PowerPoint Presentation

Colin J.L. McCartney MBChB PhD FCARCSI FRCA FRCPCProfessor and Chair of AnesthesiologyUniversity of OttawaHead of AnesthesiologyThe Ottawa HospitalScientist, Ottawa Hospital Research Institute

Enhanced Recovery and Regional Anesthesia:Do we need regional?

1Good morning. My name is Colin McCartney and I am an anesthetist and consultant in chronic pain management from Toronto Western Hospital.

Conflicts of InterestConsultant for Teleflex MedicalI will not be discussing off-label or investigative uses of commercial devices

ObjectivesDescribe the place of enhanced recovery in perioperative careLearn the place of regional anesthesia in enhanced recoveryExamine the current evidence to support regional anesthesia within the enhanced recovery processLook at the future of regional anesthesia in ERAS

SummaryERAS pathways have become common for colorectal and orthopedic surgical pathwaysRegional anesthesia techniques are used in many pathways but use has suffered due to educational and other barriersRegional anesthesia has demonstrated several benefits for patients in ERAS pathwaysAs healthcare spending becomes further constrained we need to align our outcome measures with those being used to justify funding for our interventions

Enhanced Recovery after SurgeryLargely influenced by work of Professor Henrik Kehlet (Denmark)1Integrated coordinated bundles of care with a focus on multimodal techniques and interdisciplinary careMajor focus on colorectal and orthopedic surgeryRegional anesthesia often included1Kehlet H BJA 1997; 78: 606-17

Enhanced Recovery after SurgeryLess use of ERAS pathways outside colorectal and orthopedic surgeryBarriers to implementation in many centresRegional anesthesia use often limitedSpecific focus on evidence-base for regional within ERAS not available

1Kehlet H BJA 1997; 78: 606-17

Concepts within ERASStandardization of careEvidence-based careMultimodal care pathways based on best evidenceMultidisciplinary (focus on the team)

Many reviews of efficacy of enhanced recovery protocolsLittle written about specific place of RA with ERAS protocolsScoping review to examine area

Dan McIsaac MD MPH, Evan Cole MD and Colin McCartney MB PhD BJA: in press

Scoping review: a rapid gathering of evidence in a given clinical area with an aim to accumulate as much evidence as possible and map the resultsFocus on triple aim outcomes

Dan McIsaac MD MPH, Evan Cole MD and Colin McCartney MB PhD BJA: in press

Institute for Healthcare Improvement Triple Aim in Healthcare

Searched for all articles that examined regional anesthesia within an enhanced recovery pathway (ERP)EMBASE, MEDLINE, CENTRAL, CDSR, PROSPERO and the NHS Evaluation DatabaseInception to May 2015

Dan McIsaac MD MPH, Evan Cole MD and Colin McCartney MB PhD BJA 2015

695 unique citations; 446 excluded after title review, 249 full text review with 191 excluded58 unique studies for data extraction67% RCTs and one non-randomized trial14 controlled before-and-after studies, 5 retrospective cohort studies and one prospective cohort

Dan McIsaac MD MPH, Evan Cole MD and Colin McCartney MB PhD BJA: in press

>50% of studies examined colorectal surgeryOrthopedic (21%) and other types of non-colorectal general surgery (29%)Regional techniques: Epidural, SAB, TAP block and lower limb PNB techniques

Dan McIsaac MD MPH, Evan Cole MD and Colin McCartney MB PhD BJA: in press

Dan McIsaac MD MPH, Evan Cole MD and Colin McCartney MB PhD BJA: in press

Good news! Strong evidence that RA provides:Improved pain controlImproved organ function and mobilityReduced PONV, length of stay and adverse eventsBad news: little focus on triple aim outcomes

Dan McIsaac MD MPH, Evan Cole MD and Colin McCartney MB PhD BJA: in press

Elective colon resection64 patients randomized to epidural or PCAPrimary outcome: 6 MWTSecondary outcome: HRQoL: SF-36

Both groups had decrease in 6MWT and SF-36 3 and 6 weeks following surgerySignificantly greater decrease in the PCA group (p