Safe and Efficient Local Anesthetic Continuous Injection in CPNB
Xavier Capdevila M.D.,Ph.D.
Head of Department
Department of Anesthesiology and Critical Care Medicine
Lapeyronie University Hospital and Montpellier School of Medicine
Montpellier , France
Conflicts of interest:
•
Pajunk
•
B Braun
•
GE Healthcare
•
Baxter
•
Janssen
•
Abbott
A Comprehensive Anesthesia Protocol that Emphasizes Peripheral Nerve
Blockade for Total Knee and Total Hip Arthroplasty
JAMES R. HEBL, SANDRA L. KOPP, MIR H. ALI, TERESE T. HORLOCKER, JOHN A. DILGER, MD,
ROBERT L. LENNON, BRENT A. WILLIAMS, ARLEN D. HANSSEN AND MARK W. PAGNANO
THE JOURNAL OF BONE & JOINT SURGERY ·VOLUME 87-A · SUPPLEMENT 2 · 2005
Ilfeld et al Anesthesiology 2008
Patients given 4 days of perineural ropivacaine attained
the 3 discharge criteria in a median (25th-75th
centiles) of 25 ( 21-47)h compared with 71 (46-89)h in
the selected center. Decrease in time until discharge
readiness of 46h
Ilfeld et al Pain 2010
Patients given 4 days of perineural ropivacaine attained the
3 discharge criteria in a median (25th-75th centiles) of 47 (
29-69)h compared with 62 (45-79)h in that multicentric
trial. Decrease in time until discharge readiness of 15h
• « Although more technically demanding, the inplane placement of a continuous femoral nerve
catheter resulted in fewer failed catheters for postoperative analgesia following total knee
arthroplasty.
• The posterior location of the catheter relative to
the femoral nerve may result in a higher success
rate of catheter function. »
From Tou K, Abstract A168, ASRA 2010 et Nader A, J Ultrasound Med 2009
Can we optimize the technique?
« In CFNB under ultrasound guidance, using the catheter perpendicular to the nerve technique
can shorten the time of catheter insertion while providing a similar quality of analgesia after
total knee arthroplasty as compared with the catheter parallel to the nerve technique. »
Average pain scores the day after surgery
for subjects of the 0- to 1-cm group were
a median of 2.5 (interquartile range, 0.05.0), compared with 2.0 (interquartile
range, 0.0-4.0) for subjects of the 5- to 6cm group (P = 0.42). Worst pain scores
during the same period for subjects of the
0- to 1-cm group was
a median of 6.0 (interquartile range, 3.09.0), compared with 7.0 (interquartile
range, 3.0-8.0) for subjects of the 5- to 6cm group (P = 0.37).
Patient-controlled Perineural Analgesia at Home Decreases Postoperative Pain and Enhances Patient's
Functional Exercice Capacity and Daily Activity after Ambulatory Orthopedic Surgery
Results of a Multicenter Randomized Trial
Xavier Capdevila, M.D.,Ph.D.#, Christophe Dadure, M.D.*, Sophie Bringuier-Branchereau, Pharm.D., M.Sc.&, ,
Nathalie Bernard, M.D.*, Philippe Biboulet, M.D.*, Elisabeth Gaertner, M.D.°, Philippe Macaire, M.D.§
Anesthesiology 2006
100
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PCA morph
90
Perf Cont
Bolus+cont
80
70
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The time for the 10-minutes walking test: PCA morphine group: 40.5(16-44 ) h, continuous infusion
group: 20.5 (17-42 )h, and basal-bolus group: 12.5 ( 4.5-20 )h respectively
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The Effects of Varying Local Anesthetic Concentration and Volume on Continuous Popliteal
Sciatic Nerve Blocks: A Dual-Center, Randomized, Controlled Study
Brian M. Ilfeld et al Anesth Analg. 2008 ; 107(2): 701–707
Either 0.2% (basal 8 mL/h, bolus 4 mL) or 0.4% (basal 4 mL/h, bolus 2
mL)
•
Insensate limbs were far more common with larger
volumes of relatively dilute ropivacaine.
•
During continuous sciatic nerve block in the popliteal
fossa,a relatively concentrated solution in smaller
volume thus appears preferable.
Effects of Local Anesthetic Concentration and Dose on Continuous Interscalene Nerve
Blocks: A Dual-Center, Randomized, Observer-Masked, Controlled Study
Linda T. Le et al Reg Anesth Pain Med. 2008 ; 33(6): 518–525
Either 0.2% ropivacaine (basal 8 mL/h, bolus 4 mL) or 0.4% ropivacaine (basal 4 mL/h, bolus 2 mL)
Pain (p=0.020) and dissatisfaction (p=0.011) were
greater in patients given 0.4% ropivacaine
Ropivacaine 0.1% (basal 12 ml/h; bolus 4 ml) or 0.4% (basal3 ml/h; bolus 1 ml)
Each subject’s dominant side was randomized to
either one of the two ropivacaine 0.1%
treatments—a continuous 5 ml/h basal infusion for
6 h or 6 hourly 5-ml bolus doses—and the
nondominant side received the opposite treatment.
The current point of view on pumps: Elastomeric vs Electronic
• No variation with
temperature and pump
position
• More difficult for the
patients
• Batteries
• Variations with T°
and position
• Variation of  15%
• Very well accepted
by the patients
Acute and non-acute complications associated with interscalene block and shoulder surgery
Borgeat A et al, Anesthesiology 2001
Incidence of neurological complications (%)
Perineural
catheters do not
increase the risk of
neurological
complications
Other quite important side effects 0,42%
Side effects
CPNB
LA
Due to PNB
1 Seizure
Fascia iliaca
bupi
NO
3 epidurals
CPCB
ropi
YES
1 Intra peritoneum
CPCB
ropi
YES
One unilateral
epidural due to a
CPCB
Location of one
catheter in the
peritoneal cavity
The risk of falls?
Postoperative Analgesia After Knee Surgery: A Comparison of Three Different
Concentrations of Ropivacaine for Continuous Femoral Nerve Blockade
Brodner G. et al, Anesth Analg 2007
 Ropivacaine 0.1% provided ineffective
analgesia
 Ropivacaine 0.2% and 0.3% were similar in
terms of analgesic quality.
“Initial infusion rates should be adjusted to 15
ml/h!!!!!! to obtain effective analgesia”
Falls Associated with Lower-Extremity–Nerve Blocks: A Pilot Investigation of
Mechanisms
Muraskin S.I. et al, Reg Anesth Pain Med 2007
“ Lower-extremity–nerve blocks result in decreased leg stiffness and lateral
instability, which may lead to difficulty with pivoting maneuvers”
We implemented a policy that all patients who receive LE PNB are evaluated by a
physical therapist prior to discharge. Physical therapists review their home living
environment (stairs, bathroom access, and family assistance), preoperative functional
capacity, cognitif status and a sit-to-stand test along with their ability to ambulate. If
evaluation reveals high fall risk or inadequate home care, the patient will be admitted
for overnight stay.
Fall risks following PNB
%
0,9
0,8
0.93%
0.67%
0,7
0,6
0.48%
0,5
0,4
0,3
0,2
0,1
0
2004
2005
2006
2007
900
800
700
600
500
400
300
200
100
0%
0
Year
Total PNB
Fall risk
ASRA 2008:A4 Edelman A. et al
• Continuous peripheral nerve blocks may be provided in the hospital setting, but the use of
lightweight, portable pumps permits ambulatory infusion as well.
• This technique’s most common application is providing analgesia after surgical procedures.
• Catheter insertion may be accomplished using including nerve stimulation or ultrasound
guidance
• Administered infusate generally includes exclusively long-acting, dilute, local anesthetic
delivered as a bolus only, basal only, or basal-bolus combination.
•
Documented benefits appear to be dependent on successfully improving analgesia, and
include decreasing baseline/breakthrough/dynamic pain, supplemental analgesic
requirements, opioid-related side effects, and sleep disturbances, patient satisfaction and
ambulation and the time until discharge
• Lastly, postoperative joint inflammation and inflammatory markers may be decreased.