Regional analgesia and acute pain management PDF
Preview Regional analgesia and acute pain management
RegionalAnalgesiaandAcutePainManagement Contributors CONSULTING EDITOR LEEA.FLEISHER,MD,FACC RobertD.DrippsProfessorandChairofAnesthesiologyandCriticalCare,University ofPennsylvaniaSchoolofMedicine,Philadelphia,Pennsylvania GUEST EDITORS SUGANTHAGANAPATHY,MBBS,DA,FRCA,FFARCS(I),FRCPC ProfessorofAnesthesiologyandPerioperativeMedicine,DirectorofRegionalandPain Research,DepartmentofAnesthesiologyandPerioperativeMedicine,LondonHealth SciencesCentre,UniversityHospital,UniversityofWesternOntario,London,Ontario, Canada;ConsultingProfessor,DukeUniversityMedicalCentre,Durham,NorthCarolina VINCENTCHAN,MD,FRCPC Professor,DepartmentofAnesthesiology,UniversityofToronto,TorontoWestern Hospital,Toronto,Ontario,Canada AUTHORS JOSE´ AGUIRRE,MD Consultant,DepartmentofAnesthesiology,BalgristUniversityHospital,Zurich, Switzerland JOHNG.ANTONAKAKIS,MD StaffAnesthesiologist,PortsmouthAnesthesiaAssociates,PortsmouthRegionalHospital, Portsmouth,NewHampshire ALAINBORGEAT,MD ProfessorandChief-of-Staff,DepartmentofAnesthesiology,BalgristUniversityHospital, Zurich,Switzerland ROBERTBOURNE,MD,FRCSC Professor,DivisionofOrthopedics,DepartmentofSurgery,UniversityofWesternOntario, London,Ontario,Canada JONATHANBROOKES,FRCA ClinicalFellowinRegionalAnesthesia,UniversityofWesternOntario,London,Ontario, Canada MARCDEKOCK,MD,PhD DepartmentofAnesthesiaandPerioperativeMedicine,CatholicUniversityofLouvain, StLucHospital,Brussels,Belgium iv Contributors SUGANTHAGANAPATHY,MBBS,DA,FRCA,FFARCS(I),FRCPC ProfessorofAnesthesiologyandPerioperativeMedicine,DirectorofRegionalandPain Research,DepartmentofAnesthesiologyandPerioperativeMedicine,LondonHealth SciencesCentre,UniversityHospital,UniversityofWesternOntario,London,Ontario, Canada;ConsultingProfessor,DukeUniversityMedicalCentre,Durham,NorthCarolina KISHORGANDHI,MD,MPH Director,RegionalAnesthesiaandAssistantProfessorofAnesthesiology,Thomas JeffersonUniversity,JeffersonMedicalCollege,Philadelphia,Pennsylvania IRINAGROSU,MD DepartmentofAnesthesiaandPerioperativeMedicine,CatholicUniversityofLouvain, StLucHospital,Brussels,Belgium JAMESW.HEITZ,MD,FACP Director,PostAnesthesiaCareUnitandAssociateProfessorofAnesthesiology,Thomas JeffersonUniversity,JeffersonMedicalCollege,Philadelphia,Pennsylvania NIRHOFTMAN,MD AssociateClinicalProfessorandDirectorofThoracicAnesthesia,Departmentof Anesthesiology,UniversityofCalifornia,LosAngeles,LosAngeles,California TERESET.HORLOCKER,MD ProfessorofAnesthesiologyandOrthopaedics,DepartmentofAnesthesiology,Mayo Clinic,Rochester,Minnesota BRIANM.ILFELD,MD,MS(ClinicalInvestigation) AssociateProfessor,InResidenceDirectorofClinicalResearch,SectionofRegional AnesthesiaandAcutePainMedicine,DivisionofPainMedicine,Departmentof Anesthesiology,UniversityofCalifornia,SanDiego,SanDiego,California TARAL.KNIZNER,MD Resident,DepartmentofAnesthesiology,UniversityofPittsburghMedicalCenter, Pittsburgh,Pennsylvania PILARMERCADO,MD AssistantProfessorofAnesthesiology,DepartmentofAnesthesiology,Universityof IllinoisatChicago,Chicago,Illinois DENNISP.PHILLIPS,DO AssociateChiefResident,DepartmentofAnesthesiology,UniversityofPittsburgh MedicalCenter,Pittsburgh,Pennsylvania BRIANSITES,MD AssociateProfessorofAnesthesiologyandDirectorofOrthopedicandRegional Anesthesia,Dartmouth-HitchcockMedicalCenter,DartmouthMedicalSchool,Lebanon, NewHampshire PAULH.TING,MD StaffAnesthesiologist,AlbemarleAnesthesia,PLC,MarthaJeffersonHospital, Charlottesville,Virginia EUGENER.VISCUSI,MD Director,AcutePainManagementandAssociateProfessorofAnesthesiology,Thomas JeffersonUniversity,JeffersonMedicalCollege,Philadelphia,Pennsylvania Contributors v GUYL.WEINBERG,MD ProfessorofAnesthesiology,DepartmentofAnesthesiology,UniversityofIllinois atChicago;JesseBrownVeteransAffairsMedicalCenter,Chicago,Illinois BRIANA.WILLIAMS,MD,MBA ProfessorandDirector,DivisionofAmbulatoryAnesthesia,Departmentof Anesthesiology,UniversityofPittsburghSchoolofMedicine,Pittsburgh,Pennsylvania RegionalAnalgesiaandAcutePainManagement Contents Foreword xi LeeA.Fleisher Preface:RegionalAnalgesiaandAcutePainManagement:MajorLeaps inSmallSteps? xiii SuganthaGanapathyandVincentChan Ultrasound-GuidedRegionalAnesthesiaforPeripheralNerveBlocks: AnEvidence-BasedOutcomeReview 179 JohnG.Antonakakis,PaulH.Ting,andBrianSites Ultrasound-guidedregionalanesthesia(UGRA)hasincreasedinpopularity overthepast5years.Thisinterestisreflectedbytheplethoraofpublica- tionsdevotedtotechniquedevelopment,aswellasrandomizedandcon- trolled trials. Despite the excitement around ultrasonography, skeptics argue that there is a lack of evidence-based medicine to support the unequivocaladoptionofUGRAasa“standardofcare.”Thisarticlesum- marizes and critically assesses current data comparing traditional ap- proaches to localizing nerves with those that use ultrasound guidance. Inaddition,thepotentialbenefitsofUGRAthatgobeyondcurrentinforma- tionavailablefromcomparativestudiesareexplored. ContinuousPeripheralNerveBlocksintheHospitalandatHome 193 BrianM.Ilfeld Asingle-injectionperipheralnerveblockusinglong-actinglocalanesthetic providesanalgesiafor12to24hours;however,manysurgicalprocedures resultinpainthatlastsfarlonger.Onerelativelynewoptionisacontinuous peripheralnerveblock(CPNB):localanestheticisperfusedviaaperineural catheterdirectlyadjacenttotheperipheralnerve(s)supplyingthesurgical site,providingpotent,site-specificanalgesia.CPNBresultsindecreased pain, opioid requirements, opioid-related side effects, and sleep distur- bances;insomecases,acceleratingresumptionoftoleratedpassivejoint range-of-motionandincreasingpatientsatisfaction.Ambulatoryperineu- ral infusion may be provided using a portable infusion pump, in some cases resulting in decreased hospitalization duration and related costs. Seriouscomplicationsarerare,butmayresultinsignificantmorbidity. EconomicsandPracticeManagementIssuesAssociatedWithAcute PainManagement 213 DennisP.Phillips,TaraL.Knizner,andBrianA.Williams The use of regional anesthesia (RA) improves cost benefit (hospital- centered)andcostutility(patient-centered)overgeneralanesthesiawith volatile agents (GAVA), based upon research in outpatient populations. Tomakethecostsavingsareality,theauthorsrecommend:(1)avoidance ofGAVAoratleastvolatileagents,(2)adoptingpublishedpostanesthesia viii Contents careunit(PACU)-bypasscriteriaconducivetoRA,(3)maximizingPACU- bypass rates, and (4) utilizing a block induction area. Inpatient-based acutepainservicesarenotuniform,whichmakescostanalysesandcom- parisonbetweenpracticesunreliable.Additionalreviewandcommentary address surgical site infections, cancer recurrence, blood transfusions, andchronicpostsurgicalpain. LocalAnestheticSystemicToxicity:PreventionandTreatment 233 PilarMercadoandGuyL.Weinberg Anesthesiaisasinequanonformostsurgeries.Likeanymedicaladvance, progressinregionalanesthesiahasnotcomewithoutitsshareofcompli- cations, including a spectrum extending from localized nerve injury to systemic cardiovascular toxicity and death. This article discusses the mechanisms and clinical presentation, prevention, treatment, and future trends of local anesthetic systemic toxicity. The adverse effects of lipid emulsiontherapyarealsoincluded. AssessmentandTreatmentofPostblockNeurologicInjury 243 AlainBorgeatandJose´ Aguirre Theincidenceofneurologicdamageafterregionalanesthesiaisrare.How- ever,thiscomplicationmayhavedramaticconsequencesforthepatient becauserecoverymaytakeseveralmonths.Asnerveconductionstudies and electromyography are the cornerstones of investigations in cases of postblock deficit, it is mandatory for the anesthesiologist performing regionalanesthesiatohaveabasicunderstandingoftheseteststodiscuss thecausewiththesurgeonandinformthepatientabouttheprognosis. ComplicationsofRegionalAnesthesiaandAcutePainManagement 257 TereseT.Horlocker Perioperativenerveinjuriesarerecognizedasacomplicationofregional anesthesia.Althoughrare,studiessuggestthefrequencyofcomplications isincreasing.Riskfactorsincludeneural,traumaticinjuryduringneedleor catheter placement, infection, and choice of local anesthetic solution. Neurologicinjuryduetopressurefromimproperpatientpositioning,tightly appliedcastsorsurgicaldressings,andsurgicaltraumaareoftenattrib- uted to regional anesthetic. Body habitus and preexisting neurologic dysfunctionmayalsocontribute.Thesafeconductofregionalanesthesia involvesknowledgeofpatient,anesthetic,andsurgicalriskfactors.Early diagnosisand treatment ofreversible etiologies arecritical tooptimizing neurologicoutcome. UnintentionalSubduralInjection:AComplicationofNeuraxial Anesthesia/Analgesia 279 NirHoftman Unintentional subdural injection during neuraxial anesthesia/analgesia continuestobeachallengeforanesthesiologists.Thisunusualcomplica- tionisoftenpoorlyrecognized,withthediagnosismadeinretrospect,or notatall.Theclinicalpresentationoftheseregionalblockscanbehetero- geneous,rangingfromrestricted,patchy,orunilateralsensoryblockadeall Contents ix the way to extensive and even life-threatening motor and autonomic nervous system depression. Prompt diagnosis using clinical algorithms and radiographic imaging is crucial for the early discontinuation of the offendingcatheter.Supportivecareismandatoryincasesinvolvingsevere depressionofconsciousness,motorfunction,and/orsympathetictone. ChallengesinAcutePainManagement 291 KishorGandhi,JamesW.Heitz,andEugeneR.Viscusi Themanagementofacutepainremainschallenging, withmanypatients suffering inadequate pain control following surgery. Certain populations areatuniqueriskforunrelievedpain.Evidence-basedapproachestaking intoaccountpatients’specificneedsandproblemswilllikelysubstantially improvetheirperioperativeexperience.Thesepatientsmustbeidentified inthepreoperativeprocess,andananesthetic/analgesicplandiscussed and formulated. A targeted multimodal approach to pain management shouldbeconsideredthebestclinicalpractice.Themostchallengingpa- tientsmaybenefitmostfromthesurveillanceofanacutepainservicethat isabletomonitorandcoordinatecareintothepostoperativeperiod. NewConceptsinAcutePainManagement:StrategiestoPreventChronic PostsurgicalPain,Opioid-InducedHyperalgesia,andOutcomeMeasures 311 IrinaGrosuandMarcdeKock Chronic postsurgical pain (CPSP) is a pain syndrome that has attracted attentionformorethan10years.CPSPisapainsyndromethatdevelops postoperatively and lasts for at least 2 months in the absence of other causes for pain (eg,recurrence of malignancy, chronic infection, and so forth). Pain continuing from a preexisting disease is not considered as CPSP. In this article, the authors discuss the etiopathogenesis of CPSP andinterventionsthatcanhelppreventandtreatthiscondition. LocalInfiltrationAnalgesia 329 SuganthaGanapathy,JonathanBrookes,andRobertBourne Pain after major abdominal, orthopedic, and thoracic surgeries can be significantcausingunacceptablemorbidity.Poorlycontrolledpainresults inpatientdissatisfactionandmayalsobeassociatedwithmajormorbid- ities, including perioperative myocardial ischemia, pulmonary complica- tions,alteredimmunefunction,andpostoperativecognitivedysfunction. Various techniques are currently used to manage this pain, and opioids are amongst the most frequently used. Recent literature supports the useofregionalanesthesiaintheformofvariousperipheralnerveblocks as a better alternative. This article discusses the role and evidence for woundinfiltrationanalgesiaingeneralsurgery,orthopedicsurgery,neuro- surgery,andthoracicsurgery. Index 343 RegionalAnalgesiaandAcutePainManagement Foreword LeeA.Fleisher,MD ConsultingEditor Withtheincreasingemphasisonpatient-orientedoutcomesanddeliveryofcost-effec- tivecare,therehasbeenagreatdealofinterestintheuseofinnovativemethodsto controlacutepostoperativepain.Theseincludebothnovelmedicationmanagement andtheuseofregionalanesthetics.Thereisincreasingevidencetosuggestthatthese techniques can lead to earlier discharge with greater patient satisfaction related to controlofpainsymptoms.However,thesearenotwithoutrisksandcosts.Inthisissue ofAnesthesiologyClinics,theguesteditorshavesolicitedanoutstandingcollectionof articles that highlight many of these issues including complications and the medical legal implications, enumeration of these techniques outside of the hospital, and the economic and practice management implications. In the clinical setting, the request to perform these techniques frequently comes from outside of the department and understanding these issues is critical. In the academic setting, our residents are excitedtolearnthesetechniquesandtounderstandboththerisksandthebenefits. ToidentifyeditorsforthisissueofClinics,Ireachedouttotwoleadersofregional anesthesiafromCanada.DrSuganthaGanapathyiscurrentlyProfessorintheDepart- mentofAnesthesiaandPerioperativeMedicineattheUniversityofWesternOntarioand London Health Sciences Centre. She is Director of the Regional and Pain Research Divisionandhasbeenanactiveinvestigatorandleaderinthisareaincludingbeingchair of the regional section of the Canadian Anesthesiologists Society. She has done an outstanding job in putting this issue together. She has been assisted by Dr Vincent Chan,ProfessorofAnesthesiaattheUniversityofToronto.Hehasbeenanactiveleader inthefieldofregionalanesthesiaandisontheeditorialboardsofAnesthesiaandAnal- gesia,andRegional AnesthesiaandPainMedicine. Heisheadoftheregional anes- thesiaandpainprogram at UniversityHealth Network. Hehasbeenon theboardof AnesthesiologyClin29(2011)xi–xii doi:10.1016/j.anclin.2011.04.011 anesthesiology.theclinics.com 1932-2275/11/$–seefrontmatter(cid:1)2011ElsevierInc.Allrightsreserved. xii Foreword directors of the American Society of Regional Anesthesia and Pain Medicine since 1999.Together,theyhaveassembledanoutstandingissue. LeeA. Fleisher,MD Universityof PennsylvaniaSchool ofMedicine 3400SpruceStreet,Dulles680 Philadelphia, PA19104, USA E-mail address: [email protected] RegionalAnalgesiaandAcutePainManagement Preface Regional Analgesia and Acute Pain Management: Major Leaps in Small Steps? SuganthaGanapathy,MBBS,DA, VincentChan,MD,FRCPC FRCA,FFARCS(I),FRCPC GuestEditors Managementofpainhasevolvedsteadilyoverthepastfewyearsthankstotheknowledge derivedfroma largenumberofbasicscienceand clinicalresearchstudies.Whilethe managementofchronicpainhasutilizedasignificantamountofinformationfrom this research, acute pain management has benefited to a lesser extent. Our mainstay of therapyforacutepainremainsopioidbased,butwehaverealizedthatopioiddrugsdo a less-than-optimal job of relieving activity-associated pain in many acute scenarios. Wehavealsorealizedthedownsidetousingopioidsasweseemoreandmorepatients withopioidtolerance,opioid-inducedhyperalgesia,andimmunosupression. While brachial plexus block was performed through an open dissection almost a century ago, it is only in the last three decades that we have started the practice of regional nerve blockade for managing acute pain. Regional anesthesia provides excellentpainreliefparticularlyfororthopedicsurgery,andcansignificantlyimprove activity-associated pain and functional rehabilitation outcomes. The benefits of regional anesthesia are for patients, patients’ families, as well as hospitals. For example, in the face of increasing economic restraints, regional anesthesia allows painfulsurgeriestobeperformedinoutpatientsbyprovidinggoodqualitypainrelief athome.Thiscansavehospitalcostandutilization. Theuseofcontinuousperipheralnerveblockathomeisarelativelynewconcept. Withanysuchinnovation,weinherituniqueproblemsassociatedwithadaptingitinto clinicalpractice.Wehavetomakesuretheblockcathetersareinperfectpositionin ordertosendpatientshomewiththem.Theuseofultrasonograpyforregionalanes- thesiaisgainingpopularity,andthereisgrowingevidencethatultrasoundcanimprove nerveblock accuracy. Drs Antonakakis, Ting,and Sites have provided an evidence- basedcomprehensivereviewofthistopicforusinthisissueofAnesthesiologyClinics. DrIlfeldtellsushowtoprovideeffectivecontinuousperineuralblockadeinthehospital AnesthesiologyClin29(2011)xiii–xiv doi:10.1016/j.anclin.2011.04.012 anesthesiology.theclinics.com 1932-2275/11/$–seefrontmatter(cid:1)2011ElsevierInc.Allrightsreserved.
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