CBSPAN Fall Conference
October 2013
Disclosure Statement
I have no financial or research affiliations
with any product or pharmaceutical
manufacturer displayed in this presentation
-Shafonya Turner, M.D.
Objectives





Summarize the basics of choosing regional
anesthesia as a perioperative anesthetic
options
Describe the arbitration of various technique
appropriateness in diverse perioperative
clinical scenarios
Recognize the appropriateness of single-shot
block vs catheter placement in regional
anesthesia
Discuss expectations in PACU
Discuss drawbacks, risks, complications,
concerns of regional anesthesia techniques
Clark Kent : Superman :: Bruce
Wayne :
Hulk
B. Batman
C. Spiderman
D. Wolverine
A.
0%
er
in
ol
v
W
Sp
id
er
m
an
an
tm
Ba
Hu
l
0%
e
0%
k
0%
A 91yo male presents for RUE AVF for future hemodialysis
access. PMHs includes HTN and osteoarthritis. Candidate
for regional anesthesia?
0%
0%
No
B.
Yes
No
Ye
s
A.
Objectives






Summarize the basics of choosing regional
anesthesia as a perioperative anesthetic options
Describe the arbitration of various technique
appropriateness in diverse perioperative clinical
scenarios
Recognize the appropriateness of single-shock block
vs catheter placement in regional anesthesia
Identify expectation in PACU
List options for comprehensive pain management
Discuss drawbacks, risks, complications, concerns of
regional anesthesia techniques
Patient selection…
• Everyone is a potential candidate
• Infants/neonates
• Incapacitated, intubated
• Ongoing infection, heart failure, acute psychological or
neurological derailment1
• If the site is blockable, we can block it!! Risk vs. benefit
• Contraindications
• PATIENT REFUSAL
• Infection at site of needle/catheter placement
• Coagulopathy ( i.e. neuraxial and deeper compartmental block
techniques)
• Allergy to anesthetizing medications
Lumbar  Thoracic
Patient Selection…

Great alternative for:
 Higher risk GA patients
 Chronic pain disorders (Decrease incidence of chronic
pain syndromes)6
 Same day procedures
 High incidence of PONV with
○ GA
○ Narcotics
 High risk pulmonary patients
○
○
○
○
Obesity
COPD
Rib fracture
Elderly
 Initiation of post-operative rehabilitation (orthopedic,
thoracic)
Pamela is scheduled for a partial
vulvectomy for vulvar cancer. Is there a
regional anesthesia option for her?
Yes
B. No
C. Maybe
A.
0%
M
ay
be
0%
No
Ye
s
0%
Buying a new house when the
sink is stopped up is a plausible
option.
se
0%
Fa
l
0%
ue
B.
True
False
Tr
A.
Patient Selection…
Remember overkill!!
Can selectively block just about anything
from the neck down
Patient selection…
Timing always a consideration
 Surgeon preference and discussion
 Follow-up capabilities

Objectives





Summarize the basics of choosing regional
anesthesia as a perioperative anesthetic
options
Describe the arbitration of various technique
appropriateness in diverse perioperative
clinical scenarios
Recognize the appropriateness of singleshock block vs catheter placement in regional
anesthesia
Identify expectation in PACU
Discuss drawbacks, risks, complications,
concerns of regional anesthesia techniques
Which technique?

Upper extremity
 Brachial plexus (interscale, supraclavicular, infraclavicular,
axillary, elbow, wrist, digital block)
 Bier block

Lower extremity
 Lumbar plexus, femoral, 3-in1, sciatic (infragluteal, popliteal
fossa), ankle block
 Bier block
 Lumbar epidural

Thoracic
 Intercostal, paravertebral, thoracic epidural

Abdominal
 Thoracic epidural, TAP (transversus abdominis plane), rectus
sheath

Cervical
 Cervical plexus, occipital nerve
What technique?
Most important question…
Where is the procedure taking place?
Location, Location, Location
Tim is having a nail removed from his ankle
several months after an ORIF of a fracture.
Which block would be appropriate?
at
io
bi
n
m
co
A
of
...
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o
tw
n
of
It
d
ite
al
op
l
(p
ck
bl
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t ic
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ep
en
ds
bl
al
or
..
ck
0%
.
0%
oc
k
0%
bl
o
E.
Fe
m
or
D.
e
C.
Sc
ia
B.
Ankle block
Femoral block
Sciatic block (popliteal
or infragluteal)
It depends
A combination of two of
the above
An
kl
A.
What technique?
Abdominal region and blocking techniques
TAP-Transversus Abdominis Plane
What technique?
Abdominal region and blocking techniques
Thoracic/ High Lumbar Epidural
What technique?
Lower Extremity Surgery and Pain
Usually orthopedic procedures
Vascular (e.g. vein Sclerosing)
What technique?

How long will the procedure take?
 Question in neuraxial anesthesia
○ Spinal anesthesia is finite in duration unless a
catheter left in intrathecal space
○ Epidural anesthesia is more long term (up to
5-7 days)
○ Narcotics in solution also an important point
What technique?

PNB decrease3
 duration of hospital stay
 Total narcotic use
 Time to rehabilitation and through rehab
(economic benefit??)5
 Other serious complications
○ Hypoxia, hypotension, ?DVT?, MI, CVA, GI
distress
Objectives





Summarize the basics of choosing regional
anesthesia as a perioperative anesthetic
options
Describe the arbitration of various technique
appropriateness in diverse perioperative
clinical scenarios
Recognize the appropriateness of singleshock block vs catheter placement in regional
anesthesia
Identify expectation in PACU
Discuss drawbacks, risks, complications,
concerns of regional anesthesia techniques
Dwight presents for R TKA. He refused neuraxial
anesthesia options and ops for a peripheral technique.
The block team decides to do a femoral and sciatic nerve
block. Which one, if any, should get a catheter?
Femoral
B. Sciatic
C. Neither
D. Both
A.
th
0%
Bo
ith
er
0%
Ne
t ic
0%
Sc
ia
Fe
m
or
al
0%
Single-shot vs Catheters




Decrease narcotic use in catheter patients
Decrease LA toxicity and complication due to decrease
rate of injection of LA (local anesthetic )2
In neuraxial anesthesia, possible higher dermatomal
spread of LA in combined spinal/epidural vs spinal
alone4
Prolonged blockade in catheter
Single Shot vs Catheter
Single Shot vs Catheter
Increase is catheter dislodgement
(moisture, friction) and subsequent
patient dissatisfaction
 Catheter site infection or bacteremic
seeding8
 Increased technical difficulty in
placement with larger needles and
longer procedure time
 Logistics of catheter management
services and staff

Objectives





Summarize the basics of choosing regional
anesthesia as a perioperative anesthetic
options
Describe the arbitration of various technique
appropriateness in diverse perioperative
clinical scenarios
Recognize the appropriateness of singleshock block vs catheter placement in regional
anesthesia
Identify expectations in PACU
Discuss drawbacks, risks, complications,
concerns of regional anesthesia techniques
PACU Expectations
Martha has just come out of R rotator cuff surgery. The surgeons
wanted to wait to dose her interscalene catheter until after motor
function of her extremity had been confirmed. 10 minutes before
arrival to the PACU, she receives 30mL 0.5% Ropivacaine in her
catheter. What can you expect?
.
i..
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n
he
re
sp
on
se
w
L it
t le
be
ill
w
th
a
M
ar
w
rit
h
in
g
ie
fw
re
l
pa
in
et
e
0%
yo
u.
..
0%
i..
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ur
.
yo
In
c
om
pl
sq
ue
ez
e
to
D.
0%
ty
C.
bi
li
B.
Inability to squeeze your
finger with her R hand
Incomplete pain relief with no
motor function below the
elbow
Martha will be writhing in pain
Little response when you
draw blood from her AC fossa
In
a
A.
Great Expectations
Failure of epidural analgesia after initial
7
success was observed in 6.8%
 Efficacy of RA ranges 75-85%,
depending on block, technical expertise
 Failure rates of up to 30% with come
brachial plexus techniques.

Great Expectations
Great Expectations
Ranking in order of painfulness
A
B
C
C
c.
B
b.
A
B
C
A
a.
Great Expectations

Comes down to experience
 Some outpatient centers do 75% of their
anesthetics with RA
 Quicker recovery, better infrastructure to facilitate
the initiative
 Prepare patients for the experience/expectation

Comes down to commitment
 Facility commitment to staffing, space, time, and
money
 Providers commitment to safe, good care,
education, leadership
Objectives





Summarize the basics of choosing regional
anesthesia as a perioperative anesthetic
options
Describe the arbitration of various technique
appropriateness in diverse perioperative
clinical scenarios
Recognize the appropriateness of singleshock block vs catheter placement in regional
anesthesia
Identify expectations in PACU
Discuss drawbacks, risks, complications,
concerns of regional anesthesia techniques
The good, now the bad

Everything has risk and benefits
 These are different for each patient even
with similar co-morbidities and deficits
The informed consent
 Even done perfectly, complications arise
 All that glitters is not gold

How long does the ASRA say we should
wait to place an epidural in a patient in
ASA?
A. 7 days
B. 5 days
C. 2 days
D. No days
0%
No
da
y
s
s
da
y
2
da
y
5
da
y
7
0%
s
0%
s
0%
•
•
•
•
•
•
Antiplatelet medications (ASA, Plavix, NSAIDs)
Oral anticoagulants (Warfarin)
Standard heparin
LMWH (Lovenox, Aggranox)
Thrombolytic and fibrinolytic therapy (tPA)
Herbal preparations ( Garlic, ginger, feverfew, Ginseng,
Alfalfa, chamomile, horse chestnut, ginseng, Vitamin E,
Ginko)
• New anticoagulants
Risks
Bleeding
 Infection
 Nerve injury
 Failure
 Toxicity (cardiac and neurological)

Risks

Patient safety
 Prolonged blockade patient should have support
at home
○ Falls
○ Medication toxicity
○ Injury to the anesthetized limb
○ Inablilty to complete ADL
 Given through instructions on pain management
and duration of blockade
 For those with take home catheters, instructions
and removing catheter or given options to return
for removal
Drawbacks
Hemodynamic instability – neuraxial
anesthesia
 Headaches
 Urinary retention
 Pneumothorax and vascular injury on
placement
 Pain/discomfort with block placement
 Follow up
 Incomplete relief

References
1. Barash 7th edition
2.
3.
4.
5.
6.
7.
8.
9.
Analgesic Effectiveness of a Continuous Versus Single-Injection Interscalene Block for MinorArthroscopic Shoulder
Surgery Michel J. Fredrickson, MD,* Þ Craig M. Ball, MD,* and Adam J. Dalgleish (Reg Anesth Pain Med 2010;35:
28Y33) Regional Anesthesia and Pain Medicine & Volume 35, Number 1, January-February 2010
Chelley JE, Continuous femoral blocks improve recovery and outcome of patients undergoing TKA. J arthrophasty
2001
Sensorimotor anesthesia and hypotension after subarachnoid block: combined spinal-epidural versus single-shot
spinal technique. Goy RW, Sia AT.
Capdevila, X. Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after
major knee surgery. Anesthesiology 1999;91:8-15
Perkins FM. Chronic pain as an outcome of surgery. A review of predictive factors. Anesthesiology 2000;93:11123-1133
Pan PH, Bogard TD, Owen MD. Incidence and characteristics of failures in obstetric neuraxial analgesia and
anesthesia: a retrospective analysis of 19,259 deliveries. Int J Obstet Anesth 2004;13:227-33.
Cuvillon P. The Continuous Femoral Nerve Block Catheter for Postoperative Analgesia: Bacterial Colonization,
Infectious Rate and Adverse Effects. Anesth Analg 2001;93:1045–9
Finucane B. Complications of Regional Anesthesia. Springer Science. New York. 2007.