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