Outcomes and new paradigms

for post operative analgesia

regional by peripheral nerve
is a gold
blocks Regional
analgesia
standard
nowadays

Philippe B. Macaire MD!

Senior Consultant in Anesthesiology and Pain!
Anaesthesia dpt and Interventional Pain Clinic!
Rashid Hospital - Trauma Centre!
Dubai Health Authority - UAE
 Outcome of CPNB* in surgery

Pain free > Quality of life

CPNB and chronic pain

New paradigms for CPNB

Functional analgesia

Pain management by telemedicine

!

* CPNB = Continuous peripheral nerve block

 Most of surgeries = post op pain

Acute Pain = Moderate to severe pain

40 to 55% at rest
80% during physio*
!

1/4 patients still under opioids at D7 ** (1791 patients)

!

Acute post op pain and CRPS ***

* Benedetti Advances in Pain research 1984
** Klein S Anesthesiology 2002
*** Gottscalk A Anesthesiology 2004
Perkins F Anesthesiology 2000
Reuben S Anesthesiology 2004
 Orthopaedic surgery = Early physiotherapy

Excellent for early rehabilitation but

Acute pain
Muscular spams*
!

Must start at D0 **

* Colwel C Clin Orthop 1992

** Capdevila X SFAR 2000
 2012

What then are the consequences for future

research within physiotherapy exercise after
THA and TKA?!
!

•The timing should be right. !

•A systematic recording of joint pain or swelling is
mandatory .!
•The ingredients should be right.!
•The ingredients should not be too many.!
•The ingredients should be well described,
 Orthopaedic surgery = Early physiotherapy
!
• Refusal of the physio by the
Bone or joint
surgery + physiotherapy patient
!
• Increase post op immobilization
– Amyotrophy
PAIN
Restore a function
– Osseous resorption
– osteo calcifications
close to natural
organic function !!! – Modif cartilage
– < ligament strenght
– < Protein synthesis
– > PONV
– Fatigue
!
• Acute post op pain
– Factor of CRPS

Namba Clin Orthop 1991, Anderson Circulation 2003, Allen Lancet 1999, Perkins anesthesio 2000
Salter Clin Orthop 1989, Convertino Med SportsExerc 1997, O’Meara Clin Orthop 1993
 POST OP PAIN : CPNB > OPIOIDS
Meta analysis * Max VAS Mean VAS
!

Inclusion criteria
PNB vs Opioids
Post operative analgesia
!
and RA

19 papers I read all

!
is really the
the papers best
!
Results :
VAS mean and max
CPNB > Opioids

* Richman J Anesth Analg 2006

.... Liu S Review Anesth Analg 2003
 POST OP PAIN : CPNB > OPIOIDS

Side effects Catheters Opioids Odds

ratio

Nausea 38/182 (20,9%) 95/195 < 0,001 0,278

Vomiting (48,7%)

Sedation 12/45 23/44 < 0,012 0,332

(26,7%) (52,3%)

Pruritus 11/113 29/109 < 0,001 0,297

(9,7%) (26,6%)

Sens/mot Block 22/70 9/60 < 0,023 0,386

(31,4%) (15%)

* Richman J Anesth Analg 2006

 End of the 90s : Patient’s rehabilitation

Capdevila X Anesthesiology 1999

 End of the 90s : Patient’s rehabilitation

VAS values at 24h and 48h after TKA

PCA* Fem Epi PCA* Fem Epi

Capdevila X Anesthesiology 1999

 End of the 90s : Patient rehabilitation
Flexion targets after TKA : 40° at D1 and 50 ° at D2

PCA morphin Femoral KT Epidural KT

24 h 48h 24 h 48h 24 h 48h

30 (10-40)* 40 (32-40)* 40 (34-40) 50 (48-50) 40 (40-40) 50 (45-50)

Day 5 discharge Day 5 discharge Day 5 discharge

60 (50-70)* 80 (65-90)* 80 (65-85) 90 (70-95) 85 (75-100) 90 (77-100)

Capdevila X Anesthesiology 1999

* P < 0,05 (25th – 75th) percentiles

 End of the 90s : Patient rehabilitation

Side effects :

Dysthesia : Epidural *
Hypotension : Femoral ² < Epidural *
Urinary retention : morphine ² < Epidural *
Nausea : morphine *

Peripheral nerve block > Axial block > Morphine

Capdevila X Anesthesiology 1999

* P < 0,05
 Patient’s rehabilitation
Authors Year Type Results in favor of Blocks
Capdevila 1999 TKR Targets of physio + less side effects
Singelyn 1998 TKR Targets of physio + less side effects ( but fentanyl..)
Chelly 2001 TKR Time to walk – time to discharge
Ilfeld 2005 Shoulder Targets of physio
Horloker 2005 TKR/THR Time to walk – time to discharge
Ilfeld 2008 THR Time to reach criteria of discharge
Ilfeld 2008 TKR Time to reach criteria of discharge
Martin 2008 TKR Flexion + Autonomy in daily life

CPNB > Opioids

 2007

Predictor Variables With Outcome Variables Increased Pain at 6-Month

Follow-up,!
Increased Functional Limitations at 6-Month Follow-up and Poor Global
Recovery

Pain Control +++

 2012

Better pain control!

Less nausea // Decreased need for opioid!
Better patient satisfaction!
!
!
!
!
!
!
Effects on relevants outcomes!
Long term functional outcomes! Remains!
Costs unclear
 Post op quality of life + Ambulatory
A challenge : To send the patient at home with a CPNB

First data in 1998

Editorial of Anesthesiology in 2002

Authors Year Surgery Results in favor of Blocks

Macaire 2001 Foot Quality of life- analgesia at home

Capdevila 2006 Foot Reason of activity limitation
Macaire Shoulder CPNB< Opioids
Martin 2008 TKR Autonomy in daily activity

Ilfeld 2008 Shoulder Analgesia at home

 RA Cont + Bolus
PCA opioids

RA Cont
2006

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ve
ta
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Perf Cont

J1
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an
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PCA morph
Bolus+cont

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100

0
75

50

25
 RA in Ortho-traumatology
A challenge : To involve emergency Docs in regional analgesia

Authors Year Type Results in favor of Blocks or CPNB

Cooper 2004 calcaneum VAS and opioids consuption

Foss 2007 Hip fracture SaO2 - pain - Mobilization

Schiferer 2007 femur on site pain relief anxiety HPB

Pedersen 2008 hip fracture Complication 33>20% - Hospit 16>9 days

mortality 23>12%
Rosencher 2006 Hip fracture OR of death - 0.5 [-0.3/-0.8]
Flagel 2008 rib fractures Mortality 34 > 8% ( epidural analgesia)

Karmakar 2003 Rib Fractures VAS and functionnal respiratory tests

 RA in Ortho-traumatology

!
Benjamin T. Flagel et al surgery 2005
 RA in Ortho-traumatology

• Analgesia: Femoral catheter • Analgesia: opioids

• Anesthesiologist at the door • anesthesiologist pre op
• Nutrition program • Nutrition
• Fluid and Oxygen •
• urinary cath protocol • urinary cath systematic

!
Pedersen SJ et al J Am Geriatr Soc. 2008
 RA in Ortho-traumatology

Opioids Analgesia femoral cath

Before surgery CS Anesthesia ED

Ward Hospitalisation Hip unit

BMI < 23 Nutrition systematicaly

If pneumonia O2 Therap systematicaly

Cath Urinary cath only if

!
Pedersen SJ et al J Am Geriatr Soc. 2008
 RA in Ortho-traumatology

Intensive Conventional P

Complications 20% 33% =.002

Hospitalisation 9.7 days 15.8 days <.001

12 months mortality 12% 23% =.02

!
Pedersen SJ et al J Am Geriatr Soc. 2008
RA in Ortho-traumatology
 RA in Ortho-traumatology
RA and risk of nerve injury ?

No CI of Regional block on patient with Nerves injuries

just document perfectly before nerve block performance

RA and risk of Compartment Sd ?

!
Gaertner E AFAR 1998
Clark F Crit Care Clin 2001
Schulz- Stubner S Crit Care Med 2005
Schulz- Stubner S Anesthesiology 2006
 RA as anti inflammatory ?

Studies on rats:
PGE2
Interleukins
Cytokins
» Beloeil H Anesthesiology 2006 – AA 2009
» Kuo P – Wu C Anesthesiology 2006
» Buvanedra BJA 97
2008
2008
 2010

Stress or surgery process promote T developt *

Post op pain is a mediator of T promoting effect in rats **
Morphine stimulate angiogenesis and promote breast tumor growth***
Attenuating of tumor promote effect by surgery by RA in rats ****
 Continuous regional analgesia in oncology

Author Year Type Results in favor of regional analgesia

De Olivera 2010 Ovarian K Recurrence free 60% > 25%

Exadaktylos 2006 breast K Less meta with para vertebral Block

Christopherson 2008 Colon K [meta -] + [Epidural] = OR + 1.48Y

Biki B 2008 prostate Recurrence free 86% > 45 %

Merquiol F 2013 ENT K Rec free 5 years 68 Vs 37% OR + 0.49

2013
2014
 2014

The cumulative
scores of the
ambulatory QoR
questionnaire can
vary between 29
(extremely poor QoR)
and 155 (excellent
QoR) !
CPNB
!
> PCA Opioids :
Pain
Side effects
Post op rehabilitation,
Quality of Life
Trauma
Oncology

S. Klein et al. Anesth Analg 2002

 Recent alert by surgeons :-)

Buvanendran A JBS Am 2007

 2005

Pain
at rest
Pain 3 month after surgery

Pain at
mobilization

Opiate
consumption
 2008

The TAP block

Pain chronicisation: 8% at 3 months

2013
Did we progess during the past 15 years?

Are our analgesias delaying the rehabilitation?

Are we using all the tools avalaible?

Do we perform the right studies?

Do we have the data to answer?

Kehlet H ASRA 2009

 Quality in regional analgesia = The outcome

Finally, I am delighted to announce that long-terms outcomes

will be the topic of the 2010 ANESTHESIOLOGY Journal
Symposium.
!

We look forward to an in-depth

exploration of this exciting new
dimension of anesthesia. “!
!

Daniel I. Sessler M.D. !

Department of Outcomes Research, The Cleveland Clinic,
Cleveland, Ohio.

Anesthesiology 2009; 111:1– 4

 Post graduate Diplomas
Regional Anesthesia and Analgesia
Interventional Pain Medicine
One year registration in French University
Delivered by University of Montpellier France
Courses in English + exam in Dubai
!
!

Intensive courses
Peripheral nerve blocks under US guidance ( 5 days)
Airway management (3 days)
Ventilation modes (3 days) Drager Academy

www.medinfusion.org
prmacaire@dha.gov.ae