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The Quest for Longer Block Duration: Techniques and Evidence

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I gave this talk at the 2020 Winter Anesthesiology Meeting of the California Society of Anesthesiologists (#CSAHSWinter20).

My objectives were to:
1. Discuss adjuvants for extending single-injection nerve block duration;
2. Provide an update on continuous peripheral nerve blocks; and
3. Address practical considerations and present a strategy for personalized postoperative pain medicine.

I gave this talk at the 2020 Winter Anesthesiology Meeting of the California Society of Anesthesiologists (#CSAHSWinter20).

My objectives were to:
1. Discuss adjuvants for extending single-injection nerve block duration;
2. Provide an update on continuous peripheral nerve blocks; and
3. Address practical considerations and present a strategy for personalized postoperative pain medicine.

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The Quest for Longer Block Duration: Techniques and Evidence

  1. 1. 2020 CSA Winter Anesthesia Conference @EMARIANOMD The Quest for Longer Block Duration: Techniques and Evidence 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. No financial disclosures. 2020 CSA Winter Anesthesia Conference
  3. 3. @EMARIANOMD #CSAHSWinter20 How Long Does Pain Last? Lavand’homme, et al. CORR 2014;472:1409 TKA Patients Normal Persistent Pain Neuropathic Pain
  4. 4. @EMARIANOMD #CSAHSWinter20 How Do You See Pain Medicine?
  5. 5. @EMARIANOMD #CSAHSWinter20 Overview  Adjuvants for extending single-injection nerve block duration  Update on continuous peripheral nerve blocks  Practical considerations
  6. 6. @EMARIANOMD #CSAHSWinter20 Overview  Adjuvants for extending single-injection nerve block duration  Update on continuous peripheral nerve blocks  Practical considerations
  7. 7. @EMARIANOMD #CSAHSWinter20 “We Can Place a Catheter… © Mike Mariano
  8. 8. @EMARIANOMD #CSAHSWinter20 …But Single-Injection is Fine” Heard at every anesthesiology residency program everywhere!
  9. 9. @EMARIANOMD #CSAHSWinter20 Epinephrine  Vasoconstriction decreases vascular uptake  May decrease plasma concentration and potential for systemic toxicity  Prolongs duration of lipophobic anesthetics (mepivacaine, lidocaine) but not lipophilic long-acting anesthetics – Ropivacaine already vasoconstrictive Weber A, et al. A&A 2001;93:1327 <1 Day
  10. 10. @EMARIANOMD #CSAHSWinter20 Clonidine  Clinically relevant prolongation of brachial plexus anesthesia at 0.5 mcg/kg + LA1 – May be more pronounced with lipophobic anesthetics – 1 mcg/kg prolongs ropivacaine duration with slight increase in sedation2  Systematic review (27 studies)3 – Prolongs intermediate LA (mepivacaine) for select blocks 1. Singelyn FJ, et al. A&A 1996;83:1046 2. Casati A, et al. A&A 2000;91:388 3. McCartney C, et al. RAPM 2007;32:330 <1 Day
  11. 11. @EMARIANOMD #CSAHSWinter20 Dexmedetomidine  Mean 261 min more sensory block  Mean 201 min more motor block (except interscalene)  Mean 3 min faster onset when >50 mcg  Mean 289 min more analgesia (except axillary), no difference at 24 hrs Hussain N, et al. RAPM 2017;42:184 <1 Day
  12. 12. @EMARIANOMD #CSAHSWinter20 Opioids  Peripheral opioid receptors exist: relevant for intraarticular injections  No clear benefit for most opioids – Results conflicting – Opioid-induced side effects possible  Buprenorphine of interest – RCTs have shown longer duration of analgesia when added to LA1,2 – Not FDA-approved for nerve blocks 1. Candido KD, et al. RAPM 2002;27:162 2. Candido KD, et al. Anesth 2010;113:1419 <1 Day
  13. 13. @EMARIANOMD #CSAHSWinter20 Dexamethasone • RCT of ISB: 0.5% bupiv, epi, and clonidine 75 mcg ± dex 8 mg1 – Sensory block (24 vs. 14 hr, p<0.001) – Motor block (23 vs. 14 hr, p<0.001) • RCT of axillary blocks: 1.5% lido ± dex 8 mg2 • RCT of SCB: 1.5% mepiv ± dex 8 mg3 • Mechanism? Optimal dose? Off-label USA 1. Vieira PA, et al. EJA 2009;27:285 2. Movafegh A,et al. A&A 2006;102:263 3. Parrington S,et al. RAPM 2010;35:422 IV works just as well as perineural Fredrickson et al. RAPM 2013; 38: 300 Desmet et al. BJA 2013;111:445 Rosenfeld et al. Anaesth 2016;4:380 ~1 Day
  14. 14. @EMARIANOMD #CSAHSWinter20 Dexamethasone  May be different for distal brachial plexus  8 mg Perineural > IV for axillary1 – Mean 4.6 hr more motor block – Mean 4.0 hr more sensory block + analgesia  5 mg Perineural > IV for infraclavicular2 – Mean 2.8 hr more motor block – Mean 2.9 hr more sensory block – Mean 3.5 hr more analgesia 1. Aliste J, et al. CJA 2017;64:29 2. Leurcharusmee P, et al. RAPM 2016;41:328 ~1 Day
  15. 15. @EMARIANOMD #CSAHSWinter20 Adjuvant Reliable Block Duration >24 hrs Epinephrine Clonidine Dexmedetomidine Opioids except buprenorphine Buprenorphine Dexamethasone Based on actual studies; inspired by Dr. Patrick Wong, University of Ottawa
  16. 16. @EMARIANOMD #CSAHSWinter20 4-Drug Combination Buvanendran, et al. RAPM 2016;41:589 Clonidine alone accounts for prolongation
  17. 17. @EMARIANOMD #CSAHSWinter20 Liposomal Bupivacaine  Only FDA-approved in USA for interscalene blocks for shoulder surgery Viscusi ER. RAPM 2005;30:491 1-3 Days? Not Titratable
  18. 18. @EMARIANOMD #CSAHSWinter20 Liposomal Bupivacaine
  19. 19. @EMARIANOMD #CSAHSWinter20 Ilfeld BM. Anesth 2018;129:623
  20. 20. @EMARIANOMD #CSAHSWinter20 Liposomal Bupivacaine for Block? Ohri R, et al. RAPM 2012;37:607 Boogaerts JG, et al. CJA 1993;40:1201  Is 96h of block always good? 96 hrs
  21. 21. @EMARIANOMD #CSAHSWinter20 Overview  Adjuvants for extending single-injection nerve block duration  Update on continuous peripheral nerve blocks  Practical considerations
  22. 22. @EMARIANOMD #CSAHSWinter20 How Do You See Pain Medicine?
  23. 23. @EMARIANOMD #CSAHSWinter20 How Do You See Pain Medicine?
  24. 24. @EMARIANOMD #CSAHSWinter20 The “Gold Standard”
  25. 25. @EMARIANOMD #CSAHSWinter20 Meta-analysis: CPNB vs. Opioids Richman JM, et al. A&A 2006;102:248 Mean VAS 24h 48h Infraclav 1.0 vs. 4.3 p<0.001 0.6 vs. 4.0 p<0.001 Interscal 1.4 vs. 3.6 p<0.001 0.5 vs. 2.3 p<0.001 Fem/LP 2.1 vs. 4.0 p<0.001 1.6 vs. 3.2 p<0.001 Sciatic 0.9 vs. 4.6 p<0.001 0.9 vs. 3.5 p<0.001
  26. 26. @EMARIANOMD #CSAHSWinter20 Overview  Adjuvants for extending single-injection nerve block duration  Update on continuous peripheral nerve blocks  Practical considerations
  27. 27. @EMARIANOMD #CSAHSWinter20 Use Ultrasound Ilfeld & Mariano. RAPM 2010;35:123
  28. 28. @EMARIANOMD #CSAHSWinter20 Results Popliteal Mariano ER, et al. RAPM 2009;34:480 Mariano ER, et al. JUM 2009;28:1211 Mariano ER, et al. JUM 2009;28:1453 Mariano ER, et al. JUM 2010;29:329
  29. 29. @EMARIANOMD #CSAHSWinter20 Mariano ER, et al. JUM 2015;34:1883 Lectures, Scanning Iterative Practice, Simulation 8 Hour Program
  30. 30. @EMARIANOMD #CSAHSWinter20 Single-Orifice or Multi-Orifice Stimulating or Non-Stimulating Flexible Springwound or Rigid Plastic Through or Over the Needle Catheter Designs
  31. 31. @EMARIANOMD #CSAHSWinter20 Leng & Mariano, et al. J Anesth 2015;29:308
  32. 32. @EMARIANOMD #CSAHSWinter20 Catheter Type and Migration Steffel & Mariano, et al. K J Anesth 2017;70:72 Cadaver-based study CON: 4/15 (27%) dislocated vs. CTN 0/15 (p=0.043)
  33. 33. @EMARIANOMD #CSAHSWinter20 Securing the Catheter  Consider tunneling  Use an anchoring device1  Liquid adhesive  Clear occlusive dressing  Consider glue2 1. Borg & Mariano, et al. K J Anesth 2016;69:506 2. Klein SM, et al. Anesth 2003;98:590
  34. 34. @EMARIANOMD #CSAHSWinter20 Summary  We discussed: – Adjuvants for extending single-injection nerve block duration – Update on continuous peripheral nerve blocks – Practical considerations

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