Perineural Blocks for Postoperative Pain After Upper Limb Surgery 1st Congress of Slovenian Association for Pain Therapy October 9-10 Bled, Slovenia S. Gligorijevic MD City Hospital Waid Zürich Medical School University of Zürich Switzerland

Why is postoperative pain still undermanaged ? Difficulties to understand the pain pathways lead often to misconception that postoperative pain is a short, self-limited entity Goals are frequently not clear Organisational obstacles Advances in knowledge do not necessarily lead to the same degree of progress in patient care Significant room for further improvement in postoperative pain management

Newer Developments in Postoperative Pain Management Drugs Non-opioids (NSAID’s,coxibs), ketamine, pregabalin, corticosteroids Local anaesthetics (ropivacaine, levobupivacaine) Adjuvants – in techniques such as epidural, perineural, i.v. PCA Drug delivery systems (transdermal PCA, intranasal, long-acting epidural morphine, sublingual NSAID, perineural/incisional catheter LA at home) Concepts (PROSPECT, multimodal, preemptive) Web-based guidelines www.postoppain.org www.esraeurope.org www.oqp.med.va.gov/cpg/cpg.htm Outcome debate (cost-effectiveness, risk-benefits, evidence-based) Organizational issues (APS, role of surgeons, audits)

Pharmacological Options for Postoperative Pain Management Pharmacological Options for Postoperative Pain Management Concept of Multimodal Analgesia NO Sites of action of local anaesthetics

Postoperative analgesia - what are the challenges? Increasing co-morbidity Ageing population Obesity Concurrent medical problems Changing surgical demands Early mobilisation / accelerated rehabilitation / day surgery Decreasing role of epidural analgesia No major advantages in outcome compared to alternatives Risk of complications higher than previously reported Minimal invasive and/or ambulatory surgery Patients’ preference 5

Optimal perioperative analgesia Benefits of PNB,s Quality of pain relief you will never ever achieve with any other single systemic drug or their combination or with so called multiple approach Continuous analgesia (during & following the surgery) Adjustable to pain intensity & duration Suitable for pain of different origin Appropriate for large number of patients Minimal risks to patient, minimal side effects Early mobilisation/fast rehabilitation

postop. Analgesia PNB lower Recent Developments of PNB Techniques Facilitating Factors / Improved Logistics I Increased educational efforts Training programs, RA meetings, videos, websites, guidelines, cadaver workshops, live models, companies contribution  Improved knowledge of anatomy Anatomical investigations, new text books Improved nerve localisation techniques Peripheral nerve stimulator has dramatically increased the reliability of nerve location

Recent Developments in PNB Techniques III postop. Analgesia PNB lower Recent Developments in PNB Techniques III Improved nerve localisation techniques Ultrasound technique: Nerves and surrounding structures are now visible, LA spread can be judged during injection Nerve injury can be avoided ? Improved equipment Needles: Sufficient rigid, good penetrating and gliding needles of appropriate size for specific blocks ,

Recent Developments of PNB Techniques IV postop. Analgesia PNB lower Recent Developments of PNB Techniques IV Proper organization of OR schedule Induction rooms Holding area Enhanced research Acute pain Nerve localisation New approaches Comparative studies with other methods Meta - analyses

Pessimist’s view: Peripheral Nerve Blocks Are Not Frequently Used postop. Analgesia PNB lower Peripheral Nerve Blocks Are Not Frequently Used Pessimist’s view:  Missed education (need for new skills)  Time consuming / labor intensive Multiple injections (frequently needed) Failure rate  Potential for prolonged neurologic deficit

Peripheral nerve blocks 1997 2002 n = 21.278 n= 50.223 Serious Complications Related to Regional Anaesthesia The Two Large Prospective Studies Auroy Y et al Anesthesiology 1997;87:479-86 Auroy Y et al Anesthesiology 2002;97:1274-80 Peripheral nerve blocks 1997 2002 n = 21.278 n= 50.223 Cardiac arrest 3* (1,4) 1 (0,2) Death 1 (0,5) 1 (0,2) Seizure 16**(7,5) 6 (1,2) Neurological injury 4 (1,9) 12 (2,4) ( n/10. 000 ) * Vagal, after failed bloc ** All seizures preceded by clinical signs

Peripheral Nerve Blocks for Postoperative Analgesia after Upper Limb Surgery

Upper Extremity Surgery What Challenges? Shoulder Very painful Published data that ISB offers benefits for surgery, analgesia and outcome Elbow Difficult positioning Lack of published data but some evidence that infraclavicular/axillary BPB offer perioperative benefits

Brachial Plexus Approaches Inter scalene Infra clavi cular axillary Hadzic A , 2004

Brachial Plexus Block After Shoulder Surgery Placement of interscalene catheter Success rate may vary from 75% - 100% Modified (“parallel”) approaches increase the success rate for catheter placement Boezaart AP, Can J Anesth 1999 Real time ultrasound guidance increases successful catheter placement Yang WT, Am J Roentgenol 1998

Pain Control After Shoulder Surgery postop. Analgesia PNB lower Pain Control After Shoulder Surgery Continuous interscalene block better than opioids ? Advantages over iv PCA ?  Better analgesia  Reduced opioid requirements/reduced PONV  Higher patient satisfaction (at least for the first 48h) Tuominen M, 1987. Borgeat A, 1997, 1998, 2000 Lehtipalo S, 1999. Klein SM, 2000. Fredrickson MJ, 2008 Unknown effect on success of physical rehabilitation or duration of hospitalisation Cohen NP, J Shoulder Elbow Surg 2000

PCRA (interscalene) vs iv PCA after major shoulder surgery II RCT, n = 35, surgery under interscalene block PCRA: 0.2% ropivacaine 5ml/h, bolus 3-4 ml, lockout 20 min I.V. PCA: nicomorphine 0.5 mg/h, bolus 2-3 mg, lockout 20 min PONV and pruritus: PCRA 5.5%, i.v. PCA 60% and 20% resp. PCRA technique provided better pain control, lower incidence of side effects and higher degree of patient satisfaction Borgeat A, et al Anesthesiology 2000 ; 2:102-8

Tunneled catheters (3-4cm) for 2-5 days postop. Analgesia PNB lower Acute and Nonacute Complications Associated with Interscalene Blocks and Shoulder Surgery I Borgeat A, Ekatodramis G, Kalberer F, Benz C. Anesthesiology 2001; 95:875-80 Prospective evaluation, 521 patients (234 with catheter, 286 single-injection block) Tunneled catheters (3-4cm) for 2-5 days Single injection of 40 – 50ml Ropivacaine 0,6% Continuous infusion Ropivacaine 0,2%  6h after initial dose

Puncture related complications: Acute and Nonacute Complications Associated with Interscalene Blocks and Shoulder Surgery II Borgeat A, Ekatodramis G, Kalberer F, Benz C. Anesthesiology 2001; 95:875-80 Puncture related complications: Painful catheter placement 15 (5,6%) Pneumothorax 1 (0,2%) IV injection 1 (0,2%) Vessel puncture 3 (0,6%) Pain on injection 109 (21%) 10th postop.day: Pain not clearly related to surgery 74 (14%) 9th month: 1 symptomatic patient – damage of C6 root after uneventful block  complete recovery in EMG Conclusion: Low long-term complication rate No differences between catheter and single- injection technique 19

No comparisons with IV PCA or other methods of systemic analgesia Peripheral Nerve Blocks After Hand and Forearm Surgery Brachial plexus – Axillary approach Prospective studies demonstrate excellent analgesia after hand and forearm surgery with continuous infusion of Bupivacaine 0,2% – 0,25% Success rate of catheter insertion 98% - 100% Ang ET, 1984, Pham-Dang C, 1995, Mezzatesta JP, 1997 Salomen M, Reg Anesth Pain Med 2000 No comparisons with IV PCA or other methods of systemic analgesia

Distal upper extremity blocks Indications: ♦ Surgical procedures (ambulatory surgery) Nerve decompression Tendon and nerve repair (preserved mobility) Ganglion, cyst, foreign body removal AV fistula Bilateral surgery ♦ Postoperative pain management (selective analgesia) ♦ Evaluation and treatment of chronic pain ♦ Partially successful brachial plexus block

Ulnar Nerve Block at the Elbow Medial epicondylle Olecranon proces Ulnar n. Superficial branch Deep palmar branch Injection proximal or distal to the sulcus

Nerve Blocks at the Elbow Radial Nerve Block

Nerve Blocks at the Wrist Median nerve block Ulnar nerve block Pierce the deep fascia (bone contact) Inject while withdrawing the needle!

Median,ulnar and radial nerves can be consistently seen in the forearm using ultrasound McCartney CJL, Daquan X, Constantinescu C, Abbas Sh, Chan V Reg Anesth Pain Med 2007;32:434-439

Median nerve catheter for postoperative pain relief after hand surgery Median nerve catheter for postoperative pain relief after hand surgery. Continuous infusion of levo-bupi 0,125% - 2-5 ml/h

Elastomeric Balloon Pump Rawal et al Anesth Analg 1998;86:86-9

Recommended (grade A): PROSPECT, 1966-2006, 112 study -132 excluded Anaesthesia 2008;63:1105-1123 Recommended (grade A): Femoral nerve block ( combined with GA or SA pre-/intra-operative) Spinal block with morphine intrathecal + NSAID,s / COX-2 inhibitors ( grade A) Paracetamol (grade B) Strong opioids IV for breakthrough pain (grade A) Cooling and compression techniques (grade B)

Are continuous PNB,s useful for postoperative rehabilitation? Three days after TSA - cont ISB group (Ropi 0.2%) with increased range of shoulder motion, most likely resulting from potent analgesia (retrospective study) Ilfeld BM Reg Anesth Pain Med 2005 Continuous ISB provides potent analgesia that permits greater passive shoulder movement Ilfeld BM. Anesthesiology 2006;105:999-1007 RCT, n=30

Are continuous PNB,s always useful for postoperative rehabilitation? Does Patient-Controlled Continuous Interscalene Block Improve Early Functional Rehabilitation After Open Shoulder Surgery? Hofmann-Kiefer K et al. Anesth Analg 2008;106:991-996 RCT, n=87 Open rotator cuff repair or acromioplasty Range of motion and strength of the shoulder &subjective data (Mobility and muscular strength) pre-and postop (Constant –Score ) Continuous ISB Improves analgesia but not postoperative function compared to opioid iv PCA Possible cause: swelling, stiffness and inflammation of the joint

Local Anaesthetics Drugs for Continuous Perineural Analgesia Bupivacaine 0,1 – 0,25 % Plasma level 0,5 – 1 mcg/ml after interscalene block Tuominen M, Acta Anaesthesiol Scand 1987 After lumbar plexus block 0,5 – 1,8 mcg/ml Ganapathy S, Anesth Analg 1999, Aker-Moller E, Acta Anaesthesiol Scnad 1990

Peripheral Nerve Blocks After Hand and Forearm Surgery Ropivacaine for continuous axillary plexus block Salomen M, Reg Anesth Pain Med 2000 RCT, Single block with Ropivacaine 0,75% 5mg/kg Postoperative infusion 0,1% or 0, 2% or saline 6 – 11ml/h for 24 h Results: Postoperative analgesia for 12 – 15h after single injection Similar VAS scores in all groups with continuous infusion No analgesics  Group 0,1 %  47 % Group 0,2 %  45 % Group S  28 %

Drugs for Continuous Perineural Analgesia Ropivacaine has motor block sparing properties in peripheral nerve blocks? Significantly less motor block of the hand with PC interscalene analgesia and Ropivacaine 0,2% compared with Bupivacaine 0,15% Borgeat A, Anesth Analg 2001

Which drugs for continuous perineural analgesia ? ISB after shoulder surgery Double - blinded comparison levo-bupi 0,125% vs bupivacaine 0,2% - no difference Casati A, Borghi B, Fanelli G et al. Anesth Analg 2003;96:253-259

Adjuvants for Peripheral Nerve Blocks Peripheral effects of opioids ? 1. Evidence and recognition of opioid receptors on sensory nerve terminals 2. Opioid effects more pronounced in inflamed tissue - Increased numbers of nerve terminals (nerve sprouting) - Up-regulation of opioid receptors - Disruption of perineurium

Adjuvants for Peripheral Nerve Blocks Does the addition of morphine to brachial plexus block improves analgesia after shoulder surgery? Flory N, Van Gessel E, Donald F, et al. Br J Anesth 1995; 75:23-26 Time from the end of operation to the first administration of analgesic RCT 40 patients Interscalene block with Bupivacaine 0,5 % +Adrenaline vs. addition of morphine 5 mg Conclusion: No significant difference in quality of analgesia between the groups

Clonidine as the sole analgesic for postoperative pain administered by axillary approach. Sia S, Lepri A:Anesth Analg 1999; 88:1109-12 RCT, 45 pts Axillary brachial plexus block, 40 ml 1,5 % lidocaine + catheter. Postoperative pain relief regimen (3 groups) Bupivacaine 0,25 % 15 ml Clonidine 150 mcg + Saline 0,9 % 15 ml Saline 0,9 % 15 ml All patients received ketorolac 30 mg im Morphine 5 mg im on request. Conclusion: Administration of 150 mcg clonidine into brachial plexus sheath did not produce postoperative analgesia after hand or forearm surgery

Adjuvants for Peripheral Nerve Blocks Clonidine Clonidine as adjuvant in axillary brachial plexus block in patients with end stage renal disease. Adnan T: Acta Anaesthesiol Scand 2005 RTC n= 48, double blind 40 ml 1% Lidocaine with or without Clonidine 150 mcg Conclusion: Clonidine prolongs both motor and sensory block but cause significantly more hypotension, bradycardia and sedation compared with control group

Adjuvants for Peripheral Nerve Blocks Novel Analgesic Adjuncts for Brachial Plexus Block Murphy DB et al Anesth Analg 2000; 90:1122-28 Systematic review of RCT Agent Total outcomes Systemic control outcomes 10 Opioids 6 supportive 4 systemic control 4 negative 2 supportive, 2 negative 6 no systemic control 4 supportive, 2 negative 6 Clonidine 5 supportive 1 systemic control 1 negative 1 supportive

Actually no substantial differential effect on duration of analgesia related to the type of LA (< 1 h with prilocaine and >4h with levo-bupivacaine)

“Man uses his arm and hands constantly and as a result he exposes his arms and hands to injury constantly” Little DM. Classical file. Survey of Anesthesiology 1963; 7:280-5 Complications related to peripheral nerve catheters-what we are afraid of ?

postop. Analgesia PNB lower Neurologic Complications of 405 Consecutive Continuous Axillary Catheters Bradley D et al: Anesth Analg 2003; 96:247-52 Retrospective study Catheters placed postoperatively for 55 ± 32h, Infusion rate:10 ± 2ml/h Bupivacaine 0,125% - 0,25% ( in 87,7% ) Results: Paresthesia with catheter placement 60 pts (14,8 %) Neurologic deficit non related to surgery 2 pts (0,5 %) All patients with neurologic deficit had major elbow surgery

Incidence of Serious Adverse Events of CPNB Capdevilla X. Anesthesiology 2005;103:1035-45 Serious Adverse Events Interscalene (n=256) Axillary (n=126) PCB (n=20) Femoral (n=683) Distal (n=38) Patients (n) 4 1 3 Nerve lesions 3 (0,4) [0,1-0,9)] Acute respiratory failure 2 (0,8) [0,2-2,1] Laryngeal & rec.n. laryngeal paralysis [0,-1,8] Severe hypotension 3 (15) [4-31,3] Systemic LA toxicity 1 (2,5) [0,3-3,7] Seizure 1 (0,8) [0.05-1,3] Abscess 1 (0,14) [0.01-0,8] n (%) [95% CI No complications related to fascia iliaca (n=94), sciatic (n=32), and popliteal (n=167)block

Inflammation = redness, swelling, pain (35% catheter culture positive) Acta Anaesthesiol Scand 2007;51:108-114 Axillary 600,interscalene 303, infraclavicular 92, psoas comp.65, femoral 574,sciatic 296, popliteal 355 Inflammation = redness, swelling, pain (35% catheter culture positive) Infection = pus at insertion site (100% positive culture) Local inflammation 96 pts (4,2%) Infection 73 pts (3,2%) Surgical drainage 20 pts (0,9%) Staph.epidermidis and Staph aureus in 42% and 58% of catheter tips cultures No late complications in any patient. Infection risk increased with duration Higher risk for interscalene than for anterior sciatic catheter

Adapted from Neuburger M et al, Acta Anesthesiol Scand 2007;51:108-114 Incidence of Local Inflammation and Infection for Different Perineural Catheters Adapted from Neuburger M et al, Acta Anesthesiol Scand 2007;51:108-114 Number of catheters Catheter localization Catheter duration median (range) Incidence (%) of local inflammation Incidence (%) of infection Trauma patients Borgeat , 2003 700 Interscalene 3,2 (1,5-5) days 0,7 0,1 No Cuvillon, 2001 208 Femoral 48 h 4,3 1,4 Borgeat, 2004 Borgeat, 2006 237 1.001 Popliteal 60 (48-90) h 2-4 days 0,2 Capdevilla, 2005 1.416 Different 2,3(2-5) days 3,0 0,07 Yes Neuburger, 2007 2.285 4 (1-36) days 4,2 3,2* 30 % *Surgical intervention in 0,9%

When to Use Continuous PNB’s? High initial pain level expected (incl. opioid abuse) Prolonged postoperative pain(< 48h) Early mobilisation - faster rehabilitation Elderly patient Potential for chronic pain development Complications of alternative methods expected

Incisional Catheters Simple, safe, inexpensive Liu, Kehlet Incisional Catheters Simple, safe, inexpensive Catheter placed at correct position under direct vision Eliminates risk of inadvertent penetration of vascular or neural structures (vs. perineural) Only area of surgery affected allowing normal use of extremity and early rehabilitation (vs. perineural) Useful for ambulatory and inpatient surgery

Reduction in opioid use Anesth Analg 2006;102:248-57 19 RCT’s (11 double-blind) Better analgesia for all time periods at 24, 48 and 72 h and all catheters Reduction in opioid use Lower incidence of PONV (21 % vs. 49 %), sedation (27% vs. 52%), and pruritus (10 vs. 27 %) with PNB´s Improved patient satisfaction (4 RCT’s only) ”CPNB, regardless of catheter location, provided superior postoperative analgesia and fewer opioid-related side effects when compared with opioid analgesia”

Advantages of peripheral nerve blocks in postoperative pain management postop. Analgesia PNB lower Advantages of peripheral nerve blocks in postoperative pain management ♦ High quality of analgesia in all types of pain ♦ Surgical site-targeted (continuous) analgesia ♦ Haemodynamic stability (postganglionic, unilateral sympathetic block) ♦ Less concerns regarding coagulation and infection problems ♦ Low complication rate (avoidance of potential risk of alternative methods) ♦ Less intensive ward surveillance ♦ Perineural home infusion

Peripheral nerve blocks and outcome from surgery We are now asking the right questions We have some of the right answers More research is required Advances in surgical practice will continue to challenge anaesthetic and analgesic practice

Peripheral nerve block – another point of view I don’t know much about outcome,but it doesn't hurt me!

Thank you for your attention!

Potential Economic Benefits of Regional Anaesthesia for Acute Pain Management Regional anaesthesia appears definitively better than GA/ opioids for orthopaedic procedures But, how to realize the benefits? Advances in surgical techniques & perioperative care have drastically increased NNT values of analgesic interventions Lack of trained personnel and resource support – recent staffing and productivity models are based on GA practice not considering PACU bypass, same day discharge criteria, RA-induction room Wiliams BA, Reg Anesth Pain Med, 2006

Advantages of incisional catheter techniques Simple, safe, inexpensive Catheter placed at correct position under direct vision Eliminates risk of inadvertent penetration of vascular or neural structures (vs perineural) Only area of surgery affected allowing normal use of extremity and early rehabilitation (vs perineural) Useful for ambulatory and inpatient surgery

Why PNB,s for postoperative analgesia? Decreasing role of neuraxial techniques No major advantages in outcome ( except orthopedics procedures) Higher risk of complications than previously reported Minimal invasive surgery Increasing co-morbidity Ageing population Obesity Changing surgical demands Early mobilisation / accelerated rehabilitation (cont. passive motion concept)

Why regional block for postoperative analgesia? Analgesia during and after operation Sympathetic block Muscle relaxation Preservation of consciousness Abolition of stress response Reduced morbidity & mortality Quality of pain relief you will never ever achieve with any other single systemic drug or their combination or with so called multiple approach