1. Regional Blocks in Outpatient Surgery Roy Greengrass M.D. F.R.C.P. Professor of Anesthesiology Mayo Clinic Jacksonville

2. Your Personal Case Scenario Your only son graduates from MIT in 2 days. In your excitement getting everything ready to travel for this important event you trip on a rug and fracture your arm requiring surgery. Dr. Evans recommends interscalene catheter and propofol sedation for the procedure with interscalene analgesia postoperatively. Unfortunately your hospital has no one with expertise in this procedure. What do you do?

3. Disclosure I have no relevant financial relationships with any commercial interests related to the content of this activity.

4. Learning Objective List the different kinds of peripheral nerve blocks, the choice of local anesthetics, and their role in outpatient surgery and post op pain management.

5. Why not Gas and Opioids for Everyone?

6. General Anesthesia for Ambulatory Surgery - Advantages Easy to initiate Minimal assistance required

7. General Anesthesia for Ambulatory Surgery - Disadvantages Ubiquitous nausea, vomiting Postoperative pain usually mandates opioids which have well documented side effects

8. Regional Anesthesia-Advantages Evidence-based medicine suggests that multimodal anesthesia with regional anesthesia as the primary modality results in advantages of superior analgesia,earlier discharge,enhanced convalescence and better patient satisfaction compared with more traditional approaches.

9. Regional Anesthesia for Ambulatory Surgery -Disadvantages Skill level required to perform efficiently Often requires assistance Concern for side effects

10. Regional Block-Methods to Enhance Efficacy A dedicated pre-operative area with appropriate equipment is essential for performance of blocks –do not perform blocks in the OR under “surgical” time. Early performance of blocks allows for assessment of efficacy with the opportunity to redo/rescue block if necessary.

12. Ambulatory Surgery-Nausea and Vomiting By far the most important determinant of prolonged PACU stay More debilitating than pain-patient surveys Polypharmacy with antiemetics often ineffective Recurrence of symptoms after discharge

13. Nausea and Vomiting 60% of all breast procedures- even “minor” (includes plastics) Multifactorial –General anesthetics –Opioids –?reflexes

14. Paravertebral Block A somatic block of the mixed nerve soon after exiting the intervertebral foramina Allows profound anesthesia/analgesia without the associated effects of centralneuraxial anesthesia

17. Fast Tracking with Nerve Blocks for Breast and Hernia Surgery Roy A. Greengrass, M.D. Associate Professor of Anesthesiology Mayo Clinic, Jacksonville, FL

19. Does Regional Anesthesia Impact Pain?

20. Does Continuous Peripheral Nerve Block Provide Superior Pain Control to Opioids? A Meta-Analysis Richman Anes Analg Jan/06 19 randomized clinical trials enrolling 603 patients At all times and for all catheter locations CRA provided superior analgesia Opioid related side effects were significantly reduced using CRA techniques

21. “Almost all cases of hernia, with the possible exception of those in young children, could undoubtedly be subjected to the radical operation under local anesthesia” H. Cushing Annals of Surgery 1900

22. Postherniorrhaphy Urinary Retention-Effect of Local,Regional,and General Anesthesia Jensen Reg Anes Pain Manag Nov/Dec 2002 Medline search 1996-2001 “Urinary Retention” not delay in passing urine 70 non-randomized,2 randomized studies “Regional”=central neuraxial General = 3%(11471 pt), Central =2.42%(6191),Local = 0.37%(8991) Dispels the myth of less UR with GA (GA interferes with the Autonomic Nervous System) Opioids cause urinary retention ( eg morphine relaxes the detrusor while maintaining normal sphincter tone)

24. C.R.A. Applications: Orthopaedic Surgery Upper Extremity Total elbows- CPM Total shoulders Trauma

26. Popliteal Block Hadžić A, Vloka JD: Peripheral Nerve Blocks. Principles and Practice. McGraw-Hill, New York, 2004, Figure 22-19, p 296.

27. Continuous Interscalene Analgesia How many of you routinely send patients home with interscalene catheters? How many of you routinely insert IS catheters? Why not single shot blocks?

28. Continuous Interscalene Analgesia- Indications Surgical procedures involving the shoulder, arm, lateral forearm and lateral hand Palliative analgesia in patients with metastatic disease Sympathectomy for vascular reconstructive surgery

29. Ambulatory Continuous Interscalene Nerve Blocks Decrease the Time to Discharge Readiness after Total Shoulder Arthroplasty Ilfeld Anesthesiology Nov/06 Discharge criteria ( adequate analgesia, independence from intravenous analgesics, tolerance to 50% of shoulder motion targets) achieved significantly earlier in patients receiving continuous perineural 0.2% ropivacaine vs saline controls Essentially impossible to allow 23 hour discharge unless CRA is present ( Duke and Mayo experience)

30. Analgesic Effectiveness of a Continuous Versus Single Injection Interscalene Block for Minor Arthroscopic Shoulder Surgery Fredrickson Reg Anes Pain Management Jan-Feb/10 Procedures including subacromial decompression, excision lateral clavicle, stabilization procedures Significantly less pain and enhanced range of motion versus single shot blocks Ubiquitous use of opioids in patients with chronic pain makes “minor” surgery a misnomer

32. Interscalene Block

34. Applications C.R.A: Orthopaedic Surgery Lower Extremity ACL reconstructions Total ankles, triple arthrodesis Extensive tumor surgery Total knees

37. Popliteal Block Hadžić A, Vloka JD: Peripheral Nerve Blocks. Principles and Practice. McGraw-Hill, New York, 2004, Figure 22-19, p 296.

38. Caveats to Safe Practice of Regional Anesthesia Don’t do blocks with patients under general anesthesia Inject 1ml test dose – if patient complains of severe pain don’t “reposition” the needle-remove it-and abandon the block Author avoids epinephrine CRA may be through needle or catheter-if via catheter dilate space first (DW-can still stimulate)

39. CRA-Home Catheter Service Disposable Pump Removal by patient/care giver Anesthesiology consultation available 24/7

40. Are There Other Benefits Using Regional Anesthesia?

41. Preincisional Paravertebral Block Reduces the Prevalence of Chronic Pain After Breast Surgery Kairaluoma Anes Analg Sept 2006 PVB vs GA 1 year followup: Prevalence of pain PVB<< GA ( P= 0.003) Dynamic pain PVB<< GA ( P= 0.003) Pain at Rest PVB<<GA (P= 0.01) ? Deafferentiation + enhanced blood flow (seen also with post-thoracotomy pain)

43. Can Anesthetic Technique for Primary Breast Cancer Affect Recurrence or Metastasis? Aristomenis Anesthesiology Oct 2006 GA vs PVB 32 month followup Recurrence and met free survival 1 year 94% PVB vs 82% GA/opioid

44. CRA-Significant Cost Savings Duke – TSA-formerly 3 days-23 hour with IS catheter Mayo – TAA –formerly 3 days – 23 hour with Pop catheter

45. Your Case Scenarios You choose the “gas and oid” approach, experience severe post-op pain needing excessive doses of PCA analgesics, and have nausea and vomiting related to the opioids. You are advised not to travel due to your problems and cancel your flight You choose the block approach, are discharged from PACU with a CRA device, and fly out to enjoy your son’s honor