How to set up !

a regional anaesthesia and analgesia

unit?


Philippe B. Macaire MD!

Senior Consultant
Anaesthesia and Pain Interventional
dpt
Rashid Hospital - Trauma Centre
Dubai Health Authority - UAE
How to set-up a R.A.A. unit?

Benefits of RA
Needs and requirements
Business plan
New processes = Education
Action plan
Assurance Quality
 POST
Meta analysis *OP PAIN : CPNB > OPIOIDS

Inclusion criteria
PNB vs Opioids Results :
Post operative analgesia VAS mean and max
CPNB > Opioids
19 papers
!
lev e l and RA

A1 I read all

the papers
is really the
Max VAS Mean VAS best

* Richman J Anesth Analg 2006

Liu S Review Anesth Analg 2003
 POST OP PAIN : CPNB > OPIOIDS
!
Pain
Side effects
Post op rehabilitation,
Quality of Life
Trauma and RA

I read all

Oncology the papers
is really the
best
Opioids still there....

Why Opioids instead of RA

with a Micrel Pump ???
 Opioids not the best choice....
‘Once threshold reached, every further 3–4 mg increase will be associated with 1
clinically meaningful opioid-related symptom’

Clinically meaningful events on day 1 following lap

cholecystectomy

≥ 3 events
all patients
regression for all patients
2 events

1 event

Zhao et al J Pain ***

No event Symptom Manage 2004

Morphine equivalent
0 10 20 30 40 50 dose on day 0–1 (mg)
Sometimes Opioids could be the worse
one

OPIOIDS :
• > Duration of hospital stay
• > Duration of rehabilitation
• > Costs
• > Side effects
Needs and requirement to perform RA
Needs and requirement to perform RA
Peri operative concept
First data in 1998 Rawal N,
Macaire P 2001 Shoulders, Knees, Feet
Editorial of Anesthesiology in 2002

Discharged after surgery and Home care or rehabilitation center

…
J0 J1 J2
Hospitalisation ..... .....
Needs and requirement to perform RA
Peri operative concept

Training Nurses:
PACU
Ward
Pre op = to sale the RA

Per op = to perform the RA

Post op = To follow up
Organisation:
Time
Block room
Ambu = Hot Line
 The ultrasound machine ……
Business
plan
Evidence of benefits of RA
Pain free surgery center
Patient satisfaction
Costs reduction !
Turn over in OT
!
Utility of the US machine
!
New technique = Training
!
Action Plan
!
Assurance quality Monthly Hospital Board Meeting
 Anesth Analg 2004

Delay my schedule
43%
Not reliable
12%

Prospective study of 440 Blocks in 5 months = 34% of delays:

16% by the surgeons or consents not valid
7% by anesthesiologists (RA) Kimberly W. ASRA 2007

Block performance needs time = > NEW ORGANISATION

«Block room» William et al Anesthesiology 2000
Surgeon on 2 rooms Amstrong et al Can J. Anesth. 2004
 RA will reduce the costs
LCA repair
PACU Costs Hospital costs Global costs
US$ Starts at !
US$ 50,000

GA 105,000 16,363 996,363

PNB 18,900 3,850 897,750

-86,000 US$ -12,000 US$ -98,000 US$ William B Anesthesiology 2004

Shortcut PACU Mac Cartney et al Anesthesiology 2000

Reduce duration in ambulatory room Hadzic Anesthesiology 2004

Reduce % of re-admission Hadzic Anesth Analg 2005

 RA will increase the income

Armstrong KPJ et al. Can J Anesth 2004

!
With a good organisation RA will increase the turn over in the ORs
=>
BLOCK ROOM for the block performance and assessment
!
US will improve success rate of Blocks

Lehrer I et al. ASRA 2009

US will improve success rate of Blocks
RA not reliable
After purchase an US machine
12% in teaching hospital of Dresden

Block faillure droping down years after years (16% in 2005 vs 10% in 2006 vs 6% in 2007)!
Less block faillure with US guidance (4% US+ NS vs 11% US vs 19% NS)
NS guidance
US guidance Hoffmann CF et al ASRA 2009

NS + US guidance
New Clinical pathways… with RA

Rashid Hospital Clinical pathway for hip fracture in submission

Define processes & algorithmes…
 Report of RA…
Report of RA
Pre op neurological status
Block performance with the
incidents
Efficiency
 Report of RA…
Report of RA
Pre op neurological status
Block performance with the
incidents
Efficiency
!
SSPI
Analgesia quality
Prescription of regional
analgesia if catheter
Pump connection
Instructions
!
 Report of RA…
Indicators
Report of RA
of the quality of the functional
Pre op neurologicalanalgesia
status
Block performance with the
incidents
Efficiency
!
SSPI
Analgesia quality
Prescription of regional
adaptation
analgesia if catheter
of the regimen by
Pump connection
Instructions
!
Follow up in the ward
 Report of RA...
Report of RA
Pre op neurological status
Block performance with the
incidents
Efficiency
!
SSPI
Analgesia quality
Prescription of regional
analgesia if catheter
Pump connection
Instructions
!
Follow up in the ward
!
Recovery after RA: SS +
catheter
 New techniques = Trainings
Ambulatory
PACU nurses: Day 1 call Block recovery
Block control and analgesia Home care if catheter
Pump connection if catheter
Discharge criteria
PHYSIOTHERAPISTS
How to optimise physio with the
Anesthesia nurses:
perineural catheter
Block preparation
Time out
Trolley of regional anesthesia
Intra lipid protocole

Nurse in wards
abnormal signs
catheter follow up
Infusion of LA
Limb cares …
J0 J1 J2

Once a year + Information on line

New settings in ORs prep rooms
Performing a block is not
anymore an art,....... it is a science
with processes => Check lists
Ward booklet on regional anesthesia

On line text
book for nurses
Ward booklet on regional anesthesia

Nurse follow up step by step

• Arrival in PACU, Insertion point for each type of
• Discharge from PACU regional catheter
• Arrival in the ward
• During physiotherapy ...

cutaneous territory of efficiency

for each type of block
Normal and abnormal signs

Risk of fall if lower limb block

 Action plan

Organise architecture of the ORs:

Equiped block room + slave monitors
Call the patient in advance

Start with single shot blocks

Define targets 3, 6 12 months
Motivate the surgeons
Comunicate on RA concept and benefits
Audit your practice
Side effects of peripheral nerve catheters

Richman Anesth Analg 2006

No More Caths ... peri articular
Infiltrations...

Do we perform the right studies?

Are we using all the tools available?

Anesthesia more minimalist :-) nowadays
Sartorius M.

Vastus Medialis M.

Gracilis M.
< Sapheneous N.

< Descending !
Genicular A.

Adductor Magnus M.
Fem. A.

Macaire P Personal data 1999

 Assurance quality in Regional
anaesthesia
• Quality criteria of the post op.:
– To be efficient = Pain free
– Without discomfort as Aim of satisfying the
• Numbness customers…
• Motor blockade
– Without any disability
– Fastrack to the normal social life
• Allowing
– efficient physiotherapy … maximizing results…
– to stroll
– To reach targets of discharge (earlier $$$)
• Without generating health risks
or unnecessary costs … and risk <.
 Assurance quality
Regional anaesthesia and analgesia
To define new standards in collaboration with other teams

QA
Improve Quality Measure Quality
! (Comply with norms) (The variation in standards)
One cannot improve that which one One cannot measure that which one has
has not measured not defined
 QA in regional post op. analgesia
VAS at rest = 0 > 10 Basal rate
! !
VAS at mob = 0 > 10Do we perform Bolus the right studies?

! !
Excessive numbness Y – N Basal rate
! Are we using
! all the tools available?
Motor Blockade Y – N Basal rate
! !
Physiotherapy Y - N Basal rate or bolus
! !
Difficulty to walk Y – N
! A tool able to keep a
rates
!
Activity Y - N live contact Quality
with ofpatient
life with a full
!
Insomnia Y – N interactivity
! with him:
pain ?
! ! !
Fatigue Y – N
! The telemedicine
Quality of life pump
!
Swelling dressing Y – N = Infectious risk
Follow up:
!
Satisfaction 0 - 10 The ! Micrel project
no value except commercial
2009
Regional anesthesia/analgesia

Peri-operative medicine
Philippe B. Macaire MD!
Senior Consultant
Anaesthesia and Pain Interventional
dpt
Rashid Hospital - Trauma Centre
Dubai Health Authority - UAE!
!
www.medinfusion.org!
prmacaire@dha.gov.ae
6 - 7th November 2015!
!
6th Pain symposium in Dubai involving :!
!
• MSK and sports Physicians!
• Physiotherapists!
• Radiologists!
• Surgeons!
• Anaesthesiologists (“Interventional Pain Killers”)!
!

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