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Considerations for Regional Anesthesia in the Trauma Patient

Considerations for Regional Anesthesia in the Trauma Patient

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Trauma is one of the primary causes of mortality and morbidity worldwide, and pain is the most common symptom reported by patients entering the Emergency Department. More than 5 million people in the United States report long-term disabilities due to traumatic injuries. Safe intraoperative care and effective acute pain management are essential for successful outcomes in the trauma patient.

Trauma is one of the primary causes of mortality and morbidity worldwide, and pain is the most common symptom reported by patients entering the Emergency Department. More than 5 million people in the United States report long-term disabilities due to traumatic injuries. Safe intraoperative care and effective acute pain management are essential for successful outcomes in the trauma patient.

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Considerations for Regional Anesthesia in the Trauma Patient

  1. 1. Considerations for Regional Anesthesia in the Trauma Patient Edward R. Mariano, M.D., M.A.S. Professor of Anesthesiology, Perioperative & Pain Medicine Stanford University School of Medicine Chief, Anesthesiology and Perioperative Care Veterans Affairs Palo Alto Health Care System @EMARIANOMD
  2. 2. Regional Anesthesia in Trauma Financial Disclosures  Halyard, B Braun – Unrestricted educational program funding paid to my institution The contents of the following presentation are solely the responsibility of the speaker without input from any of the above companies.
  3. 3. Regional Anesthesia in Trauma Overview  Benefits of regional anesthesia  Risks of regional anesthesia  Review of the evidence  Training in regional anesthesia  The bottom line—yes or no
  4. 4. Regional Anesthesia in Trauma Overview  Benefits of regional anesthesia  Risks of regional anesthesia  Review of the evidence  Training in regional anesthesia  The bottom line—yes or no
  5. 5. Regional Anesthesia in Trauma What is Regional Anesthesia?  Regional anesthesia generally involves the introduction of local anesthetic medications to temporarily interrupt sensation to a specific part of the body
  6. 6. Regional Anesthesia in Trauma Why Do Regional Anesthesia?
  7. 7. Regional Anesthesia in Trauma Gadsden & Warlick. Loc Reg Anes 2015;8:45
  8. 8. Regional Anesthesia in Trauma Overview  Benefits of regional anesthesia  Risks of regional anesthesia  Review of the evidence  Training in regional anesthesia  The bottom line—yes or no
  9. 9. Regional Anesthesia in Trauma What Are the Risks?  Local anesthetic toxicity  Other risks – Bleeding – Infection – Nerve injury  Incidence of nerve injury not clear: 1/41851 – 3/1002 1. Auroy Y, et al. Anesth 2002;97:1274 2. Brull R, et al. A&A 2007;104:965
  10. 10. Regional Anesthesia in Trauma Meta-Analysis of Nerve Injury  Data from 32 studies (1/1/95 - 12/31/05) in adult patients  Rates of occurrence (any neurologic symptoms): – CNB = <4:10,000 or 0.04% – PNB = <3:100 or 3% (site-dependent)  Permanent neurological injury – CNB = 0-7.6:10,000 – PNB = insufficient data (1 case) Brull R, et al. A&A 2007;104:965
  11. 11. Regional Anesthesia in Trauma Acute Compartment Syndrome  Many factors  6 classic signs/symptoms: – Pain – Pressure – Pulselessness – Paralysis – Paresthesia – Pallor  Concern over analgesia delaying diagnosis Olson SA, et al. J Am Acad Ortho 2005;13:436
  12. 12. Regional Anesthesia in Trauma Acute Compartment Syndrome Gadsden & Warlick. Loc Reg Anes 2015;8:45
  13. 13. Regional Anesthesia in Trauma Acute Compartment Syndrome  Systematic review to evaluate effect of pain management on diagnosis  All case reports and series (Level 3 evidence; 28 reports)  No randomized clinical trials to date Mar JG, et al. BJA 2009;102:3
  14. 14. Regional Anesthesia in Trauma Beware of Falls!
  15. 15. Regional Anesthesia in Trauma Overview  Benefits of regional anesthesia  Risks of regional anesthesia  Review of the evidence  Training in regional anesthesia  The bottom line—yes or no
  16. 16. Regional Anesthesia in Trauma Pre-Hospital Fascia Iliaca Blocks  Case series: 27 patients with presumed femur fx  Patients approached at scene of accident  Fascia iliaca blocks performed blindly with 20 ml 1.5% lido with epi 5 mcg/ml  1 block failure “…performed by senior anesthesiologists trained in emergency medicine and regional techniques.” Lopez S, et al. RAPM 2010;28:203
  17. 17. Regional Anesthesia in Trauma Blocks in the Emergency Dept  Double-masked RCT of fascia iliaca blocks in 48 subjects with femur fx1 – 67% success rate – Lower pain scores and morphine consumed in fascia iliaca group  Case series from ED2,3 1. Foss NB, et al. Anesth 2007;106:773 2. Beaudoin FL, et al. Am J Emerg Med 2010;28:76 3. Stewart B, et al. Emerg Med J 2007;24:113 “All investigators were junior anesthesiologists...”
  18. 18. Regional Anesthesia in Trauma Pediatric ED Experience  Fascia iliaca blocks vs. IV morphine (n=55) for femur fx1 – Lower pain scores – Less supplemental analgesics in block group  Axillary blocks vs. sedation (n=43) for fx manipulation2 – No difference in pain scores – 2/20 failed blocks – 11/20 incomplete blocks 1. Wathen JE, et al. Ann Emerg 2007;50:162 2. Kriwanek KL, et al. J Ped Ortho 2006;26:737
  19. 19. Regional Anesthesia in Trauma Overview  Benefits of regional anesthesia  Risks of regional anesthesia  Review of the evidence  Training in regional anesthesia  The bottom line—yes or no
  20. 20. Regional Anesthesia in Trauma How Hard Can It Be? NYSORA.COM -
  21. 21. Regional Anesthesia in Trauma The Newest Subspecialty
  22. 22. Regional Anesthesia in Trauma The Newest Subspecialty DON’T BE A Acute Pain Medicine = not just blocks
  23. 23. Regional Anesthesia in Trauma Overview  Benefits of regional anesthesia  Risks of regional anesthesia  Review of the evidence  Training in regional anesthesia  The bottom line—yes (with caveats)
  24. 24. Regional Anesthesia in Trauma Develop a System  Discuss with trauma surgeons in advance regarding appropriate patients and types of blocks  Who will be performing blocks? – Dedicated regional anesthesia providers vs. – All practitioners equally trained  Use consistent practices and equipment  Communication is key!
  25. 25. Regional Anesthesia in Trauma Perform Blocks in a Safe Place  Standard ASA monitors available  Oxygen source  Resuscitation equipment available  Skilled assistants nearby Mariano ER. Anesth Clin 2008;28:681
  26. 26. Regional Anesthesia in Trauma Education and Follow-Up  Coordinate postop care with primary team  Careful neurovascular assessment (be on the look-out for compartment syndrome)  Provide contact info for regional anesthesia service available 24/7  Clear instructions for infusion device  Routine daily follow-up (esp if catheter) – Caretaker for first 24 hours if discharged Ilfeld BM, et al. RAPM 2003;28:418
  27. 27. Regional Anesthesia in Trauma Take Home Message Gadsden & Warlick. Loc Reg Anes 2015;8:45
  28. 28. Regional Anesthesia in Trauma Summary  We discussed: – Benefits of regional anesthesia – Risks of regional anesthesia – Review of the evidence – Training in regional anesthesia – The bottom line—yes (with caveats)

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