REGIONAL ANESTHESIA

Regional Anesthesia: Too

Much Headache or Wave of
the Future?
Anesthesia Journal Club Series
Steve Pierre, MD and Maged
Guirgus, MD
May 26, 2010
Objectives
Block Service
On goings in the region
Pro-Cons of Regional vs GA
Feasibility in private practice?
Block Service
Consists of several staff dedicated to performing blocks


and placing catheters

 Dr. Mounir-Soliman
 Dr. Ritchey
 Dr. Zaky
 Dr. Nageeb
 Dr. Karroum
 Dr. Farag
Surgeons and anesthesiologists identify patients that may
need this service
Nurses are responsible for follow-up


Practice Details
Main OR
A60
Regional facilities
Main ORs
A variety of blocks performed by
BS
Infusion catheters
◦ Inpatients
 Femoral, popliteal and
supraclavicular
◦ Outpatients
Supraclavicular and Popliteal

Ambit Pump
 Kit includes….
◦ Preset pump
◦ Batteries
◦ Carrying case
◦ One liter bag of local
anesthetic
◦ Detailed instructions
◦ Contact number for our
APMS
 Acute Pain Service
Nurses call the patient
daily
 Patient will remove
catheters by
themselves
A 60
Most blocks are placed Block
Service (BS)
Day before surgery, surgeon or
anesthesia will contact BS for
blocks needed in A60
Most common blocks performed
◦ Supraclavicular
◦ Axillary
Rare to send patients home with
peripheral catheters

Regional Facilities
Beachwood
Strongsville
Hillcrest
Lutheran
Marymount
Lorain


Regional Facilities-No
Catheters
Beachwood
◦ Supraclavicular and popliteals
(started femoral blocks)
◦ Patient do not go home with
catheters
Strongsville
◦ All blocks
◦ Success with dexamethasone
◦ No catheters: had some
challenges with dizziness when
used
Regional Facilities
 Hillcrest
◦ All blocks
◦ Home: Interscalene and popliteal catheters
(10-15 patients per month)
◦ Own nurses for follow-up (On-Q pump)
 Lutheran
◦ All blocks
◦ Home: popliteal catheters (3-5 per month)
◦ Femoral catheters for inpatients
◦ Use our nurses for follow-up
Regional Facilities
Regional Anesthesia is
Much Better than General
Anesthesia
Benefits of Peripheral Nerve
Blocks
Improved post operative pain control
Less PONV

Earlier mobilization

Earlier discharge

Better patient satisfaction

Improved postoperative cognitive

function (less sedation)

Less unanticipated hospital admission
Before We Go On….
There may be safety concerns in dealing with
neural blockade.
SAMBA survey published in 2002

 16% never or rarely discharged patients

1. Concern about patient injury
2. Inability to care for themselves
3. Preparation time
4. Physical logistics of placing the blocks
5. Unfamiliarity with techniques

But Should They Be
Scared?
 Klein SM et al Anesth Analg.2002;94:65-70
 Retrospective study over 2300 patients received PNB
 7 ( 0 . 29 %) had a persistent paresthesia that may
have been related to the block .
 All resolved over a period of < 3m


 Hausman et al Journal of Clinical Anesthesia (2008) 22, 271–275

 123 with PNB of which 2 patients had nerve problems
that resolved over time
 1 patient with persistent paresthesias after an
axillary block which resolved within one
week .
 1 with persistent femoral neuropathy after a
femoral nerve block resolved within 3 m
Back to the Advantages
Improved post operative pain control
Less PONV
Earlier mobilization
Earlier discharge
Better patient satisfaction
Improved postoperative cognitive
function (less sedation)
Less unanticipated hospital admission
 versus
General Anesthesia for Hand and Wrist
Day-case

Surgeries
Hadzic et al anesthesiology 2004;101:127-32
Infraclavicular nerve block vs. fast-track


GENA
Criteria INB(25) GENA(25) P value

Pain score >3 3% 43% <0.001

Nausea/vomiting 8% 32% 0.001
Bypass PACU 79% 24% 0.001
Ambulation 82 min 145 min <0.001
Discharge Time 121 min 218 min <0.001
Repeat technique 81% 50% 0.05
(patient satisfaction)
Pain meds. 0 48% <0.001
Block
Anesthesia Provides Superior Same-day
Recovery over
General Anesthesia Hadzic A et al Anesthesiology
2005;102:1001-7
 In te rsca le n e vs . fa st tra ck G E N A
ISB GA P value
Moderate to severe 0 16%(64) <0.001
pain VAS >3

Nausea 3% (12) 11%(44) 0.02

Vomiting 0 4%(16) 0.05
Ambulation min 84(+/-47) 234(+/-174) 0.001
Home readiness, min 113(+/-55) 270(+/-101) <0.001

Discharge time, min 123(+/-57) 286(+/-100) <0.001

 Side effects, quality of pain control and
patient satisfaction
Lower Extremities
H a d zic e t a l A n e sth . A n a lg 2 0 0 5 ; 1 0 0 : 9 7 6 -8 1 .
 50 patients for outpatient knee arthroscopy.
PNB GA P value
VAS 0-2 84% 52% 0.02
VAS 3-7 12% 32%
VAS 8-10 4% 16%
Nausea 0.001
None 32% 15%
Mod -severe
Ondansetron 12% 62
60% 0.01
Home readiness t. 131(+/-62) 205(+/-94) 0.001
Discharge t. 162(+/-71) 226(+/-96) 0.002
Poor ability to 25% 56% 0.04
concentrate >8h
postop
Unanticipated hospital
admission
H o sp ita la d m issio n a d d s to e xp e n se o f ca re a n d
le a d s to d a ys o f m isse d w o rk
M o st co m m o n a n e sth e tic ca u se s a re P O N V ,

so m n o le n ce , la ryn g o sp a sm , d izzin e ss and

a sp ira tio n

D ’ A le ssio e t a l R e g A n e sth . 1 9 9 5 Ja n -Fe b ; 2 0 ( 1 ): 6 2 -8
 Fo r a m b u la to ry sh o u ld e r su rg e ry
 8% of 263 patients receiving GA required
unanticipated admission
 No unanticipated admissions for interscalene
block

What about Continuous
Catheters?
Continuous Infraclavicular Brachial Plexus
Block for
Postoperative Pain Control at Home
Illfeld B. et
al.Anesthesiology 2002;96:1297-1304
30 patients received Average pain with movement

infraclavicular 6
5

catheters and GA

Pain scale
4 ropivacaine
3 placebo
2
Post-operatively: 1
0
0 1 2 3
 15 received POD

ropivacaine 0.2%
at 8 ml/hr Average pain at rest

 15 received placebo
4
3.5
3

Pain scale
2.5
 Infusion was 2
1.5

maintained for 3
1
0.5
0

days.
0 1 2 3
POD


Complications : There were no apparent local
anesthetic or catheter related complications
during infusion
 Continuous Interscalene Analgesia for
Ambulatory Shoulder Surgery in a Private
Practice Setting Fredrickson et al. Reg Anesth
Pain Med 2008;33:122-128.
Fredrickson et al….
C o m p lica tio n s:


 1 required antibiotic treatment for catheter

site infection
 Neurological sequelae
 Present in 3 patients at 3 weeks
 Remained in only 1 patient at 4 weeks
 All resolved by 6 months
Conclusion:


 CISB had a high success rate (avoided use

of potent opioids in 98%)
 Low complication rate
Now, Time for the Truth!
Myths that my opponent wants you
to believe
General anesthesia is associated
with increased morbidity
◦ PONV
◦ Post-op pain
Myth #1
PONV
A comparison of Infraclavicular
Nerve Block (INB) versus
General Anesthesia for Hand
and Wrist Surgeries
They claim that “there is a less
risk of PONV in patients
receiving INB (8%) compared to
GA (32%)”

 Hadzic et al Anesth. 2004


Nonsense!
All INB patients received
continuous IV propofol sedation
GA patients were not optimally
managed
◦ Only Dolasetron 12.5 mg
preoperatively (no dexamethasone)
◦ Desflurane as maintenance
◦ Only 25% of GA cases met fast-track
criteria!
◦ No NSAIDs
◦ No BIS

Still Myth #1
Devil is in the details
 Recent meta-analysis compared
peripheral nerve block to GA showed a
“decrease in nausea”
◦ Only 3 of 7 studies used PONV prophylaxis-
only Dolasetron.
◦ Only 2 used propofol for maintenance!
◦ Data skewed
 100 of the 359 patients came from
one study which used neither
prophylactic measures nor propofol!
◦ No difference in central nerve block
techniques with GA
Liu et al. AA 2005
Myth #2
Postoperative Pain
Hadzic re-visited
Only 3% of INB had VAS score
greater than 3 compared to
43% of those with GA
Details:
◦ No NSAIDs
◦ Intraoperatively, GA group
received 5 fold increase in
narcotics
◦ No difference in VAS scores or
quantity of analgesics at 24 or 48
hours
Hadzic et al Anesth. 2004

Myth #2
Postoperative Pain
 McCartney et al hypothesized that
regional would provide improved
analgesia up to 2 weeks
postoperatively
 Results: despite improved early VAS
scores there was no difference
◦ Pain
◦ Opioid consumption
◦ Incidence of nausea/vomiting
◦ Adverse effects i.e. paraesthesia
◦ Satisfaction at POD 1, 7, 14
 And this is despite the lack of
multimodal analgesic techniques!
 McCartney et al. Anesth 2004
VAS
Problems you are not suppose
to know about
Need for sedation
Need for conversion to GA
Dysrhythmias
Cardiovascular collapse
No control of airway
PDPH
CNS toxicity

Need for Conversion
McCartney et al
◦ 10% of patients were converted to
GA because of block failure
28% of patients with RA required
local anesthetic infiltration

Complications
A recent review shows that as
more regional anesthesia is
done more complications will be
seen
◦ Direct nerve injury
◦ Systemic local anesthetic toxicity
◦ Wrong-sided and wrong-site
procedures
More complications
Recent ASA closed claims
◦ 66 of 210 PNB claims were
permanent and 71% of those
were thought to be block related
◦ 4 claims were respiratory or
cardiovascular collapse


Lee et al. SAMBA 2004

APSF Article
Letter to the editor in APSF
discusses local anesthetic
induced cardiac toxicity after
single injection block that
required emergency
cardiopulmonary bypass

Our Own Experience
◦ Issues with catheter:
Fall
Dizziness
Leaky catheters
The Truth
Studies comparing GA to RA use
an archaic GA technique
◦ No antiemetics
◦ No NSAIDS
◦ No BIS monitoring
◦ Inhalational agents instead of
propofol
◦ GA Induction times are
extraordinarily long?

More Truths
Takes more time
Takes more resources
Might have to change anesthetic
plan
May block wrong side
Needs experience/performed by
experts
Does have adverse effects
Takes significant cooperation
from patient
Feasibility in a Private
Practice?
Essentials
 Efficient and Safe
 Appropriately trained personnel
 Anesthesia providers must be comfortable and

experienced with performing a variety of

nerve blocks
 Adequate space and personnel
 Area to perform blocks must include adequate

monitoring and personnel to monitor

 Structured program and policies
 Appropriate policies, procedures and

guidelines must be in place which address

patient instructions for discharge and easy
access for follow-up issues that may arise
Time Efficiency
Hausman et al Journal of Clinical Anesthesia (2008) 22, 271–27
R e tro sp e ctive stu d y o f
2 3 8 p a tie n ts
T im e fro m a n e sth e sia
sta rt to su rg e ry sta rt
 M A C 1 9 ± 7 m in
 P N B 2 9 ± 1 1 m in
G A 3 1 ± 1 1 m in
T im e fro m su rg e ry e n d to
a n e sth e sia e n d
M A C 9 ± 3 m in
PN B 9 ± 3 m in
G A 1 2 ± 4 m in

Economic Outcome
 R e tro sp e ctive stu d y o f 9 4 8 p a tie n ts u n d e rg o in g
A C L re co n stru ctio n
 Williams B.et al.Anesthesiology 2004;100:697-706
 Type of anesthesia:
 GA ( received ETT or LMA )

 GA + nerve block for post op . pain .

 Neuraxial anesthesia .

 Neuraxial anesthesia with nerve block .

 Nerve block only .

Results:
 PACU Bypass
 153 patients received PNB-only
 144 of these patients bypassed PACU (94%)
 795 all other patients
 410 of them bypassed PACU (51%)
 Patients did not bypass PACU were more
likely
 Pain
 Needed more nursing interventions for
managing
 Pain
 PONV
Results
Unanticipated Hospital Admissions
153 patients that received PNB-only
5 were admitted unexpectedly (3%)
795 patients receiving other anesthetics
 58 were admitted unexpectedly (7.3%)

Unanticipated hospital admissions were due

to issues with pain, PONV, somnolence, or
urinary retention
Financial Analysis
PACU bypass was associated with 12% hospital
cost reduction ($420/patient)
Hospital admission was associated with 11%

hospital cost increase ($385/patient)

For 3000 ambulatory orthopedic cases/ year

Assuming that 100% of cases are done with nerve

blocks
 PACU bypass rate of 94%
 Unplanned admission rate of 3%
 Estimated savings will be……
1.2 million $