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Regional anesthesia and perioperative outcomes

Regional anesthesia and perioperative outcomes

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At the conclusion of this activity, learners will be able to: discuss the benefits of regional anesthesia on pain and rehabilitative outcomes; identify applications of “big data” in outcomes assessment; and critically evaluate the evidence related to regional anesthesia and analgesia and long-term outcomes.

At the conclusion of this activity, learners will be able to: discuss the benefits of regional anesthesia on pain and rehabilitative outcomes; identify applications of “big data” in outcomes assessment; and critically evaluate the evidence related to regional anesthesia and analgesia and long-term outcomes.

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Regional anesthesia and perioperative outcomes

  1. 1. @EMARIANOMD Regional Anesthesia and Perioperative Outcomes 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
  2. 2. @EMARIANOMD Financial Disclosures  Halyard Health, 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. @EMARIANOMD Overview  Regional Anesthesia and Postoperative Complications  Regional Analgesia and Functional Outcomes  Regional Analgesia and Perioperative Medicine
  4. 4. @EMARIANOMD Overview  Regional Anesthesia and Postoperative Complications  Regional Analgesia and Functional Outcomes  Regional Analgesia and Perioperative Medicine
  5. 5. @EMARIANOMD Neuraxial Anesthesia  30-day mortality was lower for neuraxial and neuraxial/GA vs. GA alone for TKA  Most in-hospital complications were lower for neuraxial and neuraxial/GA vs. GA alone  Transfusion requirements lowest for neuraxial Memtsoudis SG, et al. Anesth 2013;118:1046
  6. 6. @EMARIANOMD Peripheral Nerve Blocks  >1 million patients, 12.5% received PNB  PNB associated with: – Lower rates of complications – Decrease length of stay – Lower rates of transfusion – Lower rate of ICU admission (THA only) Memtsoudis SG, et al. Anesth 2013;118:1046
  7. 7. @EMARIANOMD Overview  Regional Anesthesia and Postoperative Complications  Regional Analgesia and Functional Outcomes  Regional Analgesia and Perioperative Medicine
  8. 8. @EMARIANOMD What About Function?
  9. 9. @EMARIANOMD Selection of Outcomes  Range of motion (degrees)  Timed ambulation distance (meters) – 6-MWT – 2-MWT  Muscle strength (force)  Timed performance (min) – TUG  Western Ontario and McMaster Univ Osteoarthritis Index (WOMAC)  Knee Society Score  Lower Extremity Functional Scale  Health-Related Quality of Life Choi S, et al. RAPM 2013;38:340 Bernucci & Carli. Curr Op Anaes 2012;25:621 Performance-Based Self-Reported &
  10. 10. @EMARIANOMD Epidural Analgesia  Bupiv 0.25% at 6-15 ml/h vs. opioids1 – Epid group had lower pain scores but high proportion had complete motor block  Epid bupiv+MS vs. epid MS vs. IV opioids2 – Bupiv+MS: shorter time to achieve ambulation distance and range of motion goals – Shorter hospital length of stay 1. Raj PP, et al. A&A 1987;66:401 2. Mahoney OM, et al. CORR 1990;Nov:30
  11. 11. @EMARIANOMD Anticoagulation Guidelines Horlocker TT, et al. RAPM 2010;35:64
  12. 12. @EMARIANOMD CFNB vs. Epidural for TKA  Comparable analgesia  Better side effect profile with CFNB – Less nausea and vomiting – Less urinary retention (no need for foley) – Sparing of non-operative limb – No epidural hematoma (anticoagulation)  Epidurals require hospitalization Barrington MJ, et al. A&A 2005;101:1824 Zaric D, et al. A&A 2006;102:1240
  13. 13. @EMARIANOMD Ropiv Saline CFNB: Faster Discharge Eligibility  50 subjects, tricompartment TKA  CFNB with 1 night infusion of ropivacaine: randomized to ropiv vs. saline on POD1 Ilfeld & Mariano, et al. Anesth 2008;108:703 3 Discharge Criteria: 1. NRS (pain) < 4 2. IV opioid-free x 12 hours 3. Ambulating > 30 meters
  14. 14. @EMARIANOMD CFNB and Range of Motion Knee Flexion (Degrees) PCA CFNB P Value POD #1 33 ± 15 56 ± 22 0.009 POD #3 53 ± 17 74 ± 11 <0.001 6 weeks 103 ± 12 116 ± 12 0.03 3 months 116 ± 11 124 ± 12 NS Singelyn FJ, et al. A&A 1998;87:88 Is this a possible long-term effect?? If so, what is the mechanism?
  15. 15. @EMARIANOMD CFNB vs. Local Infiltration  RCT (n=40) of CFNB vs. LIA – At 6 weeks, the CFNB group showed greater within-group improvement in 6-MWT, physical activity (CHAMPS), KSS, and WOMAC – Preop 6-MWT, walking on POD1, time spent walking during POD1-3 were predictors of 6- MWT at 6 weeks Carli F, et al. BJA 2010;105:185
  16. 16. @EMARIANOMD Long-Term Outcomes (So Far)  1 yr Western Ontario and McMaster Univ Osteoarthritis Index (WOMAC) scores Ilfeld & Mariano, et al. A&A 2009;108:1320 Ilfeld & Mariano, et al. A&A 2009;109:586
  17. 17. @EMARIANOMD Lower Extremity CPNB and Falls  Pooled analysis of 3 published RCTs (knee and hip arthroplasty) with CPNB x 4 days – 85 subjects received ropivacaine 0.2% – 86 subjects received saline  No falls in the saline group vs. 7 falls in the ropiv group (P=0.013) Ilfeld BM, et al. A&A 2010;111:1552 Memtsoudis & Mariano, et al. Anesthesiology 2014;120:551 Premier Perspective Database; n=191,570  PNB in 12.1% of cases; no association with falls  Risk factors=higher age, greater comorbidity burden
  18. 18. @EMARIANOMD Introducing Adductor Canal Block Perlas A, et al. RAPM 2013;38:334
  19. 19. @EMARIANOMD  Patients in the adductor canal group walked 37 (0-90) meters vs. 6 (0-51) meters in the femoral catheter group (p=0.003).  Pain scores, opioid consumption, and hospital length of stay were similar. Adductor Canal vs. Femoral CPNB Mudumbai & Mariano, et al. CORR 2014;472:1377
  20. 20. @EMARIANOMD Evidence from RCTs  TKA: continuous ACB vs. FNB1 – Greater preservation of quad MVIC in ACB group (median 52% vs. 18%) – No differences in pain, opioids, flexion, TUG  TKA: repeated bolus ACB vs. FNB2 – ACB had better TUG, 10 meter walk time, and 30 sec chair test – No differences in pain, opioids 1. Jaeger P, et al. RAPM 2013;38:526 2. Shah NA and Jain NP. J Arthro 2014;29:2224
  21. 21. @EMARIANOMD Masaracchia MM, et al. Acta Anaes Scand 2017;61:224
  22. 22. @EMARIANOMD Overview  Regional Anesthesia and Postoperative Complications  Regional Analgesia and Functional Outcomes  Regional Analgesia and Perioperative Medicine
  23. 23. @EMARIANOMD One Size Does Not Fit All REGIONAL ANESTHESIOLOGIST
  24. 24. @EMARIANOMD Era of “Precision” Medicine
  25. 25. @EMARIANOMD Remember Multimodal Anesthesiology 2012;116:248
  26. 26. @EMARIANOMD Remember Multimodal Anesthesiology 2012;116:248
  27. 27. @EMARIANOMD Adductor Canal Block is Not Perfect
  28. 28. @EMARIANOMD Anesth Clinics 2014;32:853
  29. 29. @EMARIANOMD Perioperative Surgical Home “a patient-centered, physician anesthesiologist-led, multidisciplinary team- based practice model that coordinates surgical patient care throughout the continuum from the decision to pursue surgery through convalescence. Mariano, et al. A&A 2015;120:1163 Kain, et al. A&A 2014;118:1126
  30. 30. @EMARIANOMD Mariano, Walters, Kim, Kain. A&A 2015;120:1163 Walters, Mariano, Clark. Pain Med 2015;16:1666.
  31. 31. @EMARIANOMD Sun, et al. A&A 2017 epub
  32. 32. @EMARIANOMD Sun, et al. A&A 2017 epub
  33. 33. @EMARIANOMD We Can Do Better Lavand’homme, et al. CORR 2014;472:1409 TKA Patients Normal Persistent Pain Neuropathic Pain
  34. 34. @EMARIANOMD 2017 epub http://www.edmariano.com/archives/1196 27%! J Arthroplasty 2016
  35. 35. @EMARIANOMD Summary  We discussed: – Regional Anesthesia and Postoperative Complications – Regional Analgesia and Functional Outcomes – Regional Analgesia and Perioperative Medicine

Notas del editor

  • A post-hoc power calculation revealed 89% power to detect this difference.

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