
Femoral, infraclavicular
US: higher success rate

Infraclavicular

Anesthesia-Controlled Time and Turnover Time

per anesthesia technique (minutes)
ACL reconstruction, n=369
RA block room, vs. GA in OR
45
40
Turnover times: no differences

across techniques
35
30
25
ACT
TOT
Total
20
15
10
RA: lowest ACT and total time

(ACT + TOT)
9-minute OR time savings
with RA / induction room
5
0
GA
GA/RA
RA
n=127 n=83 n=159
P<0.05
Anesthesiology 93(2):529-538, 2000
RA and Rehabilitation
Improve rehabilitation after major joints replacement (TKA)
Singelyn: Better pain relief and faster knee rehabilitation

with CPNB than IV PCA with morphine
Capdevila: RA techniques improve early rehabilitation and
effectively pain control after major knee surgery
Chelly: CPNBs reduced postop morphine requirement,
postoperative bleeding and provided better recovery than
IV PCA with morphine or an epidural
Singelyn FJ, et al. Anesth Analg. 1998;87:88-92.

Capdevila X, et al. Anesthesiology. 1999;91(1):8-15.
Chelly JE, et al. J Arthroplasty. 2001;16(4):436-445.
4/16/2014
Continuous Peripheral Nerve Blocks:

Decreased Time to Discharge
Ambulatory 4-day CPNB associated with decreased time to
discharge after TKA
Primary end points: 3 important discharge criteria
Adequate analgesia
Independence from IV analgesia
Ambulation 30 m
Ilfeld BM, et al. Anesthesiology. 2008;108:703-713.
Time (hours)
Median time to discharge: 25 h for CPNB group vs. 71 h for control group
Data presented are Kaplan-Meier estimates of the cumulative percentages of patients meeting all 3 discharge criteria at each time point and
subsequent time points. Reprinted from Ilfeld BM, et al. Anesthesiology. 2008;108:703-713.
Cost Savings With Ambulatory

Regional Anesthesia
Ilfeld et al (2007)
Retrospective, case-control study of TKA patients
10 received ambulatory continuous femoral nerve block (CFNB)
10 received inpatient CFNB only (control group)
M
Median
di costs
t off h
hospitalization
it li ti
$5292 ambulatory CFNB group
$7974 inpatient control group
34% decrease with ambulatory CFNB, P <0.001
Total charges
$33,646 ambulatory CFNB group
$39,100 control group
14% decrease with CFNB, P <0.001
Ilfeld BM, et al. Reg Anesth Pain Med. 2007;32:46-54.
4/16/2014
Perioperative Comparative Effictiveness

of Anesthetic in Orthopedic Patients
Retrospective study from HSS
N=400,000 primary total joint arthroplasty
Neuraxial patients were OLDER than GA patients
When neuraxial anesthesia was used:
Less 30-day mortality (P < 0.001)
Lower incidence of prolonged (>75th percentile) length of stay
Lower cost variability; fewer in-hospital complications
Most favorable complication risk profile
Doesnt detail nerve blocks at all.
Memtsoudis S et al. Anesthesiology 2013; 118(5):1046-1058
Neuraxial and Avoided GA Complications

Anesthesiology 2013; 118(5):1046-1058
Complication
Hip
Pulmonary embolism
NS
Knee
NS
Cerebrovascular event
P=0.0271
NS
y compromise
p
Pulmonary
P<0.0001
P<0.0001
Pneumonia
P=0.0029
P=0.0083
All infections
P<0.0001
P<0.0001
Acute renal failure
P<0.0001
P<0.0001
Mechanical ventilation
P=0.0085
P<0.0001
Transfusion
P<0.0001
P<0.0001
30-day mortality
NS
P=0.0211
Memtsoudis S et al. Anesthesiology 2013; 118(5):1046-1058
10
4/16/2014
Risks of Fall and RA

Clinical Science Best Abstract 11 ASA 2013
Review 190,000 TKA.
1.6% had in-hospital fall
Risks:
Advanced age
Male sex
Increased co-morbidity
Use of GA without neuraxial
Non-factors
Neuraxial with/without GA
Peripheral nerve block use
RA and Sympathectomy
Even at very low concentrations, local anesthetics
effectively block sympathetic nerves
Improving microcirculation
increase skin temperature of crushed fingers after
replantation
Major flap surgery?

Decrease wound infection (TKA)
Cancer Outcome and RA

Can anesthetic technique for primary breast cancer
surgery affect recurrence or metastasis? 94% vs.
84% and 77% at 24 and 36 months
Exadaktylos AK,
AK et al .Anesthesiology.
Anesthesiology 2006 October ;
105(4): 660664
Similar data for thyroid, ovarian and prostate cancer

Is it opioid sparing effect, GA, anesthetic gas, stress
and pain relate effect, immunomodulation, decrease
long term pain ???
11
4/16/2014
Overview

The future
Conclusions
Make a RA Program Work
RA - Organization & Set Up

Many parties involved:
The real challenge is organization
Surgeons collaboration
Patient evaluation/selection/education
Logistics
Patient flow from scheduling to follow-up
Anesthesia tech/nursing support
Block cart/area (resuscitation equipment)
Pharmacy involvement for meds and pumps
Hospital support: for all of the above and liability

Education program for patients, nursing, surgeons, and colleagues
Separate team for block placement and follow-up
-B.D. ODonnell and G. Iohom. Current Opinion in Anesth 2008,21:723728
-G.S. Cheng, et al. Current Opinion in Anesth 2008, 21:488493
12
4/16/2014
Surgeon Involvement
First to identify patients and to make the primary decision about
RA, and to inform the patient
Collaborate on follow-up, supplemental analgesics (prescribed
by the surgeons at our institution) and rehab (immobilizer)
Need to be educated about: our delivery system,
system skills and
organization
Collaborate on pathway and update practice according to new
publications
= communication and collaboration
The Orthopedic Perspective
( Adam Mirarchi, MD)

Orthopedic questions:
#1 IIs this
thi going
i tto affect
ff t turn
t
over?
?
#2 Does this $%#@ work?
#3 Whats in it for me?
#4 For what cases is it indicated?
#5 Im not sure
RA vs. GA in Ambulatory Surgery:

Meta-Analysis
Increased induction time (19.6 min vs 8.8, p<0.001)
bypass of Phase 1 recovery (81% vs 31.5% p<0.001)
Decreased PACU time (9.6 min vs 35.8 min p<0.001)
Decreased PACU pain VAS 9.6 mm vs 35.8 mm, and long term pain
Decreased use of pain medication, NV, pruritus
Decreased N/V (6% vs 30%)
Improved sleep pattern, delirium, urinary retention, patient satisfaction
(significant) / humanitarian benefit (PR)
Liu SS, et al. Anesth Analg 2005;101:1634-42
Evans H, et al. Anesth Clin North Am 2005;23(1):141-62
13
4/16/2014
#1 Is this going to affect turn over?

Anesthesia-Controlled Time and Turnover Time
per anesthesia technique (minutes)
ACL reconstruction, n=369
RA block room, vs. GA in OR
45
40
Turnover times: no differences

across techniques
35
30
25
ACT
TOT
Total
20
15
10
RA: lowest ACT and total time

(ACT + TOT)
9-minute OR time savings
with RA / induction room
P<0.05
0
GA
GA/RA
RA
n=127 n=83 n=159
Anesthesiology 93(2):529-538, 2000
Whats In It for Me (Surgeon)?

Orthopedic question #3
Whats in it for me?
- A little work up front
- A lot of satisfaction later
- Less ER visits,
visits less resident pager calls,
calls
less refill of oral analgesics
- Reduced ER bounce backs 62%
- Patient receiving one-shot blocks and not

continuous infusions, have complained that
their pain came on severely and acutely
(rebound)
-Williams BA, et al. Anesthesiology 2004; 100:697706
-Coldstein RY et al: (rebound pain). J Orth Tr 2012;26(10):557-62
Frequent Asked Questions?

- Spend some time to explain the process
- Patients often ask:
- You are still going to put me to sleep arent you?
- Is that going to hurt?
- You are still going to give me drugs right?
- I have a high tolerance for painIs it necessary?
- How do I take it out at home?
14
4/16/2014
Goal:
Balance between good pain relief
and mobility
Concern on the impact of nerve blocks on motor function
Particularly the impact of weakness on patients ability to
participate in active physiotherapy block (Ilfeld, et al)
Weakness
W k
increases
i
the
h risk
i k off ffalls
ll (F
(Feibel,
ib l et al)
l) or not?
?
Multlimodal analgesia may facilitate this goal
-Ilfeld BM, et al. Anesthesiology 2008;108(4):703-13

-Ilfeld BM, Anesthesiology 2004; 101(4):970-7
-Feibel RJ, et al. Abstract, AOA/COA Annual Meeting 2008
-Ilfeld BM, et al. Anesth Analg 2005;100:11728
Pre-op Identification of Block

Patients
As surgeons initiate the process a pre-op evaluation including
his/her preference for RA will be schedule to trigger an EPIC
identifier
HMR icon, and specific status board for regional
During the pre-op visit:
Confirm appropriateness of a RA (inclusion/exclusion criteria)
Educate the patient about RA and choices especially for home
pump(computer presentation + pamphlet)
Questions be answered
Schedule an early arrival on surgery day
Inform patients about expectations and other oral medications
to take with the CPNB
www.happypatient.org
EPIC Status Board for RA
15
4/16/2014
Pamphlet with
General Information
on Nerve Blocks
Education Pamphlet
for Home Pumps
The RA Team
Block team available 24/7 for hip fracture protocol and follow-up
Providers with interest and expertise in regional anesthesia
Assistants: fellows, residents, nurse and/or techs
Block
Bl k nurse/coordinator
/
di t with
ith dedicate
d di t block
bl k area
Good patient education system (preop clinic, web based,)
Life HMR identifier to schedule, track and follow patients
In and outpatients with single shot and continuous nerve blocks
Rapid response and treatment for complication/neuropathy
16
4/16/2014
The Mission of the RA Team

The mission of the RA division is to provide best patient care to
facilitate OR flow, patient outcome and satisfaction
Zero delay
Proper patient selection and efficient flow

Improved turnover
Early discharge from PACU, floor
Decrease delirium
Decrease long term pain
Improve long term recovery
GOOD COMMUNICATION
Happy Patients, Surgeons and Anesthesiologists

www.happypatient.org
Patients Selection and Education
Pamphlet, Web info, preop education
Consented: adequate information concerning risks/benefits
Proper expectations
Signs of LAST, specific block side effects (IS)
Ambulation precaution/fall prevention
Pressure injuring prevention
Optimal Infusion
Regimen
Multi-center RCT
83 subjects comparing
morphine IV PCA and 2
regimens for CPNB
VAS scores and analgesic
consumption highest in
control group
Early activity greatest in
basal-bolus CPNB
Capdevila X, et al. Anesth 2006;105:566
17
4/16/2014
Multimodal Pain Management

Medications
NSAIDs
-2 agonists
Acetaminophen
Ketamine
Anti-epileptics
Opioids
Menigaux et al. Anesth Analg 2005;100:1394-9

Peng et al
al. Pain Res Manag.
85 92
Manag 2007 Summer; 12(2): 8592
Adjunct relaxation, ice, acupuncture

Sun et al. BJA, 2008;149:1-10
Securing the Catheter

Drying agent
Surgical tape
(T
li )
(Tunneling)
Glue
(Suture)
Clear dressing
Anchoring device
Unplanned catheter disconnection
18
4/16/2014
Prevent that black thing from sliding loose
Tape is good,
fold and tape
More tape is good,

fold and tape
19
4/16/2014
BAM!!- Solid, you can pull that thing
27
Problems, Risks and

Complications
Serious problems are rare
Minors issues are common and easy to
manage, but often resulted from
poor understanding/education
-Wiegel M, et al.. Anesth Analg 2007; 104:15781582.

-Swenson JD, et al. Anesth Analg 2006; 103:14361443
20
4/16/2014
Minor and
Preventable Issues
Leak (reassure, instruction, reinforcing the dressing)

Ambulation difficulties, falls (immobilizers, crushes,
slings, education)
Numbness (instructions, proper expectation)
Pain (Remind about supplemental medications and
expectations)
More Serious Problems
Block Failure: 0% to 25% either primary

or secondary catheter failure
Hematoma/Bruising common.
Rarely significant, even in anticoagulated patients
Infections: rare and usually resolve with a course of
antibiotic
Now the serious things
21
4/16/2014
Serious: Nerve Injury

Rare event, incidence determined with observational
population studies
Incidence of transient neuropraxia following surgery may be
as high as 10%. Short lived, localized numbness,
paresthesia or weakness
Incidence of severe and prolonged nerve injury may be as
high as 4 per 10,000 to as low as 1:100,000.
Several studies from the Mayo Clinic show that adding a PNB
for major joint replacement does not increase the incidence of
nerve injury but may increase the severity
Importance of early diagnosis and aggressive treatment,
especially for inflammatory neuropathy
Mechanisms of Nerve Damage

Multifactorial and likely require more than 1 insult
Block Technique:
Direct Needle Trauma

High Pressure, intra-fascicular injection
Neuronal ischemia (Pressure, epinephrine)
LA/additives Neurotoxicity
Surgical Factors:
Stretch/Retractor Injury/duration/positioning
Hematoma
Tourniquet
Overview
Rationale and benefits of regional anesthesia?

Effective regional anesthesia program and risks
The plan for Stanford
Conclusions
22
Femoral
Infraclavicular
AveragePainScore
withmovement:
4.6/10
Subjective
assessmentof
overallpainrelief:
Good
65
Interscalene
49
4.5
Lumbar
AveragePainScore
atrest:2.8/10
Sciatic
At Rest
4.6
3.5
Supraclavicular Brachial Plexus

with Cath, U/S, Nerve
31

with Cath, U/S
52

with Cath, Nerve Stim
Sciatic with Cath, U/S
58
Sciatic with Cath, U/S, Nerve

Stimulation
161
Sciatic with Cath, Nerve

Stimulation
60
Lumbar Plexus with Cath, U/S
160
Lumbar Plexus with Cath, U/S,

Nerve Stimulation
80
Lumbar Plexus with Cath, Nerve

Stimulation
180
Interscalene Brachial Plexus with

Cath, U/S

Cath, U/S, Nerve Stim

Cath, Nerve Stim
29
Infraclavicular Brachial Plexus with

Cath, U/S, Nerve Stim
32

Cath, U/S
20

Cath, Nerve Stim
40
Average Pain Leve

el
Femoral with Cath with U/S
200
Femoral with Cath, U/S, Nerve

Stimulation
4/16/2014
OHSU Ambulatory CPNB Experience
Over 6 years, > 5000 patients went home with a

perineural infusion
Potentially Serious Complications:
1 pneumothorax
5 cut catheters
1 possible LA toxicity
6 retained catheters (2 surgically removed)
OHSU Ambulatory CPNB Experience :

768 Catheters
180
140
120
Type of Catheters
100
65
1
22
44
Supraclavicular
Pain Score Reported in 401 Patients

Contacted over an 8 Month Period
Pain Score
5.8
With Movement
4.2
4.6
4.6
2.4
3.7
2.8
23
4/16/2014
Side Effects in 401 Patients Contacted

Over an 8 Month Period
10.7%average
% of Pts W/Side Effe

ects
Side Effects
25%
21%
20%
20%
14%
15%
11%
10%
9%
10%
7%
Patients
5%
0%
0%
Specific Side Effects
N/V and sleepiness are low compare to historical value

Many of the side effects are not present for inpatients
Unplanned Return to Hospital

Due to Complication With the Block
May June July
Aug Sept Oct
Nov Dec
Pumpnot
working
Pump
accidently
disconnected/
catheter
pulledout
Rednessat
cathetersite
Wound
closureand
hematoma
evacuation
Number of Unplanned Re
eturns
Unplanned Returns
ReasonsforUnplannedReturn
Patients
3.5
3
2.5
2
1.5
1
0.5
24
4/16/2014
Satisfaction with Pain Control
High satisfaction with pain control

Overall postoperative pain control:
291 out of the 353 patients (82%) were satisfied
18% of patients did not feel that their pain was well managed.
.
Patient Satisfaction
89% of patients were either satisfied or very
satisfied.
6% of patients answered negatively because of side effect or pain.
Would choose the block again?

Patients were asked If you were to
have a similar surgery would you
choose to receive a nerve block
again?
87% of patients would have a
nerve block placed again.
13% of patients would not have a
block placed again.
Is that good enough?
25
4/16/2014
Overview

Selling it to our Surgeons and Administrator
The future
Conclusions
Future #1
Additives, i.e. epinephrine, clonidine, dexamethasone,
buprenorphine, to LA may increase the duration up to 40
hrs,
BUT neurotoxicity???? Need better ones
Encapsulated/liposomial bupivacaine???
New drug or drug regimen/delivery system
Future #2
New injectates: encapsulate bupivacaine, botulin toxin
New multimodal approaches: Vit C, CBT, neuromodulation
Dynamic block management
Outpatient TJR
Track your data
Collaborative research on outcome
26
4/16/2014
Overview

Selling it to our Surgeons and Administrator
The future
Conclusions
Conclusions
The RA program can improve recovery profile,
decrease LOS, unplanned admission and cost,
and improve and patient satisfaction
Keys for success reside in the organization: collaboration of all

teams involved, clear plan including multimodal analgesia,
define pathway, careful patient selection and education
(especially expectation), and follow-up
Serious complication are rare, but minor issues are frequent

and can be minimized with proper buy in from all parties
A well planed organization will

keep your patients safe and avoid
serious problems
27
4/16/2014
Thank You
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4/16/2014

2014 Winter Anesthesia Seminar

Regional Blocks Every

(Block) failure is not an option:

(Block) failure is not an option:

Success for any block

Success for any block

Success for any block

Success for any block

Success for any block

Pre-block neurologic exam for traumas

BKA, Achilles repair, tibial nails (delayed)

CSA Winter Anesthesia Seminar

2014 Winter Anesthesia Seminar

American Society European Society

FDA Approval Dates

The New Drugs

Target-Specific Oral Anticoagulants

Target-Specific Oral Anticoagulants (TSOACs)

The New Concerns About the Old Drugs

FDA Alert regarding Low-Molecular Weight Heparin

FDA Alert regarding Low-Molecular Weight Heparin

Case Reports of Neuraxial Hematoma with

73 yo woman with postlaminectomy pain syndrome

Horlocker T, RAPM, 1998

LMWH(MedWatch System)40casesofneuraxial hematoma,1/3000.

Horlocker T, A&A, 2013

Minimum time between

ANTICOAGULANTS FOR VENOUS THROMBOEMBOLISM PROPHYLAXIS

ANTICOAGULANTS AT THERAPEUTIC DOSES

ORAL ANTIPLATELET AGENTS

DIRECT THROMBIN INHIBITORS

Vandermeulen, A&A. 1994

Minimum time between

ANTICOAGULANTS FOR VENOUS THROMBOEMBOLISM PROPHYLAXIS

DIRECT THROMBIN INHIBITORS

Chronic Pain affects 100 million Americans

ASA Standards, Guidelines, and Statements

CSA Winter Anesthesia Seminar

Continuous Regional Anesthesia: How to Make it

Rationale and benefits of regional anesthesia

Rationale and benefits of regional anesthesia

Continuous PNB: an Old Story

Dr. Ambros, 1946

Survey of Postoperative Analgesia Following Ambulatory

Inguinal Hernia 62%

Severity of pain did NOT decrease over 48 hours

20% difficulty sleeping due to severe pain, 20% N, 20% tiredness, 8%

95% were satisfied with care

Rawal et al. Acta Anaesth Scan, 1997

Systemic Review and Analysis of PostDischarge Symptoms afterOutpatient Surgery

45% pain (25-35% moderate to severe 16% severe after ortho)

Wu et al. Anesthesiology 96(4):994-1003, 2002

From Acute Pain to Chronic Pain

Katz J. ASRA News. February, 2009.

Regional Anesthesia and

RA vs. GA in Ambulatory Surgery:

Liu SS, et al. Anesth Analg 2005;101:1634-42

Evans H, et al. Anesth Clin North Am 2005;23(1):141-62

Meta-analysis: CPNB vs. Opioids

2.1 vs. 4.0 p<0.001 1.6 vs. 3.2 p<0.001

0.9 vs. 4.6 p<0.001 0.9 vs. 3.5 p<0.001

N/V, sedation, pruritus and opioid usage significantly decrease

Meta--analysis: CPNB vs. Single Shot