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

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

Oct 20, 2023 199 likes •492 views

The Role of Regional Blocks- Why Arent 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

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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

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Disclosure

  • National Speakers’ Bureau
  • Halyard Health
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Large academic hospital Private practice hospital Freestanding Orthopaedic ASC NAPA Mid-Atlantic

14 Hospitals 6 ASCs >350 MDs, CRNAs

My Perspective

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Edvard Munch

What About the PAIN?!!!

I Know I Need Surgery, but...

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GET THE

PAIN MANAGEMENT

YOUR PATIENTS DESERVE!!!

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YOUR FATHER’S NERVE BLOCK

NOT

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Ultrasound-guidance… Take off the Blindfold

  • Improved Efficiency
  • Faster block placement
  • Faster onset

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

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Adductor Canal Catheter

ERAS for...

  • rthoinfo.aaos.org
  • Total knee replacement
  • Partial knee

replacement (medial)

  • ACL repair
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Pain Control Quad Strength

Adductor Canal Block Catheter

Balancing Act

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

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Sartorius

`

Adductor longus Vastus medialis

Adductor Canal

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LATERAL

Vastus medialis Sartorius A Adductor longus

Adductor Canal Block

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LATERAL

A

Adductor Canal Block Catheter

0.5% Ropivacaine 20 cc bolus 0.2% Ropivacaine @ 8cc/hr infusion In-plane

SAFETY EFFICIENCY PRECISION

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SLIDE 14 Jaegar, P. Adductor Canal Block versus Femoral Nerve Block for Analgesia after Total Knee Arthroplasty. Reg Anesth Pain Med. 2013;38: 526–532.

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

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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

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SLIDE 18 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.

Results

  • Decreased LOS (76.6 to 56.1 hrs)
  • No increase in readmission

Updated ERAS Pathway

  • Mepivacaine spinal
  • Adductor canal cath x 48 hrs
  • TXA
  • PT DOS
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Chisholm, M., et al. Postoperative Analgesia with Saphenous Block Appears Equivalent to Femoral Nerve Block in ACL Reconstruction. HSSJ June 2014.

Subsartorial Saphenous Block versus Femoral Block

No Difference Pain score at rest Opioid use

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Abdallah, FW. Anesthesiology 2016. May; 124(5): 1053-64.

Adductor Canal Block 4.8 mg less morphine >2x higher MVIC

Adductor Canal Block versus Femoral Block

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Key Considerations

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

  • 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

  • f 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.

Low

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Risk of 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

Low

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.

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Popliteal Sciatic Catheter

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

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

ERAS for...

  • Rotator cuff repair
  • Total shoulder
  • Reverse shoulder
  • AC joint
  • ORIF clavicle
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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.

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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

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Supraclavicular Catheter

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

ERAS for...

  • ORIF
  • Humerus
  • Elbow
  • Distal radius
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  • Excellent pain control
  • Minimize narcotics & nausea
  • Faster discharge
  • High patient/surgeon satisfaction
  • Complex cases as outpatient
  • Complex patients as outpatient

US-GUIDED Nerve Block Catheter