1. Regional Anesthesia In The Perioperative Setting Shelly Ferrell MD Assistant Professor Medical Director Acute Pain Service Department of Anesthesiology University of Kentucky College of Medicine Lexington, KY

2. The information contained herein has been compiled as part of UK HealthCare’s Patient Safety Evaluation Systems, is deemed to be Patient Safety Work Product, and is privileged and confidential. I have no financial disclosures to report.

4. Objectives Identify Acute Pain Generators and Treatment Options Discuss Technique Benefits and Risks Discuss Local Anesthetic Toxicity/Limits and Exparel

5. Pain Generators/Options Basic Questions: Location, Duration, Intensity, Radiation, Exacerbation, Relieving Use Knowledge of Anatomy to Discern Appropriate Targets and Possibilities for Regional Decide Best Course For Patient- Single Shot, Catheter, Epidural

6. General Options Epidural (Lumbar/Thoracic) TAP (Variance in Location) PECS 1 & 2 Paravertebral Brachial Plexus Lumbar Plexus Femoral Sciatic (Multiple Approach Options)

7. Technique Risk/Benefits Epidural: Risks: Dural Puncture, Vascular Puncture/Bleeding (Hematoma), Nerve Damage, Hypotension, LA Toxicity, Opiate Sedation, Urinary Retention Benefits: Earlier Return of Bowel Function, Reduced DVT Risk, Non-Sedating Analgesia, Improved Pulmonary Function, Hypertension and Tachycardia Avoidance, Reduced Catecholamine Surge and Reduced Stress Response

9. TAP Blocks Risks: Bleeding, Infection, Peritoneal Puncture, LA Toxicity, 8-10 hour duration single shot (Longer with Catheter) Benefits: Non-Sedating Analgesic, Reduced Opiate Requirement, Relatively Non-Invasive, No Major Vessels or Nerves, Great For Opiate Tolerant Patients Diagnostic Vs. Therapeutic (Clinic)

11. PECS 1 & 2 Uses: Breast, Upper Chest Extrathoracic Risks: Pneumothorax, Bleeding, Higher Plasma Local Concentration, Spread to Brachial Plexus Cord Segments (Upper Ext Numbness) Benefits: Non-Sedating Analgesic, Reduced Opiate Requirement Lasts 8-10 hours (more or less)

13. Paravertebral Uses: Rib Fx, Chest Tube Pain, Breast Surgery Risks: Pleura Puncture, Spread to Neuraxial Space (Hypotension), Vascular Puncture, LA Toxicity Benefits: Conventionally outside neuraxis, Targets Nerve Roots, Less Bleeding Risk

15. Brachial Plexus Risks: Varied Based on Approach, Vascular Puncture, Nerve Damage, Infection, Phrenic Nerve Relaxation(Horner’s Syndrome), PTX, LA Toxicity Benefits: Targeted Analgesia (Lasts 16-20 Hours single shot), Reduced Opiate Requirement, Great For Opiate Tolerant Patients

17. Lumbar Plexus Risks: Retroperitoneal Bleeding, Nerve Damage, Infection, Failed Block, Kidney or Major Vessel Puncture, Neuraxial Spread (Hypotension) Benefits: Covers Femoral, Illioinguinal, Illiohypogastric, Obterator, Lateral Femoral Cutaneous, Lasts around 10 hours

19. Femoral Risks: Vessel Puncture, Infection, LA Toxicity, Nerve Damage Benefits: Superficial Access, Great for Anterior Thigh, Great for Opiate Tolerant Patients, Lasts 16-20 Hours

21. Sciatic Risks: Bleeding, Infection, Nerve Damage, Discomfort With Access, LA Toxicity (Lowest Risk) Benefits: Good for Lower Leg/Foot, Great for Opiate Tolerant Patients

22. LA Toxicity Bupivacaine- 2.5mg/kg without, 3mg/kg with epi Ropivacaine- same as Bupiv Lidocaine- 5mg/kg without, 7mg/kg with epi Tetracane- 1mg/kg without, 1.5mg/kg with epi Varying Blocks Will Yield Different Plasma Concentrations

23. LA Toxicity Treatment INTRALIPID- 20% Solution Bolus Dose 1.5-2 mL/kg ASAP May Repeat Bolus Dose 5 min if no ROSC Start Infusion 0.25-0.5 mL/kg/min until ROSC Toxicity has been reported to occur up to 40 HOURS post initial event/injection

25. Exparel 1.3% Bupivacaine Solution 72 Hour Advertised Duration 48 Hour Common Duration CAN NOT Use Lidocaine Near Within 20 Min Injection Currently ONLY Approved for Soft Tissue Infiltrate- Hemorrhoid/Bunions

26. Exparel Cont No Current Reports of Cardiac Arrest from use NOT FDA Approved for TAP or Nerve Block NOT Approved for Epidural/Spinal Use MUST Let Chloraprep DRY before Use- Disrupts Liposome 2015- $300 Per Bottle Can Dilute Up To 1:14 Ration NS or LR NOT STERILE WATER

27. 3 Promises On Time On Target- Efficacy Safety Randall Malchow MD

28. References http://www.exparel.com/pdf/EXPAREL_Presc ribing_Information.pdf http://www.exparel.com/pdf/EXPAREL_Presc ribing_Information.pdf http://www.dvcipm.org/clinical- resources/dvcipm-maraa-book-project http://www.dvcipm.org/clinical- resources/dvcipm-maraa-book-project NYSORA.com http://www.usra.ca/

29. Questions, Comments, Derogatory Remarks?