JC Gerancher Making PNB last a longtime

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this presentation reviews basic information on adjuncts to local anesthetics and peripheral nerve blockade. it was last undated and used for anesthesiology resident education in 2011. hope you find this information helpful. John Gerancher JC Gerancher MD

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JC Gerancher Making PNB last a longtime

  1. 1. Making peripheral nerve blocks work … for a really, really long JC Gerancher MD Professor and Section Head Regional Anesthesia & Acute Pain Management Medical Director of Surgical Services Informatics
  2. 2. Analgesia defined… • • • • Anesthesia Motor block Sensory block “Analgesia= first request for additional analgesia.”
  3. 3. Patient Satisfaction as an outcome of regional analgesia (not anesthesia) • 7 of 10 RCT‟s demonstrate improved patient satisfaction from post-op regional analgesia • All of these 7 trials showed lower VAS pain scores • None of 5 RCT‟s demonstrate improved satisfaction from intra-op regional anesthesia - Wu 2001
  4. 4. Local Anesthesia for PNB: No Free Lunch Manufacturer’s Recommended Maximum Dose (mg) Mean Latency to Surgical Anesthesia (minutes) Mean Duration of Surgical Anesthesia (hours) Mean Duration of Postoperative Analgesia (hours) 2-chloroprocaine (Nesacaine) 980 5-15 1-2 2-3 Lidocaine (Xylocaine) 490 7-15 2-3 3-5 Mepivacaine (Polocaine, Carbocaine) 400 10-15 3-4 4-6 Bupivacaine (Marcaine) 225 15-40 6-10 12-17 Ropivacaine (Naropin) 250 15-40 5-9 8-14
  5. 5. Local Anesthesia for PNB: No Free Lunch Manufacturer’s Recommended Maximum Dose (mg) Mean Latency to Surgical Anesthesia (minutes) Mean Duration of Surgical Anesthesia (hours) Mean Duration of Postoperative Analgesia (hours) 2-chloroprocaine (Nesacaine) 980 5-15 1-2 2-3 Lidocaine (Xylocaine) 490 7-15 2-3 3-5 Mepivacaine (Polocaine, Carbocaine) 400 10-15 3-4 4-6 Bupivacaine (Marcaine) 225 15-40 6-10 12-17 Ropivacaine (Naropin) 250 15-40 5-9 8-14
  6. 6. Mixtures for Supraclavicular block 25 2% lidocaine 20 15 0.5% bupivacaine plus epi 10 5 0 Duration (hours) latency (minutes) 1% lido + 0.25% bupivacaine plus epi -Bromage 1972
  7. 7. LA‟s compared without epinephrine for fem-sciatic block 40 35 30 25 20 15 10 5 0 2% mepivacaine 0.75% ropivacaine 0.5% bupivacaine 0.5% ropivacaine duration (hours) latency (minutes) 0.5% levobupivacaine -Casati 1998,2002
  8. 8. PNB Analgesia: Bupivacaine versus Ropivacaine Author Type of PNB Equal dose? Epi used? Ropivacaine (hours) Bupivacaine (hours) Junca Cervical Plexus R>B No 6 10 Casati ISB R>B No 11 11 Fanelli ISB R>B No 11 11 Klein ISB R>B Yes 11 13 Vaghadia SCB R>B No 11 12 Bertini AXB Yes No 11 11 Raeder AXB R>B No 12 13 Liisanantti AXB Yes No 15 17 Greengrass LPB-S Yes Yes 13 17 McNamee F-S Yes No 13 15 Fanelli F-S R>B No 11 14 Connolly S R>B No 13 16
  9. 9. PNB LA choice and Analgesia • Bupivacaine probably has a longer duration of analgesia • You can‟t make ropivacaine last longer by giving more of it • Giving more than one drug probably makes sense. • Local anesthetics choice is only one factor in the safe application of PNB.
  10. 10. Epinephrine in PNB • Is a very good idea • Positive effects – Prolongs duration – Increases intensity – Reduces plasma levels (toxicity) – Marker of i.v. administration
  11. 11. Increase in PNB duration (and maybe analgesia) with epinephrine 100 80 60 % increase in Duration 40 20 0 Lido Mepiv Ropiv Bupiv -Covino 1986, Weber 1999
  12. 12. Plasma Levels: Duration •Epi no change in levels achieved with ropivacaine •ropivacaine itself a vasoconstrictor •Maybe why epi does not prolong ropivacaine block 33ml 0.5% Ropivacaine +/- Epi - Hickey 1990
  13. 13. Clonidine for PNB • Dose dependent prolongation of local anesthesia, analgesia • Analgesia is independent of a systemic effect • Mechanism: [alpha2]Adrenoreceptor agonism, hyperpolarizationactivated cation current. © Karl Harrison, University of Oxford 2004
  14. 14. Clonidine analgesia for PNB Control ? Duration Without Duration With 140 mcg No 3 7 Yes 0.5 mcg/ kg No 4 8 1.5%mepivacaine No 50 mcg No 2 4 AXB 0.75% ropivacaine No 1.0 mcg/kg No 13 15 Casati F-S 0.75% ropivacaine No 1.0 mcg/ kg No 14 17 El Saied AXB 0.75% ropivacaine No 150 mcg No 10 13 Hutschala AXB 0.25% bupivacaine Yes 2mcg/ kg Yes 1 7 Couture F-S 0.5% bupivacaine Yes 1.0 mcg/ kg No 12 12 Culebras ISB 0.5% bupivacaine Yes 150 mcg Yes 16 14 Solution Epi ? Author Block Reinhart Ankle (peds) 1.73% lidocaine No Singelyn AXB 1% mepivacaine Iskandar Mid-H Casati Clonidine Dose
  15. 15. Clonidine analgesia for PNB • • • • Prolongs shorter duration local anesthetics 30-100 mcg is an effective dose 30-100 mcg is unlikely to produce side effects Clonidine may extend prolongation achieved by epinephrine • Onset and quality of blockade is not impeded • Use with bupivacaine plus epinephrine?
  16. 16. „Single Shot‟: Proposed Maximal mean analgesia durations by approach 18 16 14 12 10 8 6 4 2 0 First request for analgesia (hrs) CPB ISB SCB AXB POP F-S
  17. 17. Continuously Prolonged PNB: Is what we do usual? • Exclusive use of stimulating catheters • Inpatient infusions >> ambulatory infusions • FNB > ICB > sciatic/popliteal >ISB • „trifecta‟ for TKA • All blocks done by CA-2 &-3‟s
  18. 18. Dosing continuous PNB • 0.2% ropivacaine and 0.25% bupivacaine at 0.1ml/kg/hr have been proven safe • Unbound drug is the fraction of concern • Little evidence for differential block - Thomas 1999,Salonen 2000, Ekatodramis 2003
  19. 19. Continuous ISB -Ilfeld 2004
  20. 20. No „clinically relevant improvements‟ adding clonidine to cPNB? • • • • • • • Worst and average VAS equal Opioid consumption equal Sleep disturbances equal Side effects no different Fewer patient controlled doses More motor block from femoral cPNB Are cPNB’s for chronic pain different? -Ilfeld 2003, Capdevilla 2005
  21. 21. Continuous PNB Summary • 0.2% ropivacaine has become most commonly used, but little studied • Adjuncts probably have little utility • Basal rate of 7-10ml or 0.1ml/kg/hour • Patient controlled dosing popular
  22. 22. Impressive Multimodal Analgesia: COX-2 plus PCEA following TKA Placebo PCEA requests (0-40 hours) Opioid consumption post PCEA Vomiting VAS daily while in hospital VAS one week after discharge Degree flexion at discharge Degree flexion at one month Rofecoxib 41 9 mg 26% 4 4 73 101 21 6 mg 6% 2 3 84 109 -Buvanendran, 2003
  23. 23. One dose of gabapentin for acute pain management: Characteristics of studies Number of studies found in the literature Dose of gabapentin studied Degree of opioid sparing Mean 24 hour morphine sparing Numbers to treat (nausea) Number to treat (vomiting) Number to treat (urinary retention) 22 300-1200mg 20-62% 30 mg 25 6 7 -Tiipana, 2007
  24. 24. U/S versus Nerve Stimulation Technique Approach Block Time (min) % ‘Success’ Williams 2003 U/S+Stim Stim SCB 5 10 85 78 Marhofer 2004 U/S Stim ICB 100 100 Soeding 2005 U/S+ “feel” “feel” alone ISB and AXB 95 90 U/S U/S Stim 1 2 2 Liu 2005 6 7 8 Onset Time (min) Duration (min) 846 652 9 15 384 310 672 618 83 90 90 -Gray 2006
  25. 25. Where to Place Needles for the Best PNB technique: “Survey says..”
  26. 26. Where to Place Needles for the Best PNB technique: “Survey says..”
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