The Role of Regional Blocks- Why Arent You Listening - Advice for - PowerPoint PPT Presentation

The Role of Regional Blocks- Why Aren’t You Listening - Advice for Your Patients’ Success 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

My Perspective Large academic hospital Freestanding Orthopaedic ASC NAPA Private practice hospital Mid-Atlantic 14 Hospitals 6 ASCs >350 MDs, CRNAs

I Know I Need Surgery, but... What About the PAIN?!!! Edvard Munch

GET THE PAIN MANAGEMENT YOUR PATIENTS DESERVE!!!

NOT YOUR FATHER’S NERVE BLOCK

Ultrasound-guidance… Take off the Blindfold • Improved Efficiency - Faster block placement - Faster onset Sites, B. et al. A comparison of sensory and motor loss after a femoral nerve block conducted with ultrasound versus ultrasound and nerve stimulation. Reg Anesth Pain Med 2009; 34:508-513. Liu, S. Ultrasound-Guided Regional Anesthesia and Analgesia. A Qualitative Systematic Review. Reg Anesth Pain Med 2009;34: 47 - 59.

Adductor Canal Catheter ERAS for... • Total knee replacement • Partial knee replacement (medial) • ACL repair orthoinfo.aaos.org

Balancing Act Quad Strength Pain Control Adductor Canal Block Catheter

Location is Everything!! Femoral Block Adductor Canal or “Mid-thigh Femoral” Block Saphenous Block

Adductor Canal Vastus Sartorius medialis Adductor longus `

Adductor Canal Block Sartorius Vastus medialis A LATERAL Adductor longus

Adductor Canal Block Catheter In-plane A LATERAL 0.5% Ropivacaine 20 cc bolus 0.2% Ropivacaine @ 8cc/hr infusion SAFETY EFFICIENCY PRECISION

ACBC preserved quad strength better than FNBC (52% vs 15% baseline) NO difference morphine consumption pain at rest, flexion adductor muscle strength n/v, sedation, antiemetics mobilization ability Jaegar, P. Adductor Canal Block versus Femoral Nerve Block for Analgesia after Total Knee Arthroplasty. Reg Anesth Pain Med. 2013;38: 526–532.

Nerve Block Catheter Infusion Pump • Lasts ~ 3 days • Adjustable rate • Pt removes at home • Easy, no sharps 0.2% Ropivacaine @ 8 mL/hr 550 mL reservoir

Results Updated ERAS Pathway • Decreased LOS (76.6 to 56.1 hrs) • Mepivacaine spinal • No increase in readmission • Adductor canal cath x 48 hrs • TXA • PT DOS Auyong DB, et al, Reduced Length of Hospitalization in Primary Total Knee Arthroplasty Patients Using an Updated Enhanced Recovery After Orthopedic ..., J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth. 2015.05.007.

Subsartorial Saphenous Block versus Femoral Block No Difference Pain score at rest Opioid use Chisholm, M., et al. Postoperative Analgesia with Saphenous Block Appears Equivalent to Femoral Nerve Block in ACL Reconstruction. HSSJ June 2014.

Adductor Canal Block versus Femoral Block Adductor Canal Block 4.8 mg less morphine >2x higher MVIC Abdallah, FW. Anesthesiology 2016. May; 124(5): 1053-64.

Key Considerations • Knee immobilizer? • No , if patient able to perform straight-leg raise • Role for femoral nerve block? • Consider for lateral knee analgesia

Risk of Nerve Injury Low • Femoral nerve palsy after surgery (TKA, ACL) - Mean rate 0.34% • Risk of permanent dysfunction - 1:13,000 • Self-limiting • Beware... - Preexisting neuropathy Brull, R. Neurological complications after regional anesthesia: contemporary estimates of risk. Anesth Analg. 2007 Apr;104(4):965-74. Sorenson, E. Neurological Injuries Associated with Regional Anesthesia. Reg Anesth Pain Med 2008;33:442-448.

Risk of Low Infection & Toxicity • >1,400 patients with nerve block catheters - No infectious events up to one year postop • Local anesthetic toxicity - Intralipid available - Monitor patients post block Capdevila X et al. Continuous peripheral nerve blocks in hospital wards after orthopaedic surgey: A multicenter prospective analysis of the quality and postoperative analgesia and complications in 1,416 patients. Anesthesiology 2005; 103:1035-1045.

Popliteal Sciatic Catheter • ERAS for… - Achilles tendon repair - Ankle ORIF - Calf (posterior/lateral)

Interscalene Catheter ERAS for... • Rotator cuff repair • Total shoulder • Reverse shoulder • AC joint • ORIF clavicle Neal, J. RAPM, vol. 32. n. 2. March-April 2009.

Why not just a single shot block? Interscalene single shot block 8 hrs pain control 12 hrs opioid-sparing effect 24 hr reduction PONV Faster PACU, hospital discharge Greater pain at 16 - 24 hrs postop versus no block Anesth Analg 2015;120:1114-29.

Interscalene catheter Faster discharge from PACU Lower mean pain score POD 1, 2 Lower use of narcotics POD 1, 2, 3 Better sleep POD 1, 2 Lowest pain POD 7

Supraclavicular Catheter ERAS for... • ORIF - Humerus - Elbow - Distal radius Neal, J. RAPM, vol. 32. n. 2. March-April 2009.

US-GUIDED Nerve Block Catheter -Excellent pain control -Minimize narcotics & nausea -Faster discharge -High patient/surgeon satisfaction -Complex cases as outpatient -Complex patients as outpatient