Category Archives: Regional Anesthesiology

Extending Nerve Block Pain Relief after Surgery: Review of the Evidence

nerve firingNerve blocks (also referred to as “regional anesthesia”) offer patients many potential advantages in the immediate postoperative period such as decreased pain, nausea and vomiting, and time spent in the recovery room (1,2). However, these beneficial effects are time-limited and do not last beyond the duration of the block (2). While the clinical effects of nerve blocks typically last long enough for patients to meet discharge eligibility from recovery and avoid hospitalization for pain control (3), these results can be easily negated if patients’ pain or opioid-related side effects warrant a return trip to the hospital and readmission following block resolution (4). Thus, extending block duration to provide longer-term, site-specific analgesia for patients on an ambulatory basis has been a high research priority. What options are currently available?

Continuous Peripheral Nerve Blocks

Continuous peripheral nerve block (CPNB) techniques (also known as perineural catheters) permit delivery of local anesthetic solutions to the site of a peripheral nerve on an ongoing basis (5). Portable infusion devices can deliver a solution of plain local anesthetic for days after surgery, often with the ability to titrate the dose up and down or even stop the infusion temporarily when patients feel too numb (6,7). In a meta-analysis comparing CPNB to single-injection peripheral nerve blocks, CPNB results in lower patient-reported worst pain scores and pain scores at rest on postoperative day (POD) 0, 1, and 2 (8). Patients who receive CPNB also experience less nausea, consume less opioids, sleep better, and are more satisfied with pain management (8). We also know how CPNB works: local anesthetic medication interrupts nerve transmission, so patients experience decreased sensation.

Managing CPNB patients (especially at home) can sometimes be challenging, and not all patients are good candidates for outpatient perineural infusion (7). Patients must have a reliable means of follow-up and should have a caretaker at home for at least the first night after surgery (7). A health care provider must be available at all times to manage common issues associated with CPNB and call patients once daily to assess for analgesic efficacy and side effects (9). Patients, especially those undergoing lower extremity surgery, and their caretakers should receive clear instructions regarding the care of their infusion device and catheter as well as their anesthetized extremities (10,11) including fall precautions (12,13).

Although the optimal duration for CPNB is unknown, 2 to 7 days has been reported for orthopedic inpatients (14) with durations as long as 34 days under special circumstances (15). At the completion of the local anesthetic infusion, perineural catheters must be removed. To date, CPNB is the only technique that offers patients the longest potential duration of block paired with the ability to titrate to the desired level of block.

Despite more than a decade of published data supporting CPNB for extending the duration of postoperative pain control, adoption of these techniques is not universal. Many of the issues are arguably system-based, and the lack of a “block” room (16) or time pressure (17) may be responsible. However, lack of training in these techniques may also be a factor (18) or negative experiences with failed placement attempts using traditional techniques (19).

Adjuvants to Local Anesthetic Solutions for Single-Injection Peripheral Nerve Blocks

For nerve blocks intended to last 1-2 days, there are a few options.  Long-acting local anesthetics (e.g., bupivacaine, levobupivacaine, and ropivacaine) generally provide analgesia of similar duration for 24 hours or less (20-23). Several different drugs have been investigated for their potential to extend single-injection peripheral nerve block duration when added to local anesthetic solutions. Epinephrine when added to local anesthetic solutions provides vasoconstriction to decrease uptake but has little or no clinical effect on the duration of longer-acting local anesthetics (24). Opioids in general do not provide additional benefits in terms of duration (25) except for buprenorphine (26) although how it works is unclear. To date, there are insufficient data to support the addition of tramadol or neostigmine to local anesthetic solutions (25). Of the available adjuvants, clonidine has been demonstrated in clinical studies and systematic reviews to extend the duration of analgesia for intermediate-acting local anesthetics (e.g., mepivacaine) with few side effects in doses up to 150 mcg but probably do not extend long-acting local anesthetics (25,27). There has been increasing interest in dexamethasone as an adjuvant to local anesthetic solutions based on clinical reports of extended duration when added to intermediate-acting local anesthetics (28,29). The mechanism is not well understood and may be less pronounced with long-acting local anesthetics; one study reported block durations of only 22 hours with dexamethasone added to either ropivacaine or bupivacaine (30). Giving dexamethasone intravenously may actually produce the same effect (31). Caution is warranted when experimenting with adjuvant mixtures that have not been specifically approved for nerve blocks (i.e., “off-label” use) as many of the usual FDA safeguards have not been performed, and these drugs may contribute to neurotoxicity or other side effects not yet known.

Novel Extended-Duration Local Anesthetics

There has been interest in liposomal formulations of extended-release bupivacaine for regional anesthesia for over two decades (32,33). A recent formulation consisting of bupivacaine encapsulated in multivesicular liposomes to produce slow release is FDA-approved for local infiltration (34) but not yet for nerve blocks although this is expected soon. A nerve block with liposomal bupivacaine can be expected to last 1-3 days. Initial nerve block studies in animals suggest a lower maximum serum concentration with the liposomal formulation compared to plain bupivacaine (35)–unless co-administered with lidocaine which facilitates release of liposomal bupivacaine (36)–and epidural administration in human volunteers more than doubles duration of sensory block (37). Once it receives FDA approval, I expect many comparative studies versus CPNB for postoperative analgesia. There are still concerns regarding local anesthetic systemic toxicity with liposomal bupivacaine as well as prolonged motor block and unpleasant numbness given the drug’s long-lasting effects. In addition, there is no option for “giving more” to augment a block in the event of inadequate pain relief.

In summary, there are currently few options to extend the duration of regional analgesia at home beyond the one day expected from most single-injection nerve blocks. CPNB with plain local anesthetic perineural infusion is the most established way to provide days of postoperative pain control and allows titration, but training in insertion techniques and a system to manage ambulatory CPNB patients are necessary. Adjuvants or liposomal formulations of local anesthetics may offer potential options for limited extension of block duration, but further studies regarding efficacy and safety for regional anesthesia as well as comparative-effectiveness versus CPNB are necessary. For major surgery like total knee replacement, block duration of several days may be optimal (38).

References

  1. Liu SS, Strodtbeck WM, Richman JM, Wu CL: A comparison of regional versus general anesthesia for ambulatory anesthesia: a meta-analysis of randomized controlled trials. Anesth Analg 2005; 101: 1634-42
  2. McCartney CJ, Brull R, Chan VW, Katz J, Abbas S, Graham B, Nova H, Rawson R, Anastakis DJ, von Schroeder H: Early but no long-term benefit of regional compared with general anesthesia for ambulatory hand surgery. Anesthesiology 2004; 101: 461-7
  3. Williams BA, Kentor ML, Vogt MT, Williams JP, Chelly JE, Valalik S, Harner CD, Fu FH: Femoral-sciatic nerve blocks for complex outpatient knee surgery are associated with less postoperative pain before same-day discharge: a review of 1,200 consecutive cases from the period 1996-1999. Anesthesiology 2003; 98: 1206-13
  4. Williams BA, Kentor ML, Vogt MT, Vogt WB, Coley KC, Williams JP, Roberts MS, Chelly JE, Harner CD, Fu FH: Economics of nerve block pain management after anterior cruciate ligament reconstruction: potential hospital cost savings via associated postanesthesia care unit bypass and same-day discharge. Anesthesiology 2004; 100: 697-706
  5. Ilfeld BM: Continuous peripheral nerve blocks: a review of the published evidence. Anesth Analg 2011; 113: 904-25
  6. Ilfeld BM: Continuous peripheral nerve blocks in the hospital and at home. Anesthesiol Clin 2011; 29: 193-211
  7. Ilfeld BM, Enneking FK: Continuous peripheral nerve blocks at home: a review. Anesth Analg 2005; 100: 1822-33
  8. Bingham AE, Fu R, Horn JL, Abrahams MS: Continuous peripheral nerve block compared with single-injection peripheral nerve block: a systematic review and meta-analysis of randomized controlled trials. Reg Anesth Pain Med 2012; 37: 583-94
  9. Ilfeld BM, Esener DE, Morey TE, Enneking FK: Ambulatory perineural infusion: the patients’ perspective. Reg Anesth Pain Med 2003; 28: 418-23
  10. Charous MT, Madison SJ, Suresh PJ, Sandhu NS, Loland VJ, Mariano ER, Donohue MC, Dutton PH, Ferguson EJ, Ilfeld BM: Continuous femoral nerve blocks: varying local anesthetic delivery method (bolus versus basal) to minimize quadriceps motor block while maintaining sensory block. Anesthesiology 2011; 115: 774-81
  11. Ilfeld BM, Moeller LK, Mariano ER, Loland VJ, Stevens-Lapsley JE, Fleisher AS, Girard PJ, Donohue MC, Ferguson EJ, Ball ST: Continuous peripheral nerve blocks: is local anesthetic dose the only factor, or do concentration and volume influence infusion effects as well? Anesthesiology 2010; 112: 347-54
  12. Feibel RJ, Dervin GF, Kim PR, Beaule PE: Major complications associated with femoral nerve catheters for knee arthroplasty: a word of caution. J Arthroplasty 2009; 24: 132-7
  13. Ilfeld BM, Duke KB, Donohue MC: The association between lower extremity continuous peripheral nerve blocks and patient falls after knee and hip arthroplasty. Anesth Analg 2010; 111: 1552-4
  14. Capdevila X, Pirat P, Bringuier S, Gaertner E, Singelyn F, Bernard N, Choquet O, Bouaziz H, Bonnet F: Continuous peripheral nerve blocks in hospital wards after orthopedic surgery: a multicenter prospective analysis of the quality of postoperative analgesia and complications in 1,416 patients. Anesthesiology 2005; 103: 1035-45
  15. Stojadinovic A, Auton A, Peoples GE, McKnight GM, Shields C, Croll SM, Bleckner LL, Winkley J, Maniscalco-Theberge ME, Buckenmaier CC, 3rd: Responding to challenges in modern combat casualty care: innovative use of advanced regional anesthesia. Pain Med 2006; 7: 330-8
  16. Mariano ER, Chu LF, Peinado CR, Mazzei WJ: Anesthesia-controlled time and turnover time for ambulatory upper extremity surgery performed with regional versus general anesthesia. J Clin Anesth 2009; 21: 253-7
  17. Oldman M, McCartney CJ, Leung A, Rawson R, Perlas A, Gadsden J, Chan VW: A survey of orthopedic surgeons’ attitudes and knowledge regarding regional anesthesia. Anesth Analg 2004; 98: 1486-90, table of contents
  18. Hadzic A, Vloka JD, Kuroda MM, Koorn R, Birnbach DJ: The practice of peripheral nerve blocks in the United States: a national survey [p2e comments]. Reg Anesth Pain Med 1998; 23: 241-6
  19. Salinas FV: Location, location, location: Continuous peripheral nerve blocks and stimulating catheters. Reg Anesth Pain Med 2003; 28: 79-82
  20. Casati A, Borghi B, Fanelli G, Cerchierini E, Santorsola R, Sassoli V, Grispigni C, Torri G: A double-blinded, randomized comparison of either 0.5% levobupivacaine or 0.5% ropivacaine for sciatic nerve block. Anesth Analg 2002; 94: 987-90
  21. Hickey R, Hoffman J, Ramamurthy S: A comparison of ropivacaine 0.5% and bupivacaine 0.5% for brachial plexus block. Anesthesiology 1991; 74: 639-42
  22. Klein SM, Greengrass RA, Steele SM, D’Ercole FJ, Speer KP, Gleason DH, DeLong ER, Warner DS: A comparison of 0.5% bupivacaine, 0.5% ropivacaine, and 0.75% ropivacaine for interscalene brachial plexus block. Anesth Analg 1998; 87: 1316-9
  23. Fanelli G, Casati A, Beccaria P, Aldegheri G, Berti M, Tarantino F, Torri G: A double-blind comparison of ropivacaine, bupivacaine, and mepivacaine during sciatic and femoral nerve blockade. Anesth Analg 1998; 87: 597-600
  24. Weber A, Fournier R, Van Gessel E, Riand N, Gamulin Z: Epinephrine does not prolong the analgesia of 20 mL ropivacaine 0.5% or 0.2% in a femoral three-in-one block. Anesth Analg 2001; 93: 1327-31
  25. Murphy DB, McCartney CJ, Chan VW: Novel analgesic adjuncts for brachial plexus block: a systematic review. Anesth Analg 2000; 90: 1122-8
  26. Candido KD, Franco CD, Khan MA, Winnie AP, Raja DS: Buprenorphine added to the local anesthetic for brachial plexus block to provide postoperative analgesia in outpatients. Reg Anesth Pain Med 2001; 26: 352-6
  27. McCartney CJ, Duggan E, Apatu E: Should we add clonidine to local anesthetic for peripheral nerve blockade? A qualitative systematic review of the literature. Reg Anesth Pain Med 2007; 32: 330-8
  28. Movafegh A, Razazian M, Hajimaohamadi F, Meysamie A: Dexamethasone added to lidocaine prolongs axillary brachial plexus blockade. Anesth Analg 2006; 102: 263-7
  29. Parrington SJ, O’Donnell D, Chan VW, Brown-Shreves D, Subramanyam R, Qu M, Brull R: Dexamethasone added to mepivacaine prolongs the duration of analgesia after supraclavicular brachial plexus blockade. Reg Anesth Pain Med 2010; 35: 422-6
  30. Cummings KC, 3rd, Napierkowski DE, Parra-Sanchez I, Kurz A, Dalton JE, Brems JJ, Sessler DI: Effect of dexamethasone on the duration of interscalene nerve blocks with ropivacaine or bupivacaine. Br J Anaesth 2011; 107: 446-53
  31. Desmet M, Braems H, Reynvoet M, et al: I.V. and perineural dexamethasone are equivalent in increasing the analgesic duration of a single-shot interscalene block with ropivacaine for shoulder surgery: a prospective, randomized, placebo-controlled study. Br J Anaesth 2013; 111: 445-52
  32. Boogaerts J, Lafont N, Donnay M, Luo H, Legros FJ: Motor blockade and absence of local nerve toxicity induced by liposomal bupivacaine injected into the brachial plexus of rabbits. Acta Anaesthesiol Belg 1995; 46: 19-24
  33. Boogaerts JG, Lafont ND, Declercq AG, Luo HC, Gravet ET, Bianchi JA, Legros FJ: Epidural administration of liposome-associated bupivacaine for the management of postsurgical pain: a first study. J Clin Anesth 1994; 6: 315-20
  34. Chahar P, Cummings KC, 3rd: Liposomal bupivacaine: a review of a new bupivacaine formulation. J Pain Res 2012; 5: 257-64
  35. Richard BM, Newton P, Ott LR, Haan D, Brubaker AN, Cole PI, Ross PE, Rebelatto MC, Nelson KG: The Safety of EXPAREL (R) (Bupivacaine Liposome Injectable Suspension) Administered by Peripheral Nerve Block in Rabbits and Dogs. J Drug Deliv 2012; 2012: 962101
  36. Richard BM, Rickert DE, Doolittle D, Mize A, Liu J, Lawson CF: Pharmacokinetic Compatibility Study of Lidocaine with EXPAREL in Yucatan Miniature Pigs. ISRN Pharm 2011; 2011: 582351
  37. Viscusi ER, Candiotti KA, Onel E, Morren M, Ludbrook GL: The pharmacokinetics and pharmacodynamics of liposome bupivacaine administered via a single epidural injection to healthy volunteers. Reg Anesth Pain Med 2012; 37: 616-22
  38. Lavand’homme PM, Grosu I, France MN, Thienpont E: Pain trajectories identify patients at risk of persistent pain after knee arthroplasty: an observational study. Clin Orthop Relat Res 2014; 472: 1409-15.

Related Posts:

Ultrasound in Regional Anesthesia: What is the Evidence?

Medical scannerThe use of ultrasound guidance in the practice of regional anesthesia arguably began in the late 1980s (1), although ultrasound Doppler technology was used to direct needle insertion for peripheral nerve blockade in the 1970s (2). This past decade has seen a rapid increase in practical applications and clinical research in the field of ultrasound-guided regional anesthesia (UGRA), and the American Society of Regional Anesthesia and Pain Medicine (ASRA) and European Society of Regional Anesthesia have even published joint committee guidelines for training in this discipline (3).

Given the rapid adoption of UGRA, evidence to support this practice was initially limited; however, many studies have emerged in an attempt to define the role of ultrasound. In 2010, ASRA published a series of important articles which distill the body of evidence related to UGRA up to that time point (4-13). Additional studies have been completed and published since 2010 and will be included in an update that should be published in the next year.

Ultrasound Guidance for Extremity Peripheral Nerve Blocks

The 2010 ASRA systematic reviews covering this subject include 24 RCTs which compare ultrasound guidance to an alternative nerve localization technique for either upper or lower extremity peripheral nerve blockade (5). For both upper and lower extremity blocks, the majority of studies report faster block onset when ultrasound is employed (5,6,11), although 5 of 15 studies in the upper extremity and 2 of 5 studies in the lower extremity fail to find a difference in onset time (5). There is evidence to support a decrease in procedural time when ultrasound is used for upper and lower extremity blocks (6-11); however, set-up time and pre-scanning with ultrasound are not consistently measured or reported. In terms of block quality, lower extremity studies are more likely to report an advantage with ultrasound than upper extremity studies; only 4 of 16 upper extremity studies show improvement with ultrasound, and these studies use nerve stimulation or transarterial injection as the comparator (5). When a fixed time point is used for assessing block success, ultrasound use is more likely to show an advantage although the definitions of successful block vary widely (6,11). Only one study in the upper extremity shows a difference in block duration in favor of ultrasound while all other RCTs do not demonstrate a difference (5). For femoral and subgluteal sciatic nerve blocks, ultrasound use decreases the minimum effective anesthesia volume to achieve a successful block in 50% of patients (11).

Ultrasound for Continuous Peripheral Nerve Blocks

Although many large case series describing ultrasound-guided techniques for continuous peripheral nerve block (CPNB) performance have been published, there are relatively-fewer RCTs comparing ultrasound to other nerve localization techniques for CPNB. When an exclusively ultrasound-guided technique is compared to a stimulating catheter technique, procedural duration is shorter with ultrasound at four distinct insertion sites (14-17) with less procedure-related pain for lower extremity catheters (14,16) and fewer inadvertent vascular punctures for femoral and infraclavicular catheters (14,15). Most studies report similar analgesia and other acute pain outcomes from catheters placed with ultrasound when compared to other methods (18-20), with the exception of one study involving popliteal-sciatic catheters which suggests that stimulating catheters may provide an analgesic advantage although successful placement occurs less often (21).

Ultrasound for Truncal and Neuraxial Blocks

To date, RCTs comparing ultrasound guidance to traditional techniques for paravertebral blockade or transversus abdominis plane (TAP) blocks have yet to be reported. For both of these procedures, the 2010 ASRA systematic review recommends the use of ultrasound although this recommendation is based on case series data only (4). In one study comparing ultrasound-guided TAP to conventional ilioinguinal/iliohypogastric nerve blocks for inguinal hernia repair, subjects who received ultrasound-guided TAP blocks reported lower pain scores for the first 24 hours (22). Ultrasound-guidance and the landmark-based technique for ilioinguinal/iliohypogastric nerve blocks have been compared in children with the ultrasound-guided technique resulting in decreased need for systemic analgesic supplementation (23). For neuraxial blocks, there is evidence to support ultrasound scanning prior to employing conventional neuraxial block techniques rather than relying solely on surface landmarks (10), especially in patients with challenging anatomy (24).

Ultrasound for Regional Anesthesia in Special Populations

Ultrasound-guided techniques for peripheral (25) and neuraxial (26) blocks in children have been described previously. The 2010 ASRA evidence-based review on ultrasound for pediatric regional anesthesia included 6 RCTs involving peripheral nerve blocks and one randomized trial in neuraxial blockade in addition to case series of >10 patients (12). In this population, ultrasound may improve the speed of block onset and duration of analgesia, increase success rates for truncal blocks compared to blind techniques, and reduce the volume of local anesthetic required (12). In obese patients, ultrasound may play a role in identifying target peripheral and neuraxial structures as well as real-time procedural performance (27). When performing CPNB in obese patients, procedural time is not prolonged compared to non-obese patients when as long as ultrasound is used (28).

MedianIn summary, there is sufficient evidence to support the use of ultrasound guidance for peripheral nerve blockade based on short-term outcomes, and the results of a large prospective registry study suggest that ultrasound may decrease in the risk of local anesthetic systemic toxicity (29). Additional prospective studies are needed to further define the role of ultrasound in neuraxial blockade, long-term patient outcomes, and advantages in special populations.

References

  1. Ting PL, Sivagnanaratnam V: Ultrasonographic study of the spread of local anaesthetic during axillary brachial plexus block. Br J Anaesth 1989; 63: 326-9
  2. la Grange P, Foster PA, Pretorius LK: Application of the Doppler ultrasound bloodflow detector in supraclavicular brachial plexus block. Br J Anaesth 1978; 50: 965-7
  3. Sites BD, Chan VW, Neal JM, Weller R, Grau T, Koscielniak-Nielsen ZJ, Ivani G: The American Society of Regional Anesthesia and Pain Medicine and the European Society Of Regional Anaesthesia and Pain Therapy Joint Committee recommendations for education and training in ultrasound-guided regional anesthesia. Reg Anesth Pain Med 2009; 34: 40-6
  4. Abrahams MS, Horn JL, Noles LM, Aziz MF: Evidence-based medicine: ultrasound guidance for truncal blocks. Reg Anesth Pain Med 2010; 35: S36-42
  5. Liu SS, Ngeow J, John RS: Evidence basis for ultrasound-guided block characteristics: onset, quality, and duration. Reg Anesth Pain Med 2010; 35: S26-35
  6. McCartney CJ, Lin L, Shastri U: Evidence basis for the use of ultrasound for upper-extremity blocks. Reg Anesth Pain Med 2010; 35: S10-5
  7. Narouze SN: Ultrasound-guided interventional procedures in pain management: Evidence-based medicine. Reg Anesth Pain Med 2010; 35: S55-8
  8. Neal JM: Ultrasound-guided regional anesthesia and patient safety: An evidence-based analysis. Reg Anesth Pain Med 2010; 35: S59-67
  9. Neal JM, Brull R, Chan VW, Grant SA, Horn JL, Liu SS, McCartney CJ, Narouze SN, Perlas A, Salinas FV, Sites BD, Tsui BC: The ASRA evidence-based medicine assessment of ultrasound-guided regional anesthesia and pain medicine: Executive summary. Reg Anesth Pain Med 2010; 35: S1-9
  10. Perlas A: Evidence for the use of ultrasound in neuraxial blocks. Reg Anesth Pain Med 2010; 35: S43-6
  11. Salinas FV: Ultrasound and review of evidence for lower extremity peripheral nerve blocks. Reg Anesth Pain Med 2010; 35: S16-25
  12. Tsui BC, Pillay JJ: Evidence-based medicine: Assessment of ultrasound imaging for regional anesthesia in infants, children, and adolescents. Reg Anesth Pain Med 2010; 35: S47-54
  13. Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, McQuay HJ: Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996; 17: 1-12
  14. Mariano ER, Cheng GS, Choy LP, Loland VJ, Bellars RH, Sandhu NS, Bishop ML, Lee DK, Maldonado RC, Ilfeld BM: Electrical stimulation versus ultrasound guidance for popliteal-sciatic perineural catheter insertion: a randomized controlled trial. Reg Anesth Pain Med 2009; 34: 480-5
  15. Mariano ER, Loland VJ, Bellars RH, Sandhu NS, Bishop ML, Abrams RA, Meunier MJ, Maldonado RC, Ferguson EJ, Ilfeld BM: Ultrasound guidance versus electrical stimulation for infraclavicular brachial plexus perineural catheter insertion. J Ultrasound Med 2009; 28: 1211-8
  16. Mariano ER, Loland VJ, Sandhu NS, Bellars RH, Bishop ML, Afra R, Ball ST, Meyer RS, Maldonado RC, Ilfeld BM: Ultrasound guidance versus electrical stimulation for femoral perineural catheter insertion. J Ultrasound Med 2009; 28: 1453-60
  17. Mariano ER, Loland VJ, Sandhu NS, Bellars RH, Bishop ML, Meunier MJ, Afra R, Ferguson EJ, Ilfeld BM: A trainee-based randomized comparison of stimulating interscalene perineural catheters with a new technique using ultrasound guidance alone. J Ultrasound Med 2010; 29: 329-336
  18. Ilfeld BM: Continuous peripheral nerve blocks: a review of the published evidence. Anesth Analg 2011; 113: 904-25
  19. Fredrickson MJ, Danesh-Clough TK: Ambulatory continuous femoral analgesia for major knee surgery: a randomised study of ultrasound-guided femoral catheter placement. Anaesth Intensive Care 2009; 37: 758-66
  20. Choi S, Brull R: Is ultrasound guidance advantageous for interventional pain management? A review of acute pain outcomes. Anesth Analg 2011; 113: 596-604
  21. Mariano ER, Loland VJ, Sandhu NS, Bishop ML, Lee DK, Schwartz AK, Girard PJ, Ferguson EJ, Ilfeld BM: Comparative efficacy of ultrasound-guided and stimulating popliteal-sciatic perineural catheters for postoperative analgesia. Can J Anaesth 2010; 57: 919-926
  22. Aveline C, Le Hetet H, Le Roux A, Vautier P, Cognet F, Vinet E, Tison C, Bonnet F: Comparison between ultrasound-guided transversus abdominis plane and conventional ilioinguinal/iliohypogastric nerve blocks for day-case open inguinal hernia repair. Br J Anaesth 2011; 106: 380-6
  23. Willschke H, Marhofer P, Bosenberg A, Johnston S, Wanzel O, Cox SG, Sitzwohl C, Kapral S: Ultrasonography for ilioinguinal/iliohypogastric nerve blocks in children. Br J Anaesth 2005; 95: 226-30
  24. Chin KJ, Perlas A, Chan V, Brown-Shreves D, Koshkin A, Vaishnav V: Ultrasound imaging facilitates spinal anesthesia in adults with difficult surface anatomic landmarks. Anesthesiology 2011; 115: 94-101
  25. Tsui B, Suresh S: Ultrasound imaging for regional anesthesia in infants, children, and adolescents: a review of current literature and its application in the practice of extremity and trunk blocks. Anesthesiology 2010; 112: 473-92
  26. Tsui BC, Suresh S: Ultrasound imaging for regional anesthesia in infants, children, and adolescents: a review of current literature and its application in the practice of neuraxial blocks. Anesthesiology 2010; 112: 719-28
  27. Brodsky JB, Mariano ER: Regional anaesthesia in the obese patient: lost landmarks and evolving ultrasound guidance. Best Pract Res Clin Anaesthesiol 2011; 25: 61-72
  28. Mariano ER, Brodsky JB: Comparison of procedural times for ultrasound-guided perineural catheter insertion in obese and nonobese patients. J Ultrasound Med 2011; 30: 1357-61
  29. Barrington MJ, Kluger R: Ultrasound guidance reduces the risk of local anesthetic systemic toxicity following peripheral nerve blockade. Reg Anesth Pain Med 2013; 38: 289-297

 

Related Posts:

Pay for Performance in Perioperative Pain Management

Costs RocketWe have all heard the “doom and gloom” statistics about rising health care spending, and maybe even some of them have begun to sink in since the roll-out of the Affordable Care Act.

For many reasons, the federal government is working to curb health care expenditures, but many of the processes currently attributed to “Obamacare” have been in the works for a long time.  As an example, the Medicare Modernization Act of 2003 introduced the Inpatient Prospective Payment System; this system encouraged participating hospitals to voluntarily report performance data to avoid payment reductions.  The Deficit Reduction Act of 2005 went further by mandating the development of what we now know as pay-for-performance or value-based purchasing (used interchangeably).

In 2012, the Institute of Medicine published “Best Care at Lower Cost:  the Path to Continuously Learning Health Care in America.”  In this report, recommendation 9 refers to performance transparency:  making data related to “quality, prices and cost, and outcomes of care” available to consumers.

VBPWhat does this mean?  Value-based purchasing in health care is supposed to reward better value, patient outcomes, and innovations – instead of just volume of services (read more).  It is funded by participating institutions based on withholding a set percentage (1.25% currently) of their estimated annual Diagnosis-Related Group (DRG) payments from Center for Medicare and Medicaid Services (CMS).  The percentage is increasing every year and will be 2% by 2017.

VBP2For FY2014, the elements of value-based purchasing have been updated to include the Clinical Process of Care Domain, Patient Experience of Care Domain, and a new Outcomes Domain.  The amount that each of these domains contributes to the eventual DRG payment return at the end of the year is 45%, 30%, and 25%, respectively.  Scores in each domain are calculated based on an institution’s improvement compared to its own historical performance and a comparison against national benchmarks (read more).

The Patient Experience Domain is assessed using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.  HCAHPS consists of 32 questions, publicly reports its results 4 times a year on http://www.hospitalcompare.hhs.gov, and contains 7 questions that directly or indirectly relate to pain.  For details, please see my previous post “Why We Need Acute Pain Medicine Specialists.”

How do we as anesthesiologists address the need for acute pain medicine physicians and have a positive impact on the patient experience?  We can take the lead in developing multimodal perioperative pain management protocols (1).  For total joint arthroplasty, many of these protocols emphasize opioid-sparing regional anesthesia techniques such as peripheral nerve blocks (PNB) and perineural catheters.  These techniques decrease patients’ reliance on opioids for postoperative pain management and are also associated with fewer opioid-related side effects, better sleep, and higher satisfaction (2).  In addition, greater selectivity in the PNB technique included in a multimodal protocol may even lead to greater functional achievements for total knee arthroplasty (TKA) patients which generates additional value (3).  For more information about TKA perioperative pain management and improving rehabilitation outcomes, please see my previous post “Regional Anesthesia & Rehabilitation Outcomes after Knee Replacement.”

Anesthesiologists can also add value through cost savings for the hospital.  More effective pain management can prevent inadvertent admissions or readmissions due to pain.  In addition, an effective multimodal analgesic protocol can directly or indirectly prevent hospital-acquired conditions (HACs).  HACs are considered by CMS to be “never events” and supposedly preventable (4); hospitals reporting HACs as secondary diagnoses are not entitled to CMS payments for related care.  Examples of HACs include:  urinary and vascular catheter-related infections, surgical site infections, DVT/PE, pressure ulcers, and inpatient falls leading to injury.

Fall riskThere remains substantial controversy related to the potential association between regional anesthesia and inpatient falls (5, 6).  We do know that falls, when they occur, are associated with worse outcomes for patients and higher resource utilization (7) and that falls may occur in lower extremity joint replacement patients with or without PNB (8).  For these reasons, these patients should always be treated as high fall risk, and anesthesiologists can take the lead in developing fall prevention education and fall reduction programs to keep them safe.

In summary, pay for performance in perioperative pain management is already here.  The HCAHPS survey assesses the Patient Experience Domain and can be heavily influenced by the effectiveness of pain management.  There are clear opportunities for anesthesiologists to take an active role in adding value and minimizing risks for surgical patients in the perioperative period.

References:

  1. Hebl JR, Kopp SL, Ali MH, Horlocker TT, Dilger JA, Lennon RL, Williams BA, Hanssen AD, Pagnano MW. A comprehensive anesthesia protocol that emphasizes peripheral nerve blockade for total knee and total hip arthroplasty. J Bone Joint Surg Am 2005;87 Suppl 2:63-70.
  2. Ilfeld BM. Continuous peripheral nerve blocks: a review of the published evidence. Anesth Analg 2011;113:904-25.
  3. Mudumbai SC, Kim TE, Howard SK, Workman JJ, Giori N, Woolson S, Ganaway T, King R, Mariano ER. Continuous Adductor Canal Blocks Are Superior to Continuous Femoral Nerve Blocks in Promoting Early Ambulation After TKA. Clinical orthopaedics and related research 2014;472:1377-83.
  4. Hospital-acquired condition (HAC) in acute inpatient payment system (IPPS) hospitals. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Downloads/HACFactsheet.pdf
  5. Ilfeld BM, Duke KB, Donohue MC. The association between lower extremity continuous peripheral nerve blocks and patient falls after knee and hip arthroplasty. Anesth Analg 2010;111:1552-4.
  6. Memtsoudis SG, Danninger T, Rasul R, Poeran J, Gerner P, Stundner O, Mariano ER, Mazumdar M. Inpatient falls after total knee arthroplasty: the role of anesthesia type and peripheral nerve blocks. Anesthesiology 2014;120:551-63.
  7. Memtsoudis SG, Dy CJ, Ma Y, Chiu YL, Della Valle AG, Mazumdar M. In-hospital patient falls after total joint arthroplasty: incidence, demographics, and risk factors in the United States. The Journal of arthroplasty 2012;27:823-8 e1.
  8. Johnson RL, Kopp SL, Hebl JR, Erwin PJ, Mantilla CB. Falls and major orthopaedic surgery with peripheral nerve blockade: a systematic review and meta-analysis. Br J Anaesth 2013;110:518-28.

 

Related Posts:

Why We Need Acute Pain Medicine Specialists

Not all pain is the same.

PainChronic pain can be palliated, but “acute” pain (new onset, often with an identifiable cause) must be stamped out. This requires a systems-based approach led by physicians dedicated to understanding acute pain pathophysiology and investigating new ways to treat it. The solution is definitely not giving more and more opioids.

As our understanding of pain mechanisms has evolved, select physicians have developed a special focus on pain in the acute injury/illness and perioperative settings that has led to the rapid advancement of systemic and site-specific interventions to effectively manage this type of pain. Acute pain medicine involves the routine use of multiple modalities concurrently (i.e., multimodal analgesia) in the in-hospital setting to reduce the intensity of acute pain and minimize the development of debilitating persistent pain, a problem that can result from even common surgical procedures or trauma. Unfortunately, the need for specialists in acute pain medicine is increasing.

In December of 2013, I submitted a 161 page letter to the Accreditation Council for Graduate Medical Education (ACGME) requesting that regional anesthesiology and acute pain medicine be considered for fellowship accreditation with the help of my fellowship director colleagues. The Board of Directors of the ACGME informed me this past fall (2014) that they have approved our fellowship to be the next accredited subspecialty within anesthesiology.

Wait – don’t we already have a fellowship program in pain medicine? Yes we do, and this one year post-residency program does include the “Acute Pain Inpatient Experience.” However, this requirement may be satisfied by documented involvement with a minimum of only 50 new patients and is not the primary emphasis of fellowship training in the specialty. Pain medicine is a board-certified subspecialty of anesthesiology, physical medicine and rehabilitation, and psychiatry and neurology; graduates from any of these residency programs can apply to the one year program. In a recent survey study of practicing pain physicians in the United States with added qualification in pain management according to the American Board of Medical Specialties (ABMS), the great majority (83.7%) of respondents defined their practices as following “chronic pain patients longitudinally” (1).

There is clearly room and a need for a subspecialty training program in acute pain medicine that can focus on improving the in-hospital pain experience. Such a program should advance, in a positive and value-added fashion, the present continuum of training in pain medicine.

HCAHPS Pain QuestionsThe Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is administered to a random sample of patients who have received inpatient care and receive government insurance through Center for Medicare and Medicaid Services (CMS). The survey consists of 32 questions and is intended to assess the “patient experience of care” domain in the value-based purchasing program. A hospital’s survey scores are publicly disclosed and make up 30% of the formula used to determine how much of its diagnosis-related group payment withholding will be paid by CMS at the end of each year. Of the 32 questions, 7 directly or indirectly relate to in-hospital pain management.

Why should acute pain medicine be a subspecialty of anesthesiology? Anesthesiology is a hospital-based medical specialty, and anesthesiologists are physicians who focus on the prevention and treatment of pain for their patients who undergo surgery, suffer trauma, or present for childbirth on a daily basis. For more details on the role of the anesthesiologist, please see “Physicians specializing in the patient experience.” Further, history supports the evolution of acute pain medicine through anesthesiology. The concept of an anesthesiology-led acute pain management service was described first in 1988 (2), but arguably the techniques employed in modern acute pain medicine and regional anesthesiology date back to Gaston Labat’s publication of Regional Anesthesia: its Technic and Clinical Application in 1922, with advancement and refinement of this subspecialty in the 1960s and 1970s (3-7).

By the time they complete the core residency in anesthesiology today, not all trainees have gained sufficient clinical experience to provide optimal care for the complete spectrum of issues experienced by patients suffering from acutely painful conditions, including the ability to reliably provide advanced interventional techniques proven to be effective in managing pain in the acute setting (8-12). We need physician leaders who can run acute pain medicine teams and design systems to provide individualized, comprehensive, and timely pain management for both medical and surgical patients in the hospital, expeditiously managing requests for assistance when pain intensity levels exceed those set forth in quality standards, or to prevent pain intensity from reaching such levels. The mission statement for the Acute Pain Medicine Special Interest Group within the American Academy of Pain Medicine provides additional justification.

In a survey of fellowship graduates and academic chairs published in 2005, 61 of 132 of academic chairs responded (46%), noting that future staffing models for their department will likely include an average of 2 additional faculty trained in regional anesthesiology and acute pain medicine (13).

Currently, there are over 60 institutions in the United States and Canada that list themselves as having non-accredited fellowship training programs focused on regional anesthesiology and acute pain medicine on the ASRA website. Since 2002, the group of regional anesthesiology and acute pain medicine fellowship directors has been meeting twice yearly at the ASRA Spring Annual Meeting and ASA Annual Meeting which takes place in the fall. Despite not being an ACGME-accredited fellowship, this group, recognizing the lack of formalized training guidelines, voluntarily began to develop such guidelines as the foundation for subspecialty fellowship training in existing and future programs. These guidelines were originally published in Regional Anesthesia and Pain Medicine in 2005 (14), then were subsequently reviewed, revised, and published as the 2nd edition in 2011 (15), and have been recently updated again (16).

As with other subspecialties, acute pain medicine has emerged due to the need for trained specialists—in this case, those who understand the complicated, multi-faceted disease processes of acute pain, and its potential continuity with chronic pain, and can apply appropriate medical and interventional treatment in a timely fashion. The fellowship-trained regional anesthesiologist and acute pain medicine specialist must be capable of collaborating with other healthcare providers in anesthesiology, surgery, medicine, nursing, pharmacy, physical therapy, and more to establish multidisciplinary programs that add value and improve patient care in the hospital setting and beyond.

REFERENCES

  1. Breuer B, Pappagallo M, Tai JY, Portenoy RK: U.S. board-certified pain physician practices: uniformity and census data of their locations. J Pain 2007; 8: 244-50
  2. Ready LB, Oden R, Chadwick HS, Benedetti C, Rooke GA, Caplan R, Wild LM: Development of an anesthesiology-based postoperative pain management service. Anesthesiology 1988; 68: 100-6
  3. Winnie AP, Ramamurthy S, Durrani Z: The inguinal paravascular technic of lumbar plexus anesthesia: the “3-in-1 block”. Anesth Analg 1973; 52: 989-96
  4. Winnie AP, Collins VJ: The Subclavian Perivascular Technique of Brachial Plexus Anesthesia. Anesthesiology 1964; 25: 353-63
  5. Raj PP, Montgomery SJ, Nettles D, Jenkins MT: Infraclavicular brachial plexus block–a new approach. Anesth Analg 1973; 52: 897-904
  6. Raj PP, Parks RI, Watson TD, Jenkins MT: A new single-position supine approach to sciatic-femoral nerve block. Anesth Analg 1975; 54: 489-93
  7. Raj PP, Rosenblatt R, Miller J, Katz RL, Carden E: Dynamics of local-anesthetic compounds in regional anesthesia. Anesth Analg 1977; 56: 110-7
  8. Buvanendran A, Kroin JS: Multimodal analgesia for controlling acute postoperative pain. Curr Opin Anaesthesiol 2009; 22: 588-93
  9. Hebl JR, Dilger JA, Byer DE, Kopp SL, Stevens SR, Pagnano MW, Hanssen AD, Horlocker TT: A pre-emptive multimodal pathway featuring peripheral nerve block improves perioperative outcomes after major orthopedic surgery. Reg Anesth Pain Med 2008; 33: 510-7
  10. Jin F, Chung F: Multimodal analgesia for postoperative pain control. J Clin Anesth 2001; 13: 524-39
  11. Kehlet H, Dahl JB: The value of “multimodal” or “balanced analgesia” in postoperative pain treatment. Anesth Analg 1993; 77: 1048-56
  12. Young A, Buvanendran A: Recent advances in multimodal analgesia. Anesthesiol Clin 2012; 30: 91-100
  13. Neal JM, Kopacz DJ, Liguori GA, Beckman JD, Hargett MJ: The training and careers of regional anesthesia fellows–1983-2002. Reg Anesth Pain Med 2005; 30: 226-32
  14. Hargett MJ, Beckman JD, Liguori GA, Neal JM: Guidelines for regional anesthesia fellowship training. Reg Anesth Pain Med 2005; 30: 218-25
  15. Guidelines for fellowship training in Regional Anesthesiology and Acute Pain Medicine: Second Edition, 2010. Reg Anesth Pain Med 2011; 36: 282-8
  16. Guidelines for fellowship training in Regional Anesthesiology and Acute Pain Medicine: Third Edition, 2014. Reg Anesth Pain Med 2015; 40: 213-7

Related Posts:

Regional Anesthesia & Rehabilitation Outcomes after Knee Replacement

kneeAmong Medicare beneficiaries in the United States, the number of primary total knee arthroplasty (TKA) procedures from 1991 to 2010 increased by 161.5% (1). Postoperative pain remains one of patients’ top concerns when undergoing elective surgery (2) and can limit patients’ functional ability in the early postoperative period (3). Providing effective perioperative pain control has potential longer-term implications since early rehabilitation may lead to improvements in functional outcomes later on (4). With the ability to select specific targets for local anesthetic injection and infusion, regional anesthesia techniques, neuraxial and peripheral, are commonly included in the perioperative analgesic protocol for joint arthroplasty patients (5-11). While the data supporting the analgesic efficacy of regional anesthesia techniques in this setting are strongly positive, studies attempting to attribute functional outcome benefits to regional anesthesia demonstrate mixed results.

The main challenge in assessing functional outcomes following joint replacement is the selection of outcomes; these can be divided into performance-based outcomes and self-reported outcomes (12, 13). Performance-based outcomes are measurable and arguably more objective, although often subject to effort. Examples of these outcomes and their units of measure include joint range of motion in degrees (e.g., flexion, extension, rotation); timed walking tests in meters (e.g., 6 minute walking test [6MWT], 2 minute walking test [2MWT]); muscle strength in units of force using a dynamometer (e.g., maximum voluntary isometric contraction [MVIC]); and timed up-and-go (TUG) in minutes (12, 13). Self-reported outcomes are typically survey-based; examples include the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC), Knee Society Score, and Lower Extremity Functional Scale (12, 13). Since patient perception of successful rehabilitation is an important factor, self-reported outcomes should be reported with performance-based outcomes (12). Another important challenge when measuring and comparing functional outcomes is that clinical pathways for joint arthroplasty that integrate pain management (including regional analgesia), physical therapy, nursing, and surgical care are often specific to individual institutions, and institutions may vary with respect to rehabilitation goals and the timeline to achieve them.

Epidural Analgesia

Epidural analgesia has been used for perioperative pain management in joint replacement patients since at least the 1980s (14, 15). In 1987, Raj and colleagues compared postoperative systemic opioid analgesia to continuous epidural analgesia (bupivacaine 0.25% at 6-15 ml/hr) for TKA patients in a prospective non-randomized study (14). Although pain scores were lower in the epidural group, not surprisingly a high proportion of these patients experienced complete motor block of the lower extremities; although the authors mention “rigorous passive exercises,” specific rehabilitation outcomes were not reported (14). Later studies have reported functional benefits associated with continuous epidural analgesia, such as shorter time to achieve ambulation distance and range of motion goals, when compared to parenteral opioids alone (16). At institutions where continuous epidural analgesia is currently employed as part of a multimodal analgesic protocol, very low doses of local anesthetic (e.g., 0.06% bupivacaine) in combination with opioid are used in order to minimize motor block (17).

Peripheral Nerve Blocks

The innervation of the knee is complex and involves contributions from both the lumbar and sacral plexuses. While epidural analgesia is effective, it is also associated with clinically-significant side effects (e.g., nausea/vomiting and motor block of the non-operative limb) (5, 18) and the potential for neuraxial hematoma in patients on pharmacologic thromboprophylaxis (19). Thus, peripheral nerve block options, either single-injection or continuous infusions, have been explored for postoperative pain management.

Two early studies by Capdevila (6) and Singelyn (20) have shown continuous femoral nerve block (FNB) to provide comparable analgesia and physical therapy outcome achievement with fewer side effects when compared to epidural analgesia. Both of these studies also demonstrated shorter hospital length of stay for the regional anesthesia groups compared to an opioid-only group (6, 20), but hospitalization duration for these studies was, on average, greater than what has been reported in other studies (21). Triple-masked, placebo-controlled randomized clinical trials have shown that CPNB can shorten the time to achieve discharge criteria, including 100 m ambulation distance, for TKA (10, 22) and total hip arthroplasty (THA) (9) patients, but actual hospital duration was similar in these studies.

One of the interesting findings from the Singelyn study was that regional anesthesia patients maintained a knee flexion advantage over the opioid-only group at 6 week follow-up (20); although this advantage did not remain at 3 months, this finding supported the potential for long-term functional improvement resulting from effective pain management and early rehabilitation in the immediate perioperative period (4). In a randomized comparison of continuous FNB to local infiltration analgesia (LIA) for TKA, the FNB group spent more time out of bed walking; at 6 weeks, the FNB group showed more improvement in performance-based (6MWT) and self-reported functional outcome assessments (23). In contrast, the one year follow-up studies of randomized clinical trial subjects (9, 10, 22) using self-reported outcome measures for functional status (WOMAC) did not show long-term improvement associated with regional anesthesia techniques (24-27).

The rehabilitation outcome measured in the immediate postoperative period that correlates best with long-term functional improvement is not yet established. Ambulation distance is often measured by physical therapists and included in discharge criteria (9, 10, 22). For institutions that emphasize ambulation in their clinical pathway for lower extremity joint arthroplasty, a major concern raised with regard to FNBs is the potential association with increased fall risk (28, 29) although a recent large database study disputes this finding. In-hospital falls can lead to prolonged hospital stays with higher costs and are associated with more frequent postoperative complications, including serious organ system dysfunction and death (30). With currently-available local anesthetic solutions and typical doses, perineural infusion does produce clinically-significant quadriceps weakness when administered near the femoral nerve or lumbar plexus (31, 32). Since the local anesthetics themselves cannot select sensory over motor nerves( 33), anesthesiologists have started exploring alternate nerve block locations to minimize the risk of motor block and maximize patient rehabilitation.

From Workman JJ, et al. Presented at 2013 ASRA Spring Annual Meeting
From Workman JJ, et al. Presented at 2013 ASRA Spring Annual Meeting

For TKA, a more distal nerve block location in the adductor canal can provide effective analgesia postoperatively (34) and has been shown to better preserve quadriceps strength compared to a FNB in both volunteers (35) and clinical patients (11). Regional analgesic techniques are only one part of the overall pain management plan. While they are often included in multimodal analgesic protocols along with non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and low-dose opioids (36), there is a growing body of evidence to support the adductor canal block as the regional analgesic technique of choice for promoting postoperative ambulation within a clinical pathway (37, 38).

For patient information with answers to frequently-asked questions about regional anesthesia, please see “Regional Anesthesia FAQs.”

References

  1. Cram P, Lu X, Kates SL, Singh JA, Li Y, Wolf BR. Total knee arthroplasty volume, utilization, and outcomes among Medicare beneficiaries, 1991-2010. JAMA. Sep 26 2012;308(12):1227-1236.
  2. Macario A, Weinger M, Carney S, Kim A. Which clinical anesthesia outcomes are important to avoid? The perspective of patients. Anesth Analg. Sep 1999;89(3):652-658.
  3. Holm B, Kristensen MT, Myhrmann L, et al. The role of pain for early rehabilitation in fast track total knee arthroplasty. Disability and rehabilitation. 2010;32(4):300-306.
  4. Munin MC, Rudy TE, Glynn NW, Crossett LS, Rubash HE. Early inpatient rehabilitation after elective hip and knee arthroplasty. JAMA. Mar 18 1998;279(11):847-852.
  5. Barrington MJ, Olive D, Low K, Scott DA, Brittain J, Choong P. Continuous femoral nerve blockade or epidural analgesia after total knee replacement: a prospective randomized controlled trial. Anesth Analg. Dec 2005;101(6):1824-1829.
  6. Capdevila X, Barthelet Y, Biboulet P, Ryckwaert Y, Rubenovitch J, d’Athis F. Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery. Anesthesiology. Jul 1999;91(1):8-15.
  7. Chelly JE, Greger J, Gebhard R, et al. Continuous femoral blocks improve recovery and outcome of patients undergoing total knee arthroplasty. J Arthroplasty. Jun 2001;16(4):436-445.
  8. Hebl JR, Dilger JA, Byer DE, et al. A pre-emptive multimodal pathway featuring peripheral nerve block improves perioperative outcomes after major orthopedic surgery. Reg Anesth Pain Med. Nov-Dec 2008;33(6):510-517.
  9. Ilfeld BM, Ball ST, Gearen PF, et al. Ambulatory continuous posterior lumbar plexus nerve blocks after hip arthroplasty: a dual-center, randomized, triple-masked, placebo-controlled trial. Anesthesiology. Sep 2008;109(3):491-501.
  10. Ilfeld BM, Le LT, Meyer RS, et al. Ambulatory continuous femoral nerve blocks decrease time to discharge readiness after tricompartment total knee arthroplasty: a randomized, triple-masked, placebo-controlled study. Anesthesiology. Apr 2008;108(4):703-713.
  11. Jaeger P, Zaric D, Fomsgaard JS, et al. Adductor canal block versus femoral nerve block for analgesia after total knee arthroplasty: a randomized, double-blind study. Reg Anesth Pain Med. Nov-Dec 2013;38(6):526-532.
  12. Choi S, Trang A, McCartney CJ. Reporting functional outcome after knee arthroplasty and regional anesthesia: a methodological primer. Reg Anesth Pain Med. Jul-Aug 2013;38(4):340-349.
  13. Bernucci F, Carli F. Functional outcome after major orthopedic surgery: the role of regional anesthesia redefined. Curr Opin Anaesthesiol. Oct 2012;25(5):621-628.
  14. Raj PP, Knarr DC, Vigdorth E, et al. Comparison of continuous epidural infusion of a local anesthetic and administration of systemic narcotics in the management of pain after total knee replacement surgery. Anesth Analg. May 1987;66(5):401-406.
  15. Pettine KA, Wedel DJ, Cabanela ME, Weeks JL. The use of epidural bupivacaine following total knee arthroplasty. Orthopaedic review. Aug 1989;18(8):894-901.
  16. Mahoney OM, Noble PC, Davidson J, Tullos HS. The effect of continuous epidural analgesia on postoperative pain, rehabilitation, and duration of hospitalization in total knee arthroplasty. Clin Orthop Relat Res. Nov 1990(260):30-37.
  17. YaDeau JT, Cahill JB, Zawadsky MW, et al. The effects of femoral nerve blockade in conjunction with epidural analgesia after total knee arthroplasty. Anesth Analg. Sep 2005;101(3):891-895, table of contents.
  18. Zaric D, Boysen K, Christiansen C, Christiansen J, Stephensen S, Christensen B. A comparison of epidural analgesia with combined continuous femoral-sciatic nerve blocks after total knee replacement. Anesth Analg. Apr 2006;102(4):1240-1246.
  19. Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med. Jan-Feb 2010;35(1):64-101.
  20. Singelyn FJ, Deyaert M, Joris D, Pendeville E, Gouverneur JM. Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty. Anesth Analg. Jul 1998;87(1):88-92.
  21. Salinas FV, Liu SS, Mulroy MF. The effect of single-injection femoral nerve block versus continuous femoral nerve block after total knee arthroplasty on hospital length of stay and long-term functional recovery within an established clinical pathway. Anesth Analg. Apr 2006;102(4):1234-1239.
  22. Ilfeld BM, Mariano ER, Girard PJ, et al. A multicenter, randomized, triple-masked, placebo-controlled trial of the effect of ambulatory continuous femoral nerve blocks on discharge-readiness following total knee arthroplasty in patients on general orthopaedic wards. Pain. Sep 2010;150(3):477-484.
  23. Carli F, Clemente A, Asenjo JF, et al. Analgesia and functional outcome after total knee arthroplasty: periarticular infiltration vs continuous femoral nerve block. Br J Anaesth. Aug 2010;105(2):185-195.
  24. Ilfeld BM, Shuster JJ, Theriaque DW, et al. Long-term pain, stiffness, and functional disability after total knee arthroplasty with and without an extended ambulatory continuous femoral nerve block: a prospective, 1-year follow-up of a multicenter, randomized, triple-masked, placebo-controlled trial. Reg Anesth Pain Med. Mar-Apr 2011;36(2):116-120.
  25. Morin AM, Kratz CD, Eberhart LH, et al. Postoperative analgesia and functional recovery after total-knee replacement: comparison of a continuous posterior lumbar plexus (psoas compartment) block, a continuous femoral nerve block, and the combination of a continuous femoral and sciatic nerve block. Reg Anesth Pain Med. Sep-Oct 2005;30(5):434-445.
  26. Ilfeld BM, Ball ST, Gearen PF, et al. Health-related quality of life after hip arthroplasty with and without an extended-duration continuous posterior lumbar plexus nerve block: a prospective, 1-year follow-up of a randomized, triple-masked, placebo-controlled study. Anesth Analg. Aug 2009;109(2):586-591.
  27. Ilfeld BM, Meyer RS, Le LT, et al. Health-related quality of life after tricompartment knee arthroplasty with and without an extended-duration continuous femoral nerve block: a prospective, 1-year follow-up of a randomized, triple-masked, placebo-controlled study. Anesth Analg. Apr 2009;108(4):1320-1325.
  28. Feibel RJ, Dervin GF, Kim PR, Beaule PE. Major complications associated with femoral nerve catheters for knee arthroplasty: a word of caution. J Arthroplasty. Sep 2009;24(6 Suppl):132-137.
  29. Ilfeld BM, Duke KB, Donohue MC. The association between lower extremity continuous peripheral nerve blocks and patient falls after knee and hip arthroplasty. Anesth Analg. Dec 2010;111(6):1552-1554.
  30. Memtsoudis SG, Dy CJ, Ma Y, Chiu YL, Della Valle AG, Mazumdar M. In-hospital patient falls after total joint arthroplasty: incidence, demographics, and risk factors in the United States. J Arthroplasty. Jun 2012;27(6):823-828 e821.
  31. Charous MT, Madison SJ, Suresh PJ, et al. Continuous femoral nerve blocks: varying local anesthetic delivery method (bolus versus basal) to minimize quadriceps motor block while maintaining sensory block. Anesthesiology. Oct 2011;115(4):774-781.
  32. Ilfeld BM, Moeller LK, Mariano ER, et al. Continuous peripheral nerve blocks: is local anesthetic dose the only factor, or do concentration and volume influence infusion effects as well? Anesthesiology. Feb 2010;112(2):347-354.
  33. Ilfeld BM, Yaksh TL. The end of postoperative pain–a fast-approaching possibility? And, if so, will we be ready? Reg Anesth Pain Med. Mar-Apr 2009;34(2):85-87.
  34. Lund J, Jenstrup MT, Jaeger P, Sorensen AM, Dahl JB. Continuous adductor-canal-blockade for adjuvant post-operative analgesia after major knee surgery: preliminary results. Acta Anaesthesiol Scand. Jan 2011;55(1):14-19.
  35. Jaeger P, Nielsen ZJ, Henningsen MH, Hilsted KL, Mathiesen O, Dahl JB. Adductor Canal Block versus Femoral Nerve Block and Quadriceps Strength: A Randomized, Double-blind, Placebo-controlled, Crossover Study in Healthy Volunteers. Anesthesiology. Feb 2013;118(2):409-415.
  36. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. Feb 2012;116(2):248-273.
  37. Perlas A, Kirkham KR, Billing R, et al. The impact of analgesic modality on early ambulation following total knee arthroplasty. Reg Anesth Pain Med. Jul-Aug 2013;38(4):334-339.
  38. Mudumbai SC, Kim TE, Howard SK, et al. Continuous adductor canal blocks are superior to continuous femoral nerve blocks in promoting early ambulation after TKA. Clin Orthop Relat Res. 2014 May;472(5):1377-83.

 

Related Posts:

Anesthesiology and Perioperative Outcomes Research: Where Should We Focus?

Since 2012, the American Society of Anesthesiologists has promoted the Perioperative Surgical Home model in which anesthesiologists function as leaders in the coordination of perioperative care for surgical patients to improve outcomes (1,2). While anesthesiologists globally have had similar interests over the years, the unifying challenge continues to be the selection of outcomes and demonstration of improvement due to the anesthesiologist’s role and/or choice of anesthetic or analgesic technique. Since the types of outcomes and frequency of occurrence vary widely, a comprehensive discussion of perioperative outcomes is beyond the scope of this summary. Therefore, this review will focus on select anesthesiologist-driven factors related to acute pain management and anesthetic technique on perioperative outcomes and potential research directions.

Rare Outcomes and Big Data

For anesthesiologists, avoiding adverse events of the lowest frequency (death, recall, and nerve injury) receives highest priority with death ranking first among complications to avoid (3). Studies involving rare outcomes, positive or negative, will invariably require accumulation of “big data.” Such studies must either involve multiple institutions over a long study period (if prospective) or access data involving a large cohort of patients for retrospective studies; these study designs involving longitudinal data may also require advanced statistical methods (4). For example, Memtsoudis and colleagues sought to evaluate postoperative morbidity and mortality for lower extremity joint arthroplasty patients in a recent study (5). They utilized a large nationwide administrative database maintained by Premier Perspective, Inc. (Charlotte, NC, USA); the study data were gathered from 382,236 patients in approximately 400 acute care hospitals throughout the United States over 4 years (5). Other retrospective cohort studies comparing the occurrence of perioperative complications such as surgical site infections, cardiopulmonary morbidity, and mortality have used the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) (6-8). NSQIP originally started within the Veterans Health Administration (VHA) system in the 1980s with a small sample of hospitals; this project, which included public reporting of outcomes data, eventually expanded to include all VHA surgical facilities and others outside the VHA system (9). Multi-center prospective registries such as the SOS Regional Anesthesia Hotline (10, 11) and AURORA (12, 13) have been developed for outcomes research and have reported the occurrence rates of rare complications related to regional anesthesia. The disadvantages to these data-driven studies include lack or randomization introducing potential bias, missing or incorrectly coded data, inability to draw conclusions regarding causation, and restrictions to access such as information security issues and/or cost (e.g., the Premier database). However, these retrospective cohort database studies may offer large samples sizes and administrative data from actual “real world” patients over a longer period of time and may identify important associations that influence clinical practice and generate hypotheses for future prospective studies.

Anesthesia Type and Perioperative Mortality

Based on the study by Memtsoudis and colleagues, overall 30-day mortality for lower extremity arthroplasty patients is lower for patients who receive neuraxial and combined neuraxial-general anesthesia compared to general anesthesia alone (5). In most categories, the rates of occurrence of in-hospital complications are also lower for the neuraxial and combined neuraxial-general anesthesia groups vs. the general anesthesia group, and transfusion requirements are lowest for the neuraxial group compared to all other groups (5). Studies using NSQIP have reported no difference in 30-day mortality for carotid endarterectomy patients associated with anesthetic technique although regional anesthesia patients are more likely to have a shorter operative time and next-day discharge (8); similarly, there is no difference in 30-day mortality for endovascular aortic aneurysm repair although general anesthesia patients are more likely to have longer length of stay and pulmonary complications (14).

Perioperative Analgesia and Cancer Recurrence

In a relatively-small matched retrospective study, Exadaktylos and colleagues have reported lower rates of recurrence and metastasis for breast cancer surgery patients who receive paravertebral analgesia vs. conventional systemic opioids (15). Although the exact mechanism was not well-understood at that time (regional anesthesia vs. reduction in the use of anesthetic agents and opioids), clinical and basic science research in this area has grown rapidly and has demonstrated mixed results. A follow-up study involving 503 patients who underwent abdominal surgery for cancer and were previously enrolled in a large multi-center clinical trial (16) and a retrospective database study of 424 colorectal cancer patients who underwent laparoscopic resection (17) have not shown a difference in recurrence-free survival or mortality. A recent meta-analysis including 14 prospective and retrospective studies involving cancer patients (colorectal, ovarian, breast, prostate, and hepatocellular) demonstrates a positive association between epidural analgesia and overall survival but no difference in recurrence-free survival compared to general anesthesia with opioid analgesia (18).

Analgesic Technique and Persistent Postsurgical Pain

Chronic pain may develop after many common operations including breast surgery, hernia repair, thoracic surgery, and amputation and is associated with severe acute pain in the postoperative period (19). While regional analgesic techniques are effective for acute pain management, currently-available data are inconclusive with regard to their ability to prevent the development of persistent postsurgical pain (20-22). There is an opportunity to use larger databases to investigate this issue further.

Ultrasound and Patient Safety

In 2010, the American Society of Regional Anesthesia and Pain Medicine published a series of articles presenting the evidence basis for ultrasound in regional anesthesia (23). According to the article focused on patient safety, evidence at the time suggested that ultrasound may decrease the incidence of minor adverse events (e.g., hemidiaphragmatic paresis from interscalene block or inadvertent vascular puncture), but serious complications such as local anesthetic systemic toxicity (LAST) and nerve injury did not occur at different rates based on the nerve localization technique (24). Since then, a large prospective multi-center registry study has shown that the use of ultrasound in regional anesthesia does reduce the incidence of LAST compared to traditional techniques (13). Similar methodology may be applied to other rare complications associated with anesthetic interventions.

Perioperative Medicine and Health Care Costs

Approximately 31% of costs related to inpatient perioperative care is attributable to the ward admission (25). Anesthesiologists as perioperative physicians have an opportunity to influence the cost of surgical care by decreasing hospital length of stay through effective pain management and by developing coordinated multi-disciplinary clinical pathways (26, 27).

REFERENCES

  1. Vetter TR, Goeddel LA, Boudreaux AM, Hunt TR, Jones KA, Pittet JF. The Perioperative Surgical Home: how can it make the case so everyone wins? BMC anesthesiology. 2013;13:6.
  2. Vetter TR, Ivankova NV, Goeddel LA, McGwin G, Jr., Pittet JF. An Analysis of Methodologies That Can Be Used to Validate if a Perioperative Surgical Home Improves the Patient-centeredness, Evidence-based Practice, Quality, Safety, and Value of Patient Care. Anesthesiology. Dec 2013;119(6):1261-1274.
  3. Macario A, Weinger M, Truong P, Lee M. Which clinical anesthesia outcomes are both common and important to avoid? The perspective of a panel of expert anesthesiologists. Anesth Analg. May 1999;88(5):1085-1091.
  4. Ma Y, Mazumdar M, Memtsoudis SG. Beyond repeated-measures analysis of variance: advanced statistical methods for the analysis of longitudinal data in anesthesia research. Reg Anesth Pain Med. Jan-Feb 2012;37(1):99-105.
  5. Memtsoudis SG, Sun X, Chiu YL, et al. Perioperative comparative effectiveness of anesthetic technique in orthopedic patients. Anesthesiology. May 2013;118(5):1046-1058.
  6. Liu J, Ma C, Elkassabany N, Fleisher LA, Neuman MD. Neuraxial anesthesia decreases postoperative systemic infection risk compared with general anesthesia in knee arthroplasty. Anesth Analg. Oct 2013;117(4):1010-1016.
  7. Radcliff TA, Henderson WG, Stoner TJ, Khuri SF, Dohm M, Hutt E. Patient risk factors, operative care, and outcomes among older community-dwelling male veterans with hip fracture. J Bone Joint Surg Am. Jan 2008;90(1):34-42.
  8. Schechter MA, Shortell CK, Scarborough JE. Regional versus general anesthesia for carotid endarterectomy: the American College of Surgeons National Surgical Quality Improvement Program perspective. Surgery. Sep 2012;152(3):309-314.
  9. Ingraham AM, Richards KE, Hall BL, Ko CY. Quality improvement in surgery: the American College of Surgeons National Surgical Quality Improvement Program approach. Advances in surgery. 2010;44:251-267.
  10. Auroy Y, Benhamou D, Bargues L, et al. Major complications of regional anesthesia in France: The SOS Regional Anesthesia Hotline Service. Anesthesiology. Nov 2002;97(5):1274-1280.
  11. Auroy Y, Narchi P, Messiah A, Litt L, Rouvier B, Samii K. Serious complications related to regional anesthesia: results of a prospective survey in France. Anesthesiology. Sep 1997;87(3):479-486.
  12. Barrington MJ, Watts SA, Gledhill SR, et al. Preliminary results of the Australasian Regional Anaesthesia Collaboration: a prospective audit of more than 7000 peripheral nerve and plexus blocks for neurologic and other complications. Reg Anesth Pain Med. Nov-Dec 2009;34(6):534-541.
  13. Barrington MJ, Kluger R. Ultrasound guidance reduces the risk of local anesthetic systemic toxicity following peripheral nerve blockade. Reg Anesth Pain Med. Jul-Aug 2013;38(4):289-297.
  14. Edwards MS, Andrews JS, Edwards AF, et al. Results of endovascular aortic aneurysm repair with general, regional, and local/monitored anesthesia care in the American College of Surgeons National Surgical Quality Improvement Program database. J Vasc Surg. Nov 2011;54(5):1273-1282.
  15. Exadaktylos AK, Buggy DJ, Moriarty DC, Mascha E, Sessler DI. Can anesthetic technique for primary breast cancer surgery affect recurrence or metastasis? Anesthesiology. Oct 2006;105(4):660-664.
  16. Myles PS, Peyton P, Silbert B, Hunt J, Rigg JR, Sessler DI. Perioperative epidural analgesia for major abdominal surgery for cancer and recurrence-free survival: randomised trial. BMJ. 2011;342:d1491.
  17. Day A, Smith R, Jourdan I, Fawcett W, Scott M, Rockall T. Retrospective analysis of the effect of postoperative analgesia on survival in patients after laparoscopic resection of colorectal cancer. Br J Anaesth. Aug 2012;109(2):185-190.
  18. Chen WK, Miao CH. The effect of anesthetic technique on survival in human cancers: a meta-analysis of retrospective and prospective studies. PloS one. 2013;8(2):e56540.
  19. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet. May 13 2006;367(9522):1618-1625.
  20. Kairaluoma PM, Bachmann MS, Rosenberg PH, Pere PJ. Preincisional paravertebral block reduces the prevalence of chronic pain after breast surgery. Anesth Analg. Sep 2006;103(3):703-708.
  21. Schnabel A, Reichl SU, Kranke P, Pogatzki-Zahn EM, Zahn PK. Efficacy and safety of paravertebral blocks in breast surgery: a meta-analysis of randomized controlled trials. Br J Anaesth. Dec 2010;105(6):842-852.
  22. Wildgaard K, Ravn J, Kehlet H. Chronic post-thoracotomy pain: a critical review of pathogenic mechanisms and strategies for prevention. Eur J Cardiothorac Surg. Jul 2009;36(1):170-180.
  23. Neal JM, Brull R, Chan VW, et al. The ASRA evidence-based medicine assessment of ultrasound-guided regional anesthesia and pain medicine: Executive summary. Reg Anesth Pain Med. Mar-Apr 2010;35(2 Suppl):S1-9.
  24. Neal JM. Ultrasound-guided regional anesthesia and patient safety: An evidence-based analysis. Reg Anesth Pain Med. Mar-Apr 2010;35(2 Suppl):S59-67.
  25. Macario A, Vitez TS, Dunn B, McDonald T. Where are the costs in perioperative care? Analysis of hospital costs and charges for inpatient surgical care. Anesthesiology. Dec 1995;83(6):1138-1144.
  26. Ilfeld BM, Mariano ER, Williams BA, Woodard JN, Macario A. Hospitalization costs of total knee arthroplasty with a continuous femoral nerve block provided only in the hospital versus on an ambulatory basis: a retrospective, case-control, cost-minimization analysis. Reg Anesth Pain Med. Jan-Feb 2007;32(1):46-54.
  27. Jakobsen DH, Sonne E, Andreasen J, Kehlet H. Convalescence after colonic surgery with fast-track vs conventional care. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland. Oct 2006;8(8):683-687.

 

Related Posts:

Do We Need the ASRA Pre-Block Checklist?

Originally included in my editorial for the May 2014 issue of ASRA News.

ASRA News May 2014I make checklists for everything.  Whenever I go on a trip, I use the same packing checklist to make sure I don’t forget anything – umbrella, jacket, socks, snacks, passport, and a few other things.  Using a checklist not only ensures that I bring everything I’m going to need on the trip; I’m convinced that it makes my packing ritual faster because I don’t have to keep going back and forth to my suitcase whenever I suddenly remember something I left out.  Even our dog has her own packing checklist for trips to her sitter’s house.  Now that my wife and I have 2 kids, the traveling checklist has gotten more complex and even more essential.

As an anesthesiologist, I believe that checklists are part of our culture whether we state them explicitly or not.  When I first started my training as a new anesthesiology resident, I learned a mnemonic “MOM SAID” (although there are variations) to check and set up my anesthesia workstation before every case.  Each letter stood for an important element of my preparation checklist:  Machine Oxygen Monitors Suction Airway IV Drugs.  I would then follow this mnemonic with reminders for myself; for example “MOM SAID, ‘don’t forget your stethoscope’ or “MOM SAID, ‘don’t forget to print a baseline EKG strip.’  Over the years, I have found modified forms of this same checklist to be useful just before and after induction, and I continue to use this method today.

Unfortunately, in the complex environment of surgery and perioperative medicine, there aren’t easy mnemonics for everything, and medical errors happen.  The use of a formal checklist for surgical and invasive procedures that promotes interactive discussion among all team members and includes important steps related to the entire surgical episode has been promoted by the World Health Organization (WHO) as part of its global Safe Surgery Saves Lives campaign (http://www.who.int/patientsafety/safesurgery/en/).  In the May 2014 issue of ASRA News, our Resident Section Committee article by Dr. Jennifer Bunch presents her experience implementing the WHO Surgical Safety Checklist abroad.

In regional anesthesiology and pain medicine, one of the most dreaded complications besides nerve injury and local anesthetic systemic toxicity (LAST) is the wrong-site block.  The risk factors related to this medical error have been well-studied and include patient, physician, procedural, environmental, and system factors (1,2).  Despite the best intentions, wrong-site blocks have not gone away (3-5).  ASRA has been hard at work developing a standardized pre-procedure checklist for regional anesthesiology that has been published in Regional Anesthesia and Pain Medicine.  ASRA’s recommended checklist includes the following elements:  patient identification with assessment of pertinent medical history, separate verifications of the surgical procedure and block plan, confirmation that appropriate equipment and medications for the block procedure and resuscitation are immediately available, and a pre-procedural time-out.  Dr. Mulroy was charged with heading this task force and has been kind enough to summarize ASRA’s checklist project in this issue of ASRA News.

Time Out Cognitive Aid
Figure 1. Pre-Block Time Out Cognitive Aid

With the publication of this checklist, ASRA is once again taking a stand in support of patient safety.  The process of verifying the correct patient, correct site, and correct implants or devices for patients undergoing any invasive procedure, including peripheral nerve blockade, must be consistently and reliably applied for every patient.  Since there is no easy mnemonic to help providers remember every step, and the order in which they must occur, I suggest using a standardized cognitive aid for block procedures (Figure 1) that should be posted in a consistent location visible to all providers involved in the procedure and in every location in which these procedures will occur.  During the time-out process, it is essential that all team members involved in the patient’s procedure stop what they are doing and actively participate.

When I started my current job in 2010, the Veterans Health Administration (VHA) had just issued Directive 2010-023, “Ensuring Correct Surgery and Invasive Procedures,” and this VHA Directive was considered inclusive of regional anesthesia procedures.  We have had a process similar to the ASRA checklist in place since then, and I acknowledge that implementing change is hard.  Yes, following a checklist requires extra steps.  Yes, it may even take more time.  The bottom line is – it takes a lot more time, effort, and expense to deal with the complications that may result if you don’t do this.  The ASRA checklist is not prescriptive and allows for local institutional interpretation and application.  If I routinely use a checklist when I pack my suitcase, I can’t think of any good reason not to use one for the safety of my patients.

References

  1. O’Neill T, Cherreau P, Bouaziz H.  Patient safety in regional anesthesia: preventing wrong-site peripheral nerve block.  J Clin Anesth. 2010 Feb;22(1):74-7.
  2. Cohen SP, Hayek SM, Datta S, Bajwa ZH, Larkin TM, Griffith S, Hobelmann G, Christo PJ, White R.  Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study.  Anesthesiology. 2010 Mar;112(3):711-8.
  3. Edmonds CR, Liguori GA, Stanton MA.  Two cases of a wrong-site peripheral nerve block and a process to prevent this complication.  Reg Anesth Pain Med. 2005 Jan-Feb;30(1):99-103.
  4. Stanton MA, Tong-Ngork S, Liguori GA, Edmonds CR.  A new approach to preanesthetic site verification after 2 cases of wrong site peripheral nerve blocks.  Reg Anesth Pain Med. 2008 Mar-Apr;33(2):174-7.
  5. Al-Nasser B.  Unintentional side error for continuous sciatic nerve block at the popliteal fossa.  Acta Anaesthesiol Belg. 2011;62(4):213-5.

Related Posts:

Regional Anesthesia and Compartment Syndrome

Originally included in my editorial for the May 2013 issue of ASRA News.

ASRA News May 2013In the May 2013 issue of ASRA News, I want to highlight a special Pro-Con feature dedicated to the controversial topic of regional anesthesia and analgesia in the patient at risk for acute compartment syndrome.  I want to personally thank our surgical colleagues from the University of Alberta who were willing to write a thoughtful “Con” article for our newsletter.  Before jumping to debate each of their points, we need to give them careful consideration.  With the paucity of evidence-based recommendations on this topic, it is crucial to have an open honest dialogue between all members of the healthcare team.  This Pro-Con is not meant to provide answers but to provide talking points for an ongoing conversation.

In my previous position at UCSD, we had a Level 1 trauma center where we would keep one operating room (OR) set up and warm at all times for the occasional direct-to-OR resuscitation. We saw all types of acute and subacute orthopedic trauma, and no two cases were approached the same way. Did I consider regional analgesia for each of these patients? Yes.  Did I perform regional analgesia for all of them? No.

In order to have a meaningful discussion on this topic with our surgical colleagues, we must first be part of the conversation.  In the specialty of Regional Anesthesia and Acute Pain Medicine, this means emphasizing more the “Acute Pain Medicine” part than the “Regional Anesthesia” part.  The value that we bring to perioperative patient care must be more than just a set of interventional peripheral nerve and neuraxial block techniques.  We have to know when these techniques are and are not indicated and have other modalities for analgesia at our disposal when providing consultation on complicated trauma patients.  In addition, the service we provide cannot be time-limited.  How can we say that superior pain control is only available from 7 am to 5 pm not including weekends and holidays?

When it comes down to it, managing patients at risk for compartment syndrome is tough.  The benefits of analgesia have to be weighed with the potential for neurovascular compromise.  Sometimes you will perform regional analgesic techniques for them; other times you won’t.  Sometimes, you will place catheters that you can dose later when the risk profile improves; other times you may be consulted for help later in the hospital stay.  Sometimes you will convince the surgeon to preemptively perform fasciotomies in a patient in whom you anticipate a difficult postoperative course.  The context for this decision-making will vary from institution to institution, but ongoing communication with the surgical team is indispensible.  Be a consultant; be available; and continue to be part of the conversation.

Related Posts:

Global Humanitarian Aid and Medical Missions

Originally included in my editorial for the November 2013 issue of ASRA News.

ASRA News Nov 2013In November 2013 issue of ASRA News, we feature two very special articles that touch on the common theme of global humanitarian aid and volunteerism.  Our Resident Section Committee article by Dr. Anish Doshi provides us with an overview of the paucity of pain management and palliative care services in the developing world.  As a new column for ASRA News, the Member Spotlight, we present the amazing work of Dr. Randy Malchow and his team in bringing regional anesthesia and perioperative pain management services and education to Kijabe Hospital in Kenya.

I should say that the contents of this editorial/blog are my own opinions and do not necessarily represent the official views of ASRA.  The subject of medical volunteerism and global humanitarian aid is important to me, having personally participated in multiple medical missions to underserved communities in the Philippines and Ecuador over the last decade.  Many of our ASRA members have dedicated their time and resources to similar causes at home and abroad, and the American Society of Anesthesiologists (ASA) has its own Global Humanitarian Outreach (GHO) Program.  The statistics related to anesthesia and pain management in the developing world are quite shocking.  It is not uncommon for developing countries to have a ratio of less than 1 anesthesiologist for every 100,000 people!  In the realm of pain management and palliative care, the article by Dr. Doshi is particularly eye-opening and should serve as a strong motivator for our members to get involved in helping the underserved.  What is the best way to do that?

The GHO offers a search engine for ASA members to look up volunteer opportunities abroad.  Not everyone can take weeks or months off work to travel to far-away places.  I have been fortunate in that my wife and I have been able to volunteer together—that is, until recently when we started our latest adventure (parenting).  In addition, although not naturally a cynic, I find myself questioning the real difference certain medical mission groups make.  Even though the before and after photos look great, how much difference does it make to a community when a medical mission group swoops in, repairs some cleft lips, and leaves without every returning?  Yes, I understand the social stigma associated with congenital deformities; I have seen it firsthand.  However, I also know that there is a bigger picture to consider—patient education on nutrition, prenatal care, and health care maintenance; access to basic resources, including food, shelter, and transportation; and infrastructure improvements that are required to sustain change.  Furthermore, does this paternalism actually do damage to future relationships with local health officials and governments within the countries in need, especially when late complications arise after the medical mission groups are long gone?

When you read Dr. Malchow’s article, one of the most impressive features of this program is its sustainability.  Not only does this volunteer group provide medical and surgical services to patients in need—a critical part of its “mission” is education of local providers.  Under the direction of Dr. Mark Newton, the Vanderbilt International Anesthesia (VIA) program is engaged in an ongoing relationship with Kijabe Hospital; and by training future generations of local anesthesia providers, VIA is raising the quality and safety of anesthesia and pain management services for the entire region.  One of the most important messages in Dr. Malchow’s article is that you don’t have to fly to Kenya to make a difference.  VIA would not be able to accomplish its goals without the countless people who have donated medical supplies and money for equipment and shipping.

I have been very fortunate to have joined medical mission groups that generally return to the same communities year after year.  One of the most rewarding aspects of participating, in my experience, has been developing relationships—with team members, local physicians and nurses, students and residents, government officials, and patients and families.  Although we can congratulate ourselves on what we have accomplished so far, there is still so much work left to do.

Related Posts:

Essentials of Regional Anesthesia Now Available

essentials-of-regional-anesthesiaThe textbook Essentials of Regional Anesthesia is now available from online booksellers. All of the chapters are written by Regional Anesthesia fellowship directors and fellows and cover various topics including regional anesthesia procedures and acute pain management for complex patients of all ages and various co-morbidities. This book is full of clinical pearls and also includes over 400 test questions based on the book’s content to assess your knowledge of the subject matter. My chapter, co-authored by my wife who has been educating nurses on regional anesthesia techniques and acute pain management for years, focuses on the practice management aspects of regional anesthesia and offers strategies to develop effective systems that emphasize teamwork with all providers involved in caring for the perioperative patient.

Related Posts: