Locoreginal anesthetic

techniqueMarkus Stevens | 18-01-2020

Conflict of interest:

• No financial conflict of interest

• Teacher for UGRA since 2004

• Council member ESRA, DARA treasurer, SKA chair

Structure• What‘s new?

– APRICOT and PRAN

– Guidelines ESRA/ASRA

– Complications

• How do you do it?• Inguinal hernia

• Forearm fracture

• Palatoschisis

• Nuss bar

• …

Dadure C Ped Anesth 2019BJ Walker Anesthesiology 2018

APRICOT and PRAN

Walker BJ Anesthesiology 2018

APRICOT and PRAN

APRICOT and PRAN

Dadure C Ped Anesth 2019

Walker BJ Anesthesiology 2018

33%

6% 6%

54%UltrasoundNerve stimulatorUltrasound + nerve stimulatorLandmark

APRICOT

Dadure C Ped Anesth 2019

Are we really that behind?

APRICOT

Dadure C Ped Anesth 2019

Are we really that behind?

APRICOT

Dadure C Ped Anesth 2019

APRICOT

Dadure C Ped Anesth 2019

APRICOT

Dadure C Ped Anesth 2019

Percentage ultrasound use per country

[all RA]

Dadure C Ped Anesth 2019Walker BJ Anesthesiology 2018

APRICOT and PRAN

CONCLUSIONS?

o Limited

o Growth opportunities

o Percentage RA

o Percentage UGRA

Ivani G RAPM 2015

ESRA/ASRA guidelines dosage

Ivani G RAPM 2015

ESRA/ASRA guidelines

Performance of RA in kids:• PRA can be savely performed under GA/DS

• Overall complication rate 0.66% (CI 0.6-0.7%)

• Risk of permanent damage 0 (CI 0-0.004%)

• Despite safety – execute maximal vigilance

• “Use of a test dose should remain discretionary”

• LOR air or fluid? Air and fluid (expert opinion)

• No evidence that RA delays diagnosis of compartment

syndrome

Suresh S RAPM 2018

ESRA/ASRA guidelines dosage

Tetracaine

(5% in 5% dext)

Bupivacaine

(iso- or hyperbaric)

Ropivacaine

< 4 kg

1 mg/kg

< 5 kg

1 mg/kg

0.5 mg/kg

> 4 kg

0.5 mg/kg

5-15 kg

0.4 mg/kg

> 15 kg

0.3 mg/kg

Spinal anesthesia:

Suresh S RAPM 2018

ESRA/ASRA guidelines dosage

Caudal:

Suresh S RAPM 2018

ESRA/ASRA guidelines dosage

Epidural:

• Loading dose ≤ 1.7 mg ropi / bupi / levobupi

• Continuous infusion

– Bupi / levobupi / ropi 0.2 mg/kg/h < 3 months

0.3 mg/kg/h 3 months – 1 yr

0.4 mg/kg/h > 1 yr

– Chloroprocaine 0.2 mg/kg/h < 3 months

0.3 mg/kg/h 3 months – 1 yr

0.5 mg/kg/h > 1 yr

Suresh S RAPM 2018

ESRA/ASRA guidelines dosage

Nerve block and fascial block:

• Nerve block upper and lower extremity

– Bupi / levobupi / ropi 0.5 – 1.5 mg/kg

• Fascial plane block

– Bupi / levobupi / ropi 0.25 – 0.75 mg/kg

• Continuous infusion

– Bupi / ropi 0.1 – 0.3 mg/kg/h

Suresh S RAPM 2018

ESRA/ASRA guidelines dosage

Adjuvants neuraxial:

• Clonidine: 1-2 μg/kg i.t. or morphine: 10-30 μg/kg i.t.

• (S-)ketamine not advised (neurotoxicity)

• Dexamedetomidine – to little data

• Synthetic opioids – no evidence of caudal advantage

• Corticosteroids – not advised (neurotoxicity)

Suresh S RAPM 2018

ESRA/ASRA guidelines dosage

Adjuvants nerve block:

• Alpha-2 adrenoceptor agonists prolong duration

– Toxicity data is limited => restrict dose

Complications

Complications

BJ Walker Anesthesiology 2018

• No permanent neurologic deficit (CI 0-0.004%)

• Transient neurologic deficit 0.024% (CI 0.016-0.036%)

• Cutaneous infections 0.5% (CI 0.43-0.64%)

• One epidural abscess 0.0076% (CI 0-0.048%)

• No epidural hematoma with epidural (CI 0-0.03%)

• One epidural hematoma with paravertebral

• AE: catheter failures 4%; Respiratory distress 0.14%

• LAST 0.0076% (CI 0-0.048%)

Complications

BJ Walker Anesthesiology 2018

Complications: NCA

Wallia H J Pain Res 2016Howard RF Ped Anesth 2010Morton NS Ped Anesth 2010

• 779 pat < 1 yr with NCA => 39 RRT or code blue (5%)

• 10,079 postop pat < 20 yrs in GOSH

– PONV 7%, itching 9.4%; sedation 4,5%

– SAE: 0.4% (resuscitation & naloxon)

• < 1 m: 2.5%

• > 1 m: 0.27%

• 10,726 pat < 18 yrs in GB (18 centres; audit)

– 1 cardiac arrest with permanent neurological damage

– 14 SAE (0.13%, resuscitation & naloxon)

HOW I DO IT:That’s what i call

“LOSS OF RESISTANCE”

Inguinal hernia

• Regional?

– Caudal

– Ilioinguinal/iliohypogastric

– TAP

• NSAIDs

– PCM 60-90 mg/d

– Ibuprofen

– Diclofenac

– Metamizol

Forearm fracture

• To block or not to block?

– Preoperative pain?

– Analgetic use?

– Kind of operation

– Surgeon

• Which block?

– Axillary

– Supraclavicular

– Infraclavicular

Palatoschisis

• Nerve block or infiltration?

– Both

• Which block?

– Infraorbitalis nerve block

– Suprazygomatic maxillary

nerve block

– Palatine and nasopalatine

nerve block

Palatoschisis

Suprazygomatic nerve block

Echaniz G EJA 2019

Chiono J Anesthesiology 2014

Palatoschisis

Palatine and nasopalatine nerve block

Echaniz G EJA 2019

Sola C Ped Anesth 2012

Nuss bar

• Which block?

– Epidural

– PCA

– Bilateral paravertebral

– Intercostal tunneled

– Bilateral ESP

• Which adjuvants?

Nuss bar

• Preoperative

– Start gabapentine 200 mg 2dd for 5d

– Premedication 150 microgr

• Intraoperative

– Epidural bupivacaine 0.25% 10-20 ml optoppen & sufenta

– Evt. Esketamine 0.25 mg/kg

– PCM 2 g & Metamizol 2 g

Nuss bar

• Postoperative

– Epidural bupivacaine 0.125% & 1 microgr/ml clonidine 4d

– PCA morphine => oxydodon scheme

– Metamizol 1g 4dd; PCM 1 g 4dd

– Gabapentine 200 mg 2dd

Pyloromyotomy

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2nd European Day of Regional Anaesthesia 26-1-2018

AMC, Vermeulen-Crunch-lecture theatre, H1-156

08:30 – 12:30

LECTURE (30 min.): Obstetric Anaesthesia: What’s New? A. Schyns-van de Berg

PODCAST (10 min.): Green (White) anaesthesia: RA an option? P. Albaladejo

LECTURE (30 min.): The real value of adjuvants for regional anaesthesia M. Stevens

PODCAST (10 min.): Fast Track surgery for arthroplasty H. Kehlet

BREAK

LECTURE (30 min.): The role of RA in Colorectal Surgery ERAS Programs A. Schyns-van de Berg /

G. van Samkar

PODCAST (10 min.): The concept of plane blocks and Live demo on plane blocks R. Blanco

LECTURE (30 min.): Live demo: Lumbar plexus J. Wegener

LUNCH

14:00 – 17:00

WORKSHOPS

PNB Upper Limb (3×15 min. rotations) Wegener / Samkar / Stevens

14:45 (CET Paris, Vienna) ROUND TABLE European Survey (25 min. online live quiz + 20 min. discussion)

PNB Lower Limb (3×15 min. rotations) Wegener / Samkar / Stevens

Central Neuraxial and Trunk Blocks (3×15 min. rotations) Wegener / Samkar / Stevens

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DARA-ESRA Symposium 2020

Friday 31st of January & Saturday 1st of February

New Perspective on Regional Anesthesia Prof. Dr. Ed Mariano / Prof. Dr. Jens Børglum / Dr. Pedro Girão

Dr. Geert-Jan van Geffen / Prof. Dr. Gerbrand Groen

Friday

12.30-13.15 -Registration - Lunch - Exhibition-

13.15-13.30 WELCOME Drs. Luc Tielens

13.30-14.15 1. From TAP to Tequila Block Prof. Dr. Jens Børglum

14.15-15.00 2. ICAROS anesthetic care recommendations for hip and knee arthroplasty Prof. Dr. Ed Mariano

15.00-15.15 -Coffee - Exhibition-

15.15-16.00 3. Comfort Talk in regional Anesthesia Dr. Geert-Jan van Geffen

16.00-17.00 WORKSHOPS (1st session)

17.00-17.15 -The - Exhibition-

17.15-18.00 WORKSHOPS (2nd session)

18.00-19.00 4. Art & Science in Anesthesia Prof. Dr. Pedro Girão

19.00-20.00 -Autumn drinks -........by the fire!!

20.00-21.30 -Walking Dinner -......with Live Band!!

21.30- ........ -After Party -….........with Disco!!

Saturday

08.30- 09.30 DARA general meeting of members Drs. Luc Tielens

09.30-10.20 WORKSHOPS (3th session)

10.20-11.10 WORKSHOPS (4th session)

WS 1 Tequila Block Prof. Dr. Jens Børglum

WS 2 IPACK block Prof. Dr. Ed Mariano

WS 3 Comfort Talk Dr. Geert-Jan van Geffen

WS 4 Anatomie, hoe en wat is nieuw Prof. Dr. Gerbrand Groen

WS 5 All you want to know but forgot to ask before Dr. Markus Stevens / Dr. Arjan Konijn / Dr. Werner ten Hoope

WS 6 AIOS session Drs. Jorrit van Wees / Dr. Karin Schoenmaker / Drs. Luc Tielens

11.10-11.30 -Coffee - Exhibition-

11.30-12.15 5. Regional Anesthesia education and social media Prof. Dr. Ed Mariano

12.15- 13.15 6. Mathieu Gielen Prize Awards Dr. Markus Stevens

13.15-13.30 Closing DARA-ESRA Symposium 2020 Drs. Luc Tielens

13.30 -Lunch & Farewell-

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