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Facts and fiction of surgeons about PNB
Markus F. Stevens Academic Medical Center Amsterdam
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Known for recurrent conflict of interest with surgeons regarding
Faculty Disclosure Known for recurrent conflict of interest with surgeons regarding Patient scheduling Indications for regional anesthesia Indication for operations Attribution of complications Duration of operations Duration of (regional) anesthesia induction Advantages of regional anesthesia Appropriate habits & appropriate language
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Fact or fiction Orthopedics are smarter than anesthesiologists
Risk of compartment syndrome => no PNB PNB causes “steal” in transplantations PNB cost “my” operating theatre time PNB keeps the patients in bed/hospital PNB have a high risk of nerve injury From a look at your shoe I can tell who you are
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Orthopedics vs. Anesthesia
Fact or fiction Orthopedics are smarter than anesthesiologists Orthopedics vs. Anesthesia
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Fact or fiction “Orthopedic surgeons: as strong as an ox but half as clever.” Multicenter prospective comparative study N = vs 40 Short version (20 min) Subramanian P. BMJ 2011
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Fact or fiction P=0.0274 Subramanian P. BMJ 2011
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FACT Fact or fiction Orthopedics are smarter than anesthesiologists
Subramanian P. BMJ 2011
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Fact or fiction Risk of compartment syndrome => no PNB Fact Fiction
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Fact or fiction Risk of compartment syndrome => no PNB
5 P mnemonic: Palor Pain out of proportion / pain on passive stetch Pulselessness Paresthesia Paralysis Keudell A.G. Lancet 2011
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Fact or fiction Risk of compartment syndrome => no PNB
5 P mnemonic: Pain Keudell A.G. Lancet 2011
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Fact or fiction Risk of compartment syndrome => no PNB
Ulmer TJ Ortho Trauma 2002
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Fact or fiction Risk of compartment syndrome => no PNB
Keudell A.G. Lancet 2011
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Fact or fiction Risk of compartment syndrome => no PNB
Systematic review In 32 of 35 there were classic signs despite epidural anesthesia 12 cases used a PCA 1 case delayed diagnosis after tibial fracture because of femoral nerve block 1 case of ankle block delaying foot compartement syndrome No case of PNB delaying diagnosis of upper limb compartement syndrome Mar G.J. Brit J Anaesth 2009
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Wrong question Fact or fiction
Risk of compartment syndrome => no PNB Wrong question Regardless of kind of analgesia missed compartment syndrome is a problem of clinical inattention
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Fact or fiction Risk of compartment syndrome => no PNB
Keudell A.G. Lancet 2011
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Fact or fiction Risk of compartment syndrome => no PNB
Bhattacharyya B.T. JBJS 2004
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Fact or fiction PNB cases “steal” in transplantations no PNB PNB
anastomosis anastomosis
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Fiction Fact or fiction PNB causes “steal” in transplantations
PNB increase skin temperature of transplant PNB increase blood flow to the transplant BNB no benefit on transplant survival Niazi A.U. Hand Surgery 2013 Su H.H. Chan Gung Med J 2005 Kurt E. Ann Plast Surg 2005 Berger A. Ann Plast Surg 1985
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Increased blood flow & no harm
Fact or fiction PNB cases “steal” in transplantations No clinical benefit Increased blood flow & no harm
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Fact or fiction PNB cost “my” operating theatre time Fact Fiction
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Fact or fiction PNB cost “my” operating theatre time
Type of anesthesia N ACT TOT GA 67 32 (12)* 24 (12) PNB 99 28 (15)* 25 (20) i.v.RA or LA 63 25 (10)* 21 (20) TOT = Turnover time ACT = Anesthesia controlled time Head S.J. Can J Anesth 2011 Williams B.A. Anesthesiology 2000 Mariano E.R. J Clin Anesth 2009
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Fact or fiction PNB cost “my” operating theatre time
Do you have enough staffing? Do you have enough equipment? Do you have enough ORs? What is your time for a block? What is your success percentage? What is your rescue plan? Are the time savings meaningful?
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Fiction Fact or fiction PNB cost “my” operating theatre time
Show me our data Orthopedic OR Düsseldorf 2001 2002 2003 Percentage RA 32 % 42 % 46 % Ratio: Neuraxial / PNB 1 / 0.5 1 / 1.4 1 / 2.6 Average non-staf costs of anesthesia 107 € 112 € 109 € Average ACT 26 min 24 min Average time in PACU 39 min 30 min 28 min ???
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Fact or fiction Paravertebral block vs. GA herniorraphy
PNB keeps the patients in bed/hospital Paravertebral block vs. GA herniorraphy 4 studies (n=268) -> no difference LOS 2 studies (n=108) -> PACU bypass 13% ->18% 1 study (n=60) -> PACU time 41 min -> 26 min Paravertebral block vs. SpA herniorraphy 3 studies (n=159) -> no difference LOS Law L.S. AA 2015
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Yun X.-D. Ortho Trauma Surg Res 2015
Fact or fiction PNB keeps the patients in bed/hospital LIA vs. FNB for TKA 6 studies (n=464) -> no difference LOS Yun X.-D. Ortho Trauma Surg Res 2015
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Fact or fiction LIA vs. FNB for TKA
PNB keeps the patients in bed/hospital LIA vs. FNB for TKA 6 studies (n=390) -> in advantage of LIA Wang C.J. Arthroplasty 2015
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Yun X.-D. Ortho Trauma Surg Res 2015
Fact or fiction PNB keeps the patients in bed/hospital FNB: FNB single shot FNB continuous FNB single shot & single shot SNB FNB continuous & single shot SNB 10 different mixtures 40 – 200 mg ropivacaine LIA: LIA single shot LIA continuous 10 different mixtures mg ropivacaine Wang C. J Arthroplasty 2015 Yun X.-D. Ortho Trauma Surg Res 2015
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Xu J. Cochrane database Syst Rev 2014
Fact or fiction PNB keeps the patients in bed/hospital Nerve block vs. GA for major knee surgery 4 studies -> 3 neg. 1 pos. in favor PNB => Insufficient data to draw conclusions Xu J. Cochrane database Syst Rev 2014
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Xu J. Cochrane database Syst Rev 2014
Fact or fiction PNB keeps the patients in bed/hospital Nerve block vs. GA for major knee surgery 4 studies -> 3 neg. 1 pos. in favor PNB => Insufficient data to draw conclusions Fiction Xu J. Cochrane database Syst Rev 2014
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Warning Fact or fiction Cont. PNB vs. single shot/no PNB for falls
PNB keeps the patients in bed/hospital Cont. PNB vs. single shot/no PNB for falls Warning 2.2 % => 0.5 %, NNH = 59 Johnson R.L. BJA 2013
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Stay in bed to avoid falling Possibly reduced length of stay
Fact or fiction PNB keeps the patients in bed/hospital Stay in bed to avoid falling Possibly reduced length of stay
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Fact or fiction PNB have a high risk of nerve injury
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LA-induced apoptosis and neurotoxicity
Fact or fiction PNB have a high risk of nerve injury LA-induced apoptosis and neurotoxicity Verlinde M. Int J Mol Sci 2016
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Fact or fiction PNB have a high risk of nerve injury
Widmer B. Knee 2013
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Fact or fiction PNB have a high risk of nerve injury
Lenters T.R. J Shoulder Elbow Surg 2007
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Fact or fiction PNB have a high risk of nerve injury
That’s what i told you! Wait a minute! Just 3 points:
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Fact or fiction PNB have a high risk of nerve injury n = 12,329
Jacob A.K. Anesthesiology 2011
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Fact or fiction PNB have a high risk of nerve injury
Jacob A.K. Anesthesiology 2011
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Fact or fiction PNB have a high risk of nerve injury n = 1,569
Sivggum H.R. RAPM 2012
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Permanent Nerve Injury
Fact or fiction PNB have a high risk of nerve injury Fiction Surgery Nerve injury Permanent Nerve Injury Open shoulder surgery 5.5 % 1.2 % Total shoulder arthroplasty 3.8 % 1.3 % Elbow Surgery 5.6 % 0.6 % Total hip replacement 0.5 % 0.4 % Total knee replacement 1.1 % 0.3% ACL replacement 16.7 % 4.4 % Arthroscopic ankle procedure 3.7 % 0.2 % Total ankle replacement NR Dwyer T. RAPM 2015; Dwyer T. RAPM 2015; Veljkovic A. RAPM 2015
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Fact or fiction From a look at you I can tell who you are
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Fact or fiction From a look at you I can tell who you are
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Fiction Fact or fiction
From a look at your shoe I can tell who you are Fiction Giesinger K. BMJ 2015
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Thank you for your attention
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