Considerations for Regional Anesthesia in the Trauma
PatientEdward R. Mariano, M.D., M.A.S.
Professor of Anesthesiology, Perioperative & Pain Medicine
Stanford University School of MedicineChief, Anesthesiology and Perioperative CareVeterans Affairs Palo Alto Health Care System
@EMARIANOMD
Regional Anesthesia in Trauma
Financial Disclosures Halyard, B Braun – Unrestricted
educational program funding paid to my institution
The contents of the following presentation are solely the responsibility of the speaker without input from any of the above companies.
Regional Anesthesia in Trauma
Overview Benefits of regional anesthesia Risks of regional anesthesia Review of the evidence Training in regional anesthesia The bottom line—yes or no
Regional Anesthesia in Trauma
Overview Benefits of regional anesthesia Risks of regional anesthesia Review of the evidence Training in regional anesthesia The bottom line—yes or no
Regional Anesthesia in Trauma
What is Regional Anesthesia?
Regional anesthesia generally involves the introduction of local anesthetic medications to temporarily interrupt sensation to a specific part of the body
Regional Anesthesia in Trauma
Why Do Regional Anesthesia?
Regional Anesthesia in Trauma
Gadsden & Warlick. Loc Reg Anes 2015;8:45
Regional Anesthesia in Trauma
Overview Benefits of regional anesthesia Risks of regional anesthesia Review of the evidence Training in regional anesthesia The bottom line—yes or no
Regional Anesthesia in Trauma
What Are the Risks? Local anesthetic toxicity Other risks
– Bleeding– Infection– Nerve injury
Incidence of nerve injury not clear: 1/41851 – 3/1002
1. Auroy Y, et al. Anesth 2002;97:1274
2. Brull R, et al. A&A 2007;104:965
Regional Anesthesia in Trauma
Meta-Analysis of Nerve Injury
Data from 32 studies (1/1/95 - 12/31/05) in adult patients
Rates of occurrence (any neurologic symptoms):– CNB = <4:10,000 or 0.04% – PNB = <3:100 or 3% (site-dependent)
Permanent neurological injury– CNB = 0-7.6:10,000– PNB = insufficient data (1 case)
Brull R, et al. A&A 2007;104:965
Regional Anesthesia in Trauma
Acute Compartment Syndrome
Many factors 6 classic
signs/symptoms:– Pain– Pressure– Pulselessness– Paralysis– Paresthesia – Pallor
Concern over analgesia delaying diagnosis
Olson SA, et al. J Am Acad Ortho 2005;13:436
Regional Anesthesia in Trauma
Acute Compartment Syndrome
Gadsden & Warlick. Loc Reg Anes 2015;8:45
Regional Anesthesia in Trauma
Acute Compartment Syndrome
Systematic review to evaluate effect of pain management on diagnosis
All case reports and series (Level 3 evidence; 28 reports)
No randomized clinical trials to date
Mar JG, et al. BJA 2009;102:3
Regional Anesthesia in Trauma
Beware of Falls!
Regional Anesthesia in Trauma
Overview Benefits of regional anesthesia Risks of regional anesthesia Review of the evidence Training in regional anesthesia The bottom line—yes or no
Regional Anesthesia in Trauma
Pre-Hospital Fascia Iliaca Blocks
Case series: 27 patients with presumed femur fx
Patients approached at scene of accident
Fascia iliaca blocks performed blindly with 20 ml 1.5% lido with epi 5 mcg/ml
1 block failure
“…performed by senior anesthesiologists trained in emergency medicine and regional techniques.”
Lopez S, et al. RAPM 2010;28:203
Regional Anesthesia in Trauma
Blocks in the Emergency Dept
Double-masked RCT of fascia iliaca blocks in 48 subjects with femur fx1
– 67% success rate
– Lower pain scores and morphine consumed in fascia iliaca group
Case series from ED2,3
1. Foss NB, et al. Anesth 2007;106:7732. Beaudoin FL, et al. Am J Emerg Med
2010;28:763. Stewart B, et al. Emerg Med J 2007;24:113
“All investigators were junior anesthesiologists...”
Regional Anesthesia in Trauma
Pediatric ED Experience Fascia iliaca blocks vs. IV
morphine (n=55) for femur fx1
– Lower pain scores – Less supplemental
analgesics in block group
Axillary blocks vs. sedation (n=43) for fx manipulation2
– No difference in pain scores– 2/20 failed blocks– 11/20 incomplete blocks
1. Wathen JE, et al. Ann Emerg 2007;50:162
2. Kriwanek KL, et al. J Ped Ortho 2006;26:737
Regional Anesthesia in Trauma
Overview Benefits of regional anesthesia Risks of regional anesthesia Review of the evidence Training in regional anesthesia The bottom line—yes or no
Regional Anesthesia in Trauma
How Hard Can It Be?
NYSORA.COM -
Regional Anesthesia in Trauma
The Newest Subspecialty
Regional Anesthesia in Trauma
The Newest Subspecialty
DON’T BE A
Acute Pain Medicine = not just blocks
Regional Anesthesia in Trauma
Overview Benefits of regional anesthesia Risks of regional anesthesia Review of the evidence Training in regional anesthesia The bottom line—yes (with caveats)
Regional Anesthesia in Trauma
Develop a System Discuss with trauma surgeons in
advance regarding appropriate patients and types of blocks
Who will be performing blocks?– Dedicated regional anesthesia providers
vs.– All practitioners equally trained
Use consistent practices and equipment
Communication is key!
Regional Anesthesia in Trauma
Perform Blocks in a Safe Place
Standard ASA monitors available
Oxygen source Resuscitation
equipment available
Skilled assistants nearby
Mariano ER. Anesth Clin 2008;28:681
Regional Anesthesia in Trauma
Education and Follow-Up Coordinate postop care with primary
team Careful neurovascular assessment
(be on the look-out for compartment syndrome)
Provide contact info for regional anesthesia service available 24/7
Clear instructions for infusion device Routine daily follow-up (esp if
catheter)–Caretaker for first 24 hours if
discharged
Ilfeld BM, et al. RAPM 2003;28:418
Regional Anesthesia in Trauma
Take Home Message
Gadsden & Warlick. Loc Reg Anes 2015;8:45
Regional Anesthesia in Trauma
Summary We discussed:
– Benefits of regional anesthesia– Risks of regional anesthesia– Review of the evidence– Training in regional anesthesia– The bottom line—yes (with caveats)