Regional Anaesthesia Regional Anaesthesia Techniques for Day-Techniques for Day-SurgerySurgeryCSM 2011CSM 2011

Dr Michael BarringtonDr Michael Barrington

Department of AnaesthesiaDepartment of Anaesthesia

St Vincent’s Hospital, MelbourneSt Vincent’s Hospital, Melbourne

Attributes of the ideal Attributes of the ideal anaesthetic for day-anaesthetic for day-surgery surgery

High quality analgesiaHigh quality analgesia

low pain scorelow pain score

low incidence of side-effectslow incidence of side-effects

long durationlong duration

EfficientEfficient

Patient acceptancePatient acceptance

Range of techniques Range of techniques availableavailable

Central neural blockade (CNB)Central neural blockade (CNB)

Peripheral nerve blockade (PNB)Peripheral nerve blockade (PNB)

Local infiltration analgesia (LIA)Local infiltration analgesia (LIA)

CNB and PNB result in:CNB and PNB result in:

decreased pain scores in PACU decreased pain scores in PACU

decreased requirement for PACU analgesiadecreased requirement for PACU analgesia

CNB was not associated CNB was not associated

with decreased PACU time with decreased PACU time

with reduced nausea with reduced nausea

Ambulatory Surgical Unit (ASU) discharge Ambulatory Surgical Unit (ASU) discharge was increased by 35 minswas increased by 35 mins

Peripheral Nerve Blockade Peripheral Nerve Blockade

increased ability to bypass PACU (OR14)increased ability to bypass PACU (OR14)

decreased PACU time (24 mins)decreased PACU time (24 mins)

decreased risk of nausea (OR 0.17)decreased risk of nausea (OR 0.17)

increased patient satisfactionincreased patient satisfaction

not associated with decreased discharge not associated with decreased discharge ASUASU

Entire diamond lies to the right of line, RR = 1, indicating Entire diamond lies to the right of line, RR = 1, indicating that ultrasound guided blocks are more likely to be that ultrasound guided blocks are more likely to be successfulsuccessful

Shoulder surgeryShoulder surgery

Ambulatory shoulder surgeryAmbulatory shoulder surgeryUltrasound-guided techniques:Ultrasound-guided techniques: interscalene (n = 515)interscalene (n = 515) supraclavicular (n = 654) blockssupraclavicular (n = 654) blocks

Pain score (VAS) in PACU 0/10Pain score (VAS) in PACU 0/10Need for IV analgesia in PACU 0.6%Need for IV analgesia in PACU 0.6%Time in PACU 168 minsTime in PACU 168 mins

Body mass index 22 kg/m2Body mass index 22 kg/m2Volume of local anaesthetic 50 mlsVolume of local anaesthetic 50 mlsHospital for Special SurgeryHospital for Special Surgery

Side-effects/complicationsSide-effects/complicationsHoarseness 26%Hoarseness 26%Dyspnoea 8%Dyspnoea 8%Pneumothorax 0%Pneumothorax 0%LA toxicity 0%LA toxicity 0%

The role of UltrasoundThe role of Ultrasound

Low dose efficacy studies (both single shot and Low dose efficacy studies (both single shot and continuous infusions)continuous infusions)

Dose reductionDose reduction

Severe hypotension following Severe hypotension following interscalene blockinterscalene blockBilateral upper limb block in PACUBilateral upper limb block in PACUDifferential diagnosis:Differential diagnosis:Bezold-Jarisch reflexBezold-Jarisch reflexAnaphylaxisAnaphylaxisIntrathecal spreadIntrathecal spreadEpidural spreadEpidural spread

Hand surgeryHand surgery

Infraclavicular block (ICB), chloroprocaine Infraclavicular block (ICB), chloroprocaine compared with GA (LMA, desflurane) and compared with GA (LMA, desflurane) and wound infiltration in RCTwound infiltration in RCT

PACU nurses “blinded” to technique PACU nurses “blinded” to technique scored patients for readyness for PACU scored patients for readyness for PACU dischargedischarge

76% of patients who received ICB met 76% of patients who received ICB met criteria for PACU bypass compared to 25% criteria for PACU bypass compared to 25% in the GA groupin the GA group

None of the patients in the ICB group None of the patients in the ICB group requested pain medication in hospital requested pain medication in hospital compared to 48% in the GA groupcompared to 48% in the GA group

Patients receiving ICB were able to Patients receiving ICB were able to ambulate earlier 82 min vs 145 min with GAambulate earlier 82 min vs 145 min with GA

Results from St Vincent’s Results from St Vincent’s Hospital, MelbourneHospital, Melbourne

Data obtained from 933 patients (received 1216 Data obtained from 933 patients (received 1216 PNBs)PNBs)

Median (worst) pain score 1.1Median (worst) pain score 1.1

Most common pain score 0Most common pain score 0

757 (81%) required no analgesia in PACU757 (81%) required no analgesia in PACU

Average time to readiness for discharge 25 Average time to readiness for discharge 25 minsmins

464 (50%) achieved discharge criteria on PACU 464 (50%) achieved discharge criteria on PACU arrivalarrival

Breast surgeryBreast surgery

Unilateral breast surgery without Unilateral breast surgery without reconstructionreconstruction

Randomised to single-shot paravertebral block Randomised to single-shot paravertebral block (PVB) or continuous (PVB)(PVB) or continuous (PVB)

0.1 %, 0.2% or saline infusion for 48 hrs0.1 %, 0.2% or saline infusion for 48 hrs

Validated pain assessment instruments Validated pain assessment instruments includingincluding

McGill Pain QuestionnaireMcGill Pain Questionnaire

No clinically significant difference in:No clinically significant difference in:degree of postoperative paindegree of postoperative pain

NauseaNauseaMood stateMood state

Level of symptom distressLevel of symptom distressReturn to normal activityReturn to normal activity

Patients having unilateral breast surgery Patients having unilateral breast surgery without reconstruction were randomised to without reconstruction were randomised to receive either GA alone or combined GA receive either GA alone or combined GA and PVBand PVB

Multilevel blocks T1 - T6 PVBMultilevel blocks T1 - T6 PVB

Ropivacaine 5mg/kg + Adrenaline (350mg Ropivacaine 5mg/kg + Adrenaline (350mg maximum) was usedmaximum) was used

Pain was study endpointPain was study endpoint

Pain scores were lower following PVB at Pain scores were lower following PVB at one hour and at three hours, but not at one hour and at three hours, but not at later time pointslater time points

Pain scores were higher in PVB at 24 hrs Pain scores were higher in PVB at 24 hrs compared to GA alonecompared to GA alone

Hernea surgeryHernea surgery

Inguinal hernea repairInguinal hernea repairRandomised to GA or paravertebral blockadeRandomised to GA or paravertebral blockade

Patients randomised to paravertebral blockade Patients randomised to paravertebral blockade had improved outcomes including analgesia had improved outcomes including analgesia

and recoveryand recovery

Inguinal hernea repairInguinal hernea repairRandomised to transversus abdominis plane Randomised to transversus abdominis plane

block or conventional block or conventional ilioinguinal/ileohypogastric nerve blocks (n= ilioinguinal/ileohypogastric nerve blocks (n=

273)273)

Ultrasound techniques:Ultrasound techniques:Reduced pain scores at 4, 12 and 24 hoursReduced pain scores at 4, 12 and 24 hours

No difference in PACU, Postoperative day 1 or No difference in PACU, Postoperative day 1 or thereafterthereafter

Wound infiltrationWound infiltration

1. Single injection wound 1. Single injection wound

2. Continuous local anaesthetic wound infusions2. Continuous local anaesthetic wound infusions

3. High volume local anaesthetic wound infiltration3. High volume local anaesthetic wound infiltration

Need for procedure specific randomised controlled trialsNeed for procedure specific randomised controlled trials

1. Single injection wound 1. Single injection wound

2. Continuous local anaesthetic wound infusions2. Continuous local anaesthetic wound infusions

3. High volume local anaesthetic wound 3. High volume local anaesthetic wound infiltrationinfiltration

Need for procedure specific randomised Need for procedure specific randomised controlled trialscontrolled trials

Wound infiltrationWound infiltration

Efficacy should be procedure specificEfficacy should be procedure specific

Single injection of local anaesthetic at Single injection of local anaesthetic at completion of surgery reduce analgesia - completion of surgery reduce analgesia - short duration onlyshort duration only

Choice of local anaesthetic importantChoice of local anaesthetic important

Catheter typeCatheter type

AdjuvantsAdjuvants

Note anatomical location of infiltrationNote anatomical location of infiltration

Sites of wound catheter Sites of wound catheter placementplacement

IntraperitonealIntraperitoneal

IntraarticularIntraarticular

SubfascialSubfascial

SubcutaneousSubcutaneous

IntrapleuralIntrapleural

SubsternalSubsternal

Knee ArthroscopyKnee Arthroscopy

One of the most common lower limb One of the most common lower limb ambulatory surgical proceduresambulatory surgical procedures

Multitude of intraarticular agents used for Multitude of intraarticular agents used for postoperative analgesia (opiates, NSAID, postoperative analgesia (opiates, NSAID, local anaesthetics)local anaesthetics)

Peripheral blocksPeripheral blocks

Four groups: 0.9 % saline, bupivacaine 0.25%, Four groups: 0.9 % saline, bupivacaine 0.25%, ropivacaine 0.2%, ropivacaine 0.75%ropivacaine 0.2%, ropivacaine 0.75%

No difference within LA groupsNo difference within LA groups40% of patients receiving placebo had motor block40% of patients receiving placebo had motor block

Low dose (4 - 5 mg) compared with Low dose (4 - 5 mg) compared with intermediate dose and high dose (10 - intermediate dose and high dose (10 - 15mg)15mg)

Low dose requires unilateral positioning of Low dose requires unilateral positioning of patientpatient

Associated with reduced discharge timesAssociated with reduced discharge times

Ambulatory arthroscopic surgery of the kneeAmbulatory arthroscopic surgery of the kneeSpinal anaesthesiaSpinal anaesthesiaRandomised to prilocaine 20 mg or Randomised to prilocaine 20 mg or plain bupivacaine 7.5 mg plain bupivacaine 7.5 mg

In summaryIn summary

Wide range of regional techniques Wide range of regional techniques available for ambulatory techniquesavailable for ambulatory techniques

Large number of studies supporting these Large number of studies supporting these techniques for various surgical procedurestechniques for various surgical procedures

EfficacyEfficacy vs vs effectivenesseffectiveness vs vs cost-cost-effectivenesseffectiveness in our own practice is in our own practice is importantimportant

In summaryIn summary

Evidence supports PNB upper limb Evidence supports PNB upper limb surgery surgery

Choice of ideal regional anaesthesia Choice of ideal regional anaesthesia technique for ambulatory trunk surgery technique for ambulatory trunk surgery unclearunclear

RA for ambulatory lower limb surgery is a RA for ambulatory lower limb surgery is a challenge - motor blockchallenge - motor block

Thank you for your Thank you for your attentionattention