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Update on continuous peripheral nerve block techniques

Update on continuous peripheral nerve block techniques

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There are currently few options to extend the duration of regional analgesia at home beyond the one day expected from most single-injection nerve blocks. Continuous peripheral nerve block (CPNB) with a plain local anesthetic perineural infusion is the most established way to provide days of postoperative pain control and allows titration, but training in insertion techniques and a system to manage ambulatory CPNB patients are necessary. Adjuvants or depot formulations of local anesthetics may offer potential options for limited extension of block duration, but further studies regarding efficacy and safety for regional anesthesia as well as comparative-effectiveness versus CPNB are necessary.

At the conclusion of this activity, learners will be able to: discuss the indications for continuous peripheral nerve blocks; identify obstacles to implementing a continuous peripheral nerve block system; examine various techniques and equipment for continuous peripheral nerve block performance; and discuss the application of ultrasound guidance for perineural catheter insertion.

There are currently few options to extend the duration of regional analgesia at home beyond the one day expected from most single-injection nerve blocks. Continuous peripheral nerve block (CPNB) with a plain local anesthetic perineural infusion is the most established way to provide days of postoperative pain control and allows titration, but training in insertion techniques and a system to manage ambulatory CPNB patients are necessary. Adjuvants or depot formulations of local anesthetics may offer potential options for limited extension of block duration, but further studies regarding efficacy and safety for regional anesthesia as well as comparative-effectiveness versus CPNB are necessary.

At the conclusion of this activity, learners will be able to: discuss the indications for continuous peripheral nerve blocks; identify obstacles to implementing a continuous peripheral nerve block system; examine various techniques and equipment for continuous peripheral nerve block performance; and discuss the application of ultrasound guidance for perineural catheter insertion.

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Update on continuous peripheral nerve block techniques

  1. 1. @EMARIANOMD Update on Continuous Peripheral Nerve Blocks 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, 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 “Precision” Acute Pain Medicine
  4. 4. @EMARIANOMD Overview  Who can do it?  What do you need?  Where should you place them?  Why bother?  How do you make it work?
  5. 5. @EMARIANOMD Overview  Who can do it?  What do you need?  Where should you place them?  Why bother?  How do you make it work?
  6. 6. @EMARIANOMD
  7. 7. @EMARIANOMD Mariano ER, et al. JUM 2015;34:1883 Lectures, Scanning Iterative Practice, Simulation 8 Hour Program
  8. 8. @EMARIANOMD Overview  Who can do it?  What do you need?  Where should you place them?  Why bother?  How do you make it work?
  9. 9. @EMARIANOMD Single-Orifice or Multi-Orifice Stimulating or Non-Stimulating Flexible Springwound or Rigid Plastic Through or Over the Needle Catheter Designs
  10. 10. @EMARIANOMD Remember Other Supplies
  11. 11. @EMARIANOMD Overview  Who can do it?  What do you need?  Where should you place them?  Why bother?  How do you make it work?
  12. 12. @EMARIANOMD Indications  Surgery limited to one extremity (ideally one nerve distribution)  Moderate to severe postoperative pain anticipated  Facilitate same-day discharge and avoid hospitalization for pain management  Improve vascular supply  Early physical therapy and rehabilitation
  13. 13. @EMARIANOMD Possible CPNB Insertion Sites Catheter Site Surgical Site Interscalene Brachial Plexus Shoulder, proximal humerus Supra- or Infraclavicular Brachial Plexus Elbow, forearm, wrist, hand Axillary Brachial Plexus Wrist, hand Posterior Lumbar Plexus or Femoral Nerve/Fascia Iliaca Hip, thigh, knee Femoral Nerve/Adductor Canal Knee Sciatic Nerve Leg, ankle, foot
  14. 14. @EMARIANOMD Interscalene vs. Supraclavicular  RCT: arthroscopic shoulder surgery Supraclavicular US-Guided Catheter Randomized (n=120, observer blinded) Interscalene US-Guided Catheter  Primary outcome: hemidiaphragmatic paresis in PACU and POD1  Secondary outcomes: pain scores, opioid consumption, lung function, complications Wiesmann, et al. Acta Anaes Sc 2016;60:1142
  15. 15. @EMARIANOMD Interscalene vs. Supraclavicular  Any phrenic palsy (PACU) 55% in SC group vs. 82% in IS group  No clinical differences in pulmonary function  No differences in pain or opioid consumption Wiesmann, et al. Acta Anaes Sc 2016;60:1142
  16. 16. @EMARIANOMD Supra- vs. Infraclavicular CPNB  IRB-approved, distal upper extremity surgery Infraclavicular US-Guided Catheter Randomized (n=60, observer blinded) Supraclavicular US-Guided Catheter  Primary outcome: average pain on POD 1  Secondary outcomes: onset time, least and worst pain on POD 1, opioid consumption, leakage rates, awakenings, and satisfaction Mariano ER, et al. RAPM 2011;36:26
  17. 17. @EMARIANOMD Results  Oxycodone: IC 0.0 (0.0-5.0) vs. SC 5.0 (0.0- 15.0; p=0.048)  No other differences Mariano ER, et al. RAPM 2011;36:26
  18. 18. @EMARIANOMD Femoral vs. Lumbar Plexus CPNB  IRB-approved, total hip arthroplasty Lumbar Plexus Stimulating Catheter Randomized (n=50, observer blinded) Femoral Nerve Stimulating Catheter  Primary outcome: average of pain scores for 24 h (equivalency trial)  Secondary outcomes: procedural time, ambulation, opioid consumption, and satisfaction Ilfeld BM, Mariano ER, et al. A&A 2011;113:897
  19. 19. @EMARIANOMD Results  Lumbar plexus catheters took longer to place than femoral catheters – 12.5 (6.2-19.7) min LP – 7 (4-17.2) min femoral – P=0.03  No other differences Ilfeld BM, Mariano ER, et al. A&A 2011;113:897
  20. 20. @EMARIANOMD Overview  Who can do it?  What do you need?  Where should you place them?  Why bother?  How do you make it work?
  21. 21. @EMARIANOMD CFNB and Knee Arthroplasty 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??
  22. 22. @EMARIANOMD Ropiv Saline Can Patients Go Home Faster?  50 subjects, tricompartment TKA  CFNB with 1 night infusion of ropivacaine: randomized to ropiv vs. saline on POD1 Ilfeld BM, et al. Anesth 2008;108:703 3 Discharge Criteria: 1. NRS (pain) < 4 2. IV opioid-free x 12 hours 3. Ambulating > 30 meters
  23. 23. @EMARIANOMD We Know They Work… Ilfeld BM, et al. Anesth 2002;97:959 Ilfeld BM, et al. Anesth 2002;96:1297 Ilfeld BM, et al. A&A 2003;96:1089 Placebo group received initial bolus of LA = single-injection block So Why Isn’t Everyone Doing Them?
  24. 24. @EMARIANOMD Overview  Who can do it?  What do you need?  Where should you place them?  Why bother?  How do you make it work?
  25. 25. @EMARIANOMD The “Gold Standard”
  26. 26. @EMARIANOMD Why Ultrasound for CPNB?
  27. 27. @EMARIANOMD Needle Guidance Options Ilfeld & Mariano. RAPM 2010;35:123 ?
  28. 28. @EMARIANOMD Short-Axis In-Plane Technique Ilfeld & Mariano. RAPM 2010;35:123
  29. 29. @EMARIANOMD US vs. NS for CPNB  4 IRB-approved randomized clinical trials Nerve Stimulation Stimulating Catheter Randomized (n=160, not blinded) Ultrasound Nonstimulating Catheter  Primary outcome: catheter placement time (min)  Secondary outcomes: pain during placement, venous puncture and leakage rates, pain on POD 1 Mariano ER, et al. JUM 2009;28:1453 Mariano ER, et al. JUM 2010;29:329 Mariano ER, et al. RAPM 2009;34:480 Mariano ER, et al. JUM 2009;28:1211
  30. 30. @EMARIANOMD 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
  31. 31. @EMARIANOMD Results  US: less procedure-related pain – Femoral, popliteal  US: less inadvertent vascular punctures – Femoral, infraclavicular  US: higher success rate – Infraclavicular 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
  32. 32. @EMARIANOMD Long-Axis In-Plane Technique Ilfeld & Mariano. RAPM 2010;35:123
  33. 33. @EMARIANOMD Long- vs. Short-Axis In-Plane  IRB-approved; 2 substudies (both lower extremity) Short-Axis In-Plane US-Guided Catheter Randomized (n=100, observer blinded) Long-Axis In-Plane US-Guided Catheter  Primary outcome: onset time following bolus (min)  Secondary outcomes: procedural time, pain during placement, venous puncture and leakage rates, pain and weakness on POD 1
  34. 34. @EMARIANOMD Results: Femoral (n=50)  Onset time: SAX took 9.0 (6.0-20.4) min vs. 6.0 (3.0-14.4) min for LAX (p=0.044)  Procedural time: SAX 5.0 (4.0-7.8) min vs. 9.0 (7.0-14.8) min for LAX (p<0.001)  No other differences  Similar results for popliteal-sciatic Mariano ER, et al. JUM 2013;32:149 Kim TE, et al. J Anesth 2014;28:854
  35. 35. @EMARIANOMD  Stimulating techniques: catheters do not stay “next” to nerves1,2 – Non-stimulating catheters: advance <3 cm1 for >96% success rate3,4 – For 4-10 cm: stimulating beats non-stimulating5-6  What about ultrasound-guided catheters? – 1 cm vs. 5 cm (in-plane): no difference7 2. Capdevila X, et al. A&A 2002;94:1001 1. Enneking K. RAPM 2007;32:280 4. Capdevila X, et al. Anesth 2005;103:1035 5. Rodriguez J, et al. A&A 2006;102:258 6. Casati A, et al. A&A 2005;101:11923. Borgeat A, et al. Anesth 2003;99:436 How Far Should You Insert? 7. Ilfeld BM, et al. RAPM 2011;36:261
  36. 36. @EMARIANOMD Leng & Mariano, et al. J Anesth 2015;29:308
  37. 37. @EMARIANOMD 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)
  38. 38. @EMARIANOMD  Fluid injection (1-3 mL) – Good: does not hinder subsequent ultrasound visualization – Bad: catheter tip location inferred, not visualized  Air injection (0.5-1 mL) – Good: excellent visualization of catheter tip location – Bad: may hinder subsequent ultrasound visualization  Agitated fluid injection (1-2 mL) with Color Doppler – Combination of pros & cons of above two methods – Bad: requires additional time to agitate fluid Checking Catheter Tip Position Sandhu NS, et al. Anesth 2006;104:199 Swenson, JD, et al. A&A 2008;106:1015 Kan & Mariano et al. JUM 2013;32:529 Johns & Mariano et al. JUM 2014;33:2197
  39. 39. @EMARIANOMD Dressing the Catheter  Consider tunneling to minimize leakage  Use an anchoring device1  Liquid adhesive  Clear occlusive dressing  Consider glue2 No sutures: patients can remove catheter themselves at home after infusion ends 1. Borg and Mariano, et al. K J Anesth 2016;69:506 2. Klein SM, et al. Anesth 2003;98:590
  40. 40. @EMARIANOMD Select a Regimen  Infuse local anesthetic solution (no adjuvants)  Ropivacaine preferred over bupivacaine  Should include basal rate (4-8 ml/hr) with PC bolus (2-5 ml) every 20-60 min Start: Ropivacaine 0.2%, 6 ml/hr + PCA 5 ml q 30 min initially May need to hold femoral and lumbar plexus infusions before PT Titrate infusion and adjust settings to individual patient
  41. 41. @EMARIANOMD Educate Patients  Tell patients to expect leakage  Warn patients about motor block  Give them contact info for provider 24/7  Clear instructions for infusion device  Routine follow-up (esp if catheter) – Home nursing not necessary – Phone contact by provider once daily – Caretaker for first 24 hours preferred Ilfeld BM, et al. RAPM 2003;28:418
  42. 42. @EMARIANOMD Summary  We discussed: – Who can do it? – What do you need? – Where should you place them? – Why bother? – How do you make it work?

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