Nerve Blocks for Trauma Patients: Stop Worrying, Theyre Safe - - - PowerPoint PPT Presentation

Nerve Blocks for Trauma Patients: Stop Worrying, They’re Safe - Patients Will Do Well

Sonia Szlyk, MD

Director of Regional Anesthesia North American Partners in Anesthesia, Mid-Atlantic Division

INOVA Fair Oaks Hospital, VA

Disclosure

• National Speakers’ Bureau
• Halyard Health

Large academic hospital Private practice hospital Freestanding Orthopaedic ASC NAPA Mid-Atlantic

14 Hospitals 6 ASCs >350 MDs, CRNAs

My Perspective

Edvard Munch

“There is PAIN!”

“There is a FRACTURE!”

“There is a BLOCK!”

Opioid-based Pain Management

• Undesirable side effects
• Respiratory depression
• Vasodilation and hypotension when hypovolemic
• Delirium
• Nausea, vomiting
• Immunosuppression
• Increased monitoring requirements
• Increased LOS
• Opioid epidemic

Gadsden, J. Regional Anesthesia for the Trauma Patient. Local and Regional Anesthesia 2015:8 45 - 55.

Chronic Pain Syndrome

• Pain lasting > 3 months after injury
• Up to 77% of patients with severe MSK trauma
• Increased risk with intense acute pain at time of

injury

• Association with post-traumatic stress disorder

Gadsden, J. Regional Anesthesia for the Trauma Patient. Local and Regional Anesthesia 2015:8 45 - 55.

Peripheral Nerve Block Benefits

• Excellent site-specific analgesia
• Avoid or reduce opioid requirements and related side

effects

• Decreased morbidity and mortality
• Femur, hip fracture, digital replantation
• Avoid general anesthesia or sedation
• Reduced LOS in ER, OR, and CCU
• Decreased cost

Gadsden, J. Regional Anesthesia for the Trauma Patient. Local and Regional Anesthesia 2015:8 45 - 55.

Role of Nerve Block Catheters

• Initial surgical procedure
• Serial procedures
• Debridements
• Fracture fixation
• Skin grafting
• Postoperative pain management

Gadsden, J. Regional Anesthesia for the Trauma Patient. Local and Regional Anesthesia 2015:8 45 - 55.

Nerve Blocks for Hip & Femur Fracture

• Fascia iliaca block
• Femoral nerve block
• Lumbar plexus block
• Not commonly used

due to anticoagulation

Gadsden, J. Regional Anesthesia for the Trauma Patient. Local and Regional Anesthesia 2015:8 45 - 55.

Mayo Foundation for Medical Education.

Nerve Blocks for Hip & Femur Fracture

• Best modality for reducing acute pain associated

with hip fracture

• versus… opioids, traction, multimodal,

neurostimulation

Gadsden, J. Regional Anesthesia for the Trauma Patient. Local and Regional Anesthesia 2015:8 45 - 55.

Fascia Iliaca Block

• Lateral femoral cutaneous
• Femoral
• Obturator
• “Anterior approach lumbar plexus”
• Allows anticoagulation

Bow-Tie Approach FIB

• Compartment block = High volume
• 50 - 60 cc local anesthetic

Sartorius Internal Oblique Iliacus

SUPERIOR INFERIOR Fascia Iliaca

50 cc Compartment Block 20 cc 0.2% Ropivacaine 30 cc 0.5% Ropivacaine

Fascia Iliaca Block

No Block FIB cath

POD 0 Pain POD 1 Pain Ave LOS

4.1 1.7 2.9 5.9 days 1.4 4.8 days

Incidence of Delirium

10.78% 23.8%

Mean Duration of Delirium

5.22 days

FIB Placebo

10.97 days

In - plane Decreased number of needle passes Decreased vascular injury

Liu, S. Ultrasound-Guided Regional Anesthesia and Analgesia. A Qualitative Systematic Review. Reg Anesth Pain Med 2009;34: 47 - 59.

LATERAL Nerve

Ultrasound-guided Femoral Nerve Block

LATERAL Single Shot Block 0.5% Ropivacaine 30 cc Nerve Block Catheter 0.5% Ropivacaine 30 cc bolus 0.2% Ropivacaine @ 8cc/hr

Ultrasound-guided Femoral Nerve Block

Liu, S. Ultrasound-Guided Regional Anesthesia and Analgesia. A Qualitative Systematic Review. Reg Anesth Pain Med 2009;34: 47 - 59.

Popliteal Sciatic Catheter

• Tibia/Fibula Fracture
• Ankle fracture
• Achilles rupture

Start in fossa, then scan up leg

LATERAL

Interscalene Catheter

• Clavicle fracture
• Shoulder reduction

Gadsden, J. Regional Anesthesia for the Trauma Patient. Local and Regional Anesthesia 2015:8 45 - 55.

• Benefits
• Reduced sedation
• Reduced monitoring
• Decreased LOS

!

LATERAL

MSM ASM

!

LATERAL

Local anesthetic spread

Supraclavicular Catheter

Neal, J. RAPM, vol. 32. n. 2. March-April 2009.

• ORIF humerus
• ORIF distal radius
• ORIF elbow
• Digital replantation

LATERAL

0.5% Ropivacaine 30 mL

Nerve Block for Digital Replantation

• Sympathetic blockade
• Maximal vasodilation
• Decreased vasospasm
• Reduced stress response
• Decreased hypercoagulability and thrombotic

events

Gadsden, J. Regional Anesthesia for the Trauma Patient. Local and Regional Anesthesia 2015:8 45 - 55.

Acute Compartment Syndrome

• High-energy injury to soft tissue
• 1/3 of cases are tibial fracture (prox. diaphysis)
• Forearm fracture
• Crush injury
• Burns
• Arterial puncture
• Circumferential dressing
• Snake bites

Gadsden, J. Regional Anesthesia for the Trauma Patient. Local and Regional Anesthesia 2015:8 45 - 55.

Acute Compartment Syndrome Diagnosis

• Diagnosis reliant on vigilance
• Pain out of proportion to injury (passive stretch)
• Paresthesia
• Compartment pressure
• No evidence that peripheral nerve blocks delay

diagnosis of ACS

• May facilitate the recognition of pathologic

breakthrough pain

Gadsden, J. Regional Anesthesia for the Trauma Patient. Local and Regional Anesthesia 2015:8 45 - 55.

Nerve Block Considerations for Acute Compartment Syndrome

• Lower concentration and rate of local anesthetic
• 0.1% Ropivacaine
• Catheter enables flexibility
• Adjust rate for surgical vs post pain use
• Can stop infusion, restart, or bolus prn
• Increased concern if patient develops new onset

breakthrough pain

Gadsden, J. Regional Anesthesia for the Trauma Patient. Local and Regional Anesthesia 2015:8 45 - 55.

Risk of…

• Infection (0 - 3%)
• Risk inherent to trauma population, increased if ICU
• Most commonly superficial infection
• Nerve Injury
• Reduced risk with ultrasound guidance & experience
• Anticoagulation-related bleeding
• Benefit of peripheral nerve blocks vs. spinal or epidural
• Avoid lumbar plexus block if anticoagulated

Gadsden, J. Regional Anesthesia for the Trauma Patient. Local and Regional Anesthesia 2015:8 45 - 55. Choi, J. Regional Anesthesia for Trauma Outside the Operating

• Theater. Current Opinion Anesthesiology 2013, 26:495 - 500.

Low

Strategy for

• Vigilance
• Communication
• Experienced orthopedic and anesthesia team

Gadsden, J. Regional Anesthesia for the Trauma Patient. Local and Regional Anesthesia 2015:8 45 - 55.

BETTER PAIN CONTROL IMPROVED OUTCOMES