CBSPAN Fall Conference October 2013

Disclosure Statement I have no financial or research affiliations with any product or pharmaceutical manufacturer displayed in this presentation -Shafonya Turner, M.D.

Objectives  Summarize the basics of choosing regional anesthesia as a perioperative anesthetic options  Describe the arbitration of various technique appropriateness in diverse perioperative clinical scenarios  Recognize the appropriateness of single-shot block vs catheter placement in regional anesthesia  Discuss expectations in PACU  Discuss drawbacks, risks, complications, concerns of regional anesthesia techniques

Clark Kent : Superman :: Bruce Wayne : A. Hulk B. Batman C. Spiderman D. Wolverine

A 91yo male presents for RUE AVF for future hemodialysis access. PMHs includes HTN and osteoarthritis. Candidate for regional anesthesia? A. Yes B. No

Objectives  Summarize the basics of choosing regional anesthesia as a perioperative anesthetic options  Describe the arbitration of various technique appropriateness in diverse perioperative clinical scenarios  Recognize the appropriateness of single-shock block vs catheter placement in regional anesthesia  Identify expectation in PACU  List options for comprehensive pain management  Discuss drawbacks, risks, complications, concerns of regional anesthesia techniques

Patient selection… Everyone is a potential candidate Infants/neonates Incapacitated, intubated Ongoing infection, heart failure, acute psychological or neurological derailment 1 If the site is blockable, we can block it!! Risk vs. benefit Contraindications PATIENT REFUSAL Infection at site of needle/catheter placement Coagulopathy ( i.e. neuraxial and deeper compartmental block techniques) Allergy to anesthetizing medications

Lumbar  Thoracic

Patient Selection…  Great alternative for: Higher risk GA patients Chronic pain disorders (Decrease incidence of chronic pain syndromes) 6 Same day procedures High incidence of PONV with ○ GA ○ Narcotics High risk pulmonary patients ○ Obesity ○ COPD ○ Rib fracture ○ Elderly Initiation of post-operative rehabilitation (orthopedic, thoracic)

Pamela is scheduled for a partial vulvectomy for vulvar cancer. Is there a regional anesthesia option for her? A. Yes B. No C. Maybe

Buying a new house when the sink is stopped up is a plausible option. A. True B. False

Patient Selection… Remember overkill!! Can selectively block just about anything from the neck down

Patient selection…  Timing always a consideration  Surgeon preference and discussion  Follow-up capabilities

Objectives  Summarize the basics of choosing regional anesthesia as a perioperative anesthetic options  Describe the arbitration of various technique appropriateness in diverse perioperative clinical scenarios  Recognize the appropriateness of single- shock block vs catheter placement in regional anesthesia  Identify expectation in PACU  Discuss drawbacks, risks, complications, concerns of regional anesthesia techniques

Which technique?  Upper extremity Brachial plexus (interscale, supraclavicular, infraclavicular, axillary, elbow, wrist, digital block) Bier block  Lower extremity Lumbar plexus, femoral, 3-in1, sciatic (infragluteal, popliteal fossa), ankle block Bier block Lumbar epidural  Thoracic Intercostal, paravertebral, thoracic epidural  Abdominal Thoracic epidural, TAP (transversus abdominis plane), rectus sheath  Cervical Cervical plexus, occipital nerve

What technique? Most important question… Where is the procedure taking place?

Location, Location, Location

Tim is having a nail removed from his ankle several months after an ORIF of a fracture. Which block would be appropriate? A. Ankle block B. Femoral block C. Sciatic block (popliteal or infragluteal) D. It depends E. A combination of two of the above

What technique? Abdominal region and blocking techniques TAP-Transversus Abdominis Plane

What technique? Abdominal region and blocking techniques Thoracic/ High Lumbar Epidural

What technique? Lower Extremity Surgery and Pain Usually orthopedic proce- dures Vascular (e.g. vein Sclerosing)

What technique?  How long will the procedure take? Question in neuraxial anesthesia ○ Spinal anesthesia is finite in duration unless a catheter left in intrathecal space ○ Epidural anesthesia is more long term (up to 5-7 days) ○ Narcotics in solution also an important point

What technique?  PNB decrease 3 duration of hospital stay Total narcotic use Time to rehabilitation and through rehab (economic benefit??) 5 Other serious complications ○ Hypoxia, hypotension, ?DVT?, MI, CVA, GI distress

Objectives  Summarize the basics of choosing regional anesthesia as a perioperative anesthetic options  Describe the arbitration of various technique appropriateness in diverse perioperative clinical scenarios  Recognize the appropriateness of single- shock block vs catheter placement in regional anesthesia  Identify expectation in PACU  Discuss drawbacks, risks, complications, concerns of regional anesthesia techniques

Dwight presents for R TKA. He refused neuraxial anesthesia options and ops for a peripheral technique. The block team decides to do a femoral and sciatic nerve block. Which one, if any, should get a catheter? A. Femoral B. Sciatic C. Neither D. Both

Single-shot vs Catheters  Decrease narcotic use in catheter patients  Decrease LA toxicity and complication due to decrease rate of injection of LA (local anesthetic ) 2  In neuraxial anesthesia, possible higher dermatomal spread of LA in combined spinal/epidural vs spinal alone 4  Prolonged blockade in catheter

Single Shot vs Catheter

 Increase is catheter dislodgement (moisture, friction) and subsequent patient dissatisfaction  Catheter site infection or bacteremic seeding 8  Increased technical difficulty in placement with larger needles and longer procedure time  Logistics of catheter management services and staff

Objectives  Summarize the basics of choosing regional anesthesia as a perioperative anesthetic options  Describe the arbitration of various technique appropriateness in diverse perioperative clinical scenarios  Recognize the appropriateness of single- shock block vs catheter placement in regional anesthesia  Identify expectations in PACU  Discuss drawbacks, risks, complications, concerns of regional anesthesia techniques

PACU Expectations

Martha has just come out of R rotator cuff surgery. The surgeons wanted to wait to dose her interscalene catheter until after motor function of her extremity had been confirmed. 10 minutes before arrival to the PACU, she receives 30mL 0.5% Ropivacaine in her catheter. What can you expect? A. Inability to squeeze your finger with her R hand B. Incomplete pain relief with no motor function below the elbow C. Martha will be writhing in pain D. Little response when you draw blood from her AC fossa

Great Expectations  Failure of epidural analgesia after initial success was observed in 6.8% 7  Efficacy of RA ranges 75-85%, depending on block, technical expertise  Failure rates of up to 30% with come brachial plexus techniques.

Great Expectations

Ranking in order of painfulness a. A b. B c. C AB C

Great Expectations  Comes down to experience Some outpatient centers do 75% of their anesthetics with RA Quicker recovery, better infrastructure to facilitate the initiative Prepare patients for the experience/expectation  Comes down to commitment Facility commitment to staffing, space, time, and money Providers commitment to safe, good care, education, leadership

Objectives  Summarize the basics of choosing regional anesthesia as a perioperative anesthetic options  Describe the arbitration of various technique appropriateness in diverse perioperative clinical scenarios  Recognize the appropriateness of single- shock block vs catheter placement in regional anesthesia  Identify expectations in PACU  Discuss drawbacks, risks, complications, concerns of regional anesthesia techniques

The good, now the bad  Everything has risk and benefits These are different for each patient even with similar co-morbidities and deficits  The informed consent  Even done perfectly, complications arise  All that glitters is not gold

How long does the ASRA say we should wait to place an epidural in a patient in ASA? A. 7 days B. 5 days C. 2 days D. No days

Antiplatelet medications (ASA, Plavix, NSAIDs) Oral anticoagulants (Warfarin) Standard heparin LMWH (Lovenox, Aggranox) Thrombolytic and fibrinolytic therapy (tPA) Herbal preparations ( Garlic, ginger, feverfew, Ginseng, Alfalfa, chamomile, horse chestnut, ginseng, Vitamin E, Ginko) New anticoagulants

Risks  Bleeding  Infection  Nerve injury  Failure  Toxicity (cardiac and neurological)

Risks  Patient safety Prolonged blockade patient should have support at home ○ Falls ○ Medication toxicity ○ Injury to the anesthetized limb ○ Inablilty to complete ADL Given through instructions on pain management and duration of blockade For those with take home catheters, instructions and removing catheter or given options to return for removal

Drawbacks  Hemodynamic instability – neuraxial anesthesia  Headaches  Urinary retention  Pneumothorax and vascular injury on placement  Pain/discomfort with block placement  Follow up  Incomplete relief

References 1.Barash 7 th edition 2.Analgesic Effectiveness of a Continuous Versus Single-Injection Interscalene Block for MinorArthroscopic Shoulder Surgery Michel J. Fredrickson, MD,* Þ Craig M. Ball, MD,* and Adam J. Dalgleish (Reg Anesth Pain Med 2010;35: 28Y33) Regional Anesthesia and Pain Medicine & Volume 35, Number 1, January-February Chelley JE, Continuous femoral blocks improve recovery and outcome of patients undergoing TKA. J arthrophasty Sensorimotor anesthesia and hypotension after subarachnoid block: combined spinal-epidural versus single-shot spinal technique. Goy RW, Sia AT.Goy RWSia AT 5.Capdevila, X. Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery. Anesthesiology 1999;91: Perkins FM. Chronic pain as an outcome of surgery. A review of predictive factors. Anesthesiology 2000;93: Pan PH, Bogard TD, Owen MD. Incidence and characteristics of failures in obstetric neuraxial analgesia and anesthesia: a retrospective analysis of 19,259 deliveries. Int J Obstet Anesth 2004;13: Cuvillon P. The Continuous Femoral Nerve Block Catheter for Postoperative Analgesia: Bacterial Colonization, Infectious Rate and Adverse Effects. Anesth Analg 2001;93:1045–9 9.Finucane B. Complications of Regional Anesthesia. Springer Science. New York