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How Does Regional Anesthesia Stay Relevant in the Future?

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How Does Regional Anesthesia Stay Relevant in the Future?

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By the end of this lecture, learners will be able to:
1. Discuss current problems related to perioperative pain medicine and access to regional anesthesia;
2. Identify ways to personalize pain medicine;
3. Compare currently available methods to extend nerve block duration including adjuncts and continuous peripheral nerve blocks; and
4. Identify opportunities to improve outcomes that matter to patients.

By the end of this lecture, learners will be able to:
1. Discuss current problems related to perioperative pain medicine and access to regional anesthesia;
2. Identify ways to personalize pain medicine;
3. Compare currently available methods to extend nerve block duration including adjuncts and continuous peripheral nerve blocks; and
4. Identify opportunities to improve outcomes that matter to patients.

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How Does Regional Anesthesia Stay Relevant in the Future?

  1. 1. @EMARIANOMD How Does Regional Anesthesia Stay Relevant in the Future? 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 Disclosures  None financial.  Other disclosures: – Consultant to the FDA on the current and future practice of regional anesthesia – Clinical subcommittee member, CMS MACRA episode-based cost measures – Standards review panel, TJC hospital-based pain management – ACGME milestones Chair for regional anesthesiology and acute pain medicine
  3. 3. @EMARIANOMD
  4. 4. @EMARIANOMD Problem: The Opioid Epidemic https://www.nytimes.com/interactive/2016/01/07/us/drug-overdose-deaths-in-the-us.html?_r=0
  5. 5. @EMARIANOMD Problem: Postop Readmissions Hernandez-Boussard, et al. Ann Surg 2017;266:516 Postoperative pain trajectories identify populations at risk for 30-day readmissions and ED visits
  6. 6. @EMARIANOMD Problem: Chronic Pain after Surgery
  7. 7. @EMARIANOMD Overview  Increasing access  Personalizing pain medicine  Improving outcomes
  8. 8. @EMARIANOMD Overview  Increasing access  Personalizing pain medicine  Improving outcomes
  9. 9. @EMARIANOMD Kurtz S, et al. JBJS 2007 Apr;89(4):780 Arthroplasties Are Increasing
  10. 10. @EMARIANOMD Kurtz S, et al. JBJS 2007 Apr;89(4):780 Arthroplasties Are Increasing Now Over 1,000,000 THA and TKA Cases Annually
  11. 11. @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
  12. 12. @EMARIANOMD 2017;42:368 http://www.edmariano.com/archives/1196 27%! J Arthroplasty 2016
  13. 13. @EMARIANOMD We Can Be Change Agents
  14. 14. @EMARIANOMD Evaluate New Blocks/Protocols http://www.commonwealthfund.org/interactives/2017/july/mirror-mirror/ • Access • Efficiency • Equity • Outcomes How Do Blocks or New Protocols Perform in These Categories?
  15. 15. @EMARIANOMD Masaracchia MM, et al. Acta Anaes Scand 2017;61:224
  16. 16. @EMARIANOMD Patient Care Pathways Hebl JR, et al. JBJS 2005;87 Suppl 2:63
  17. 17. @EMARIANOMD Overview  Increasing access  Personalizing pain medicine  Improving outcomes
  18. 18. @EMARIANOMD “Precision” Pain Medicine
  19. 19. @EMARIANOMD What Regional Anesthesia Does  Mitigates maximal pain intensity after surgery1 and can be titratable  Decreases opioid consumption2 (maybe less opioid-induced hyperalgesia)  Facilitates early mobility3  Avoids immobility which can produce hyperalgesia and persistent pain4,5 1. Ilfeld BM. A&A 2011;113(4):904 2. Richman JM, et al. A&A 2006;102:248 3. Ilfeld & Mariano, et al. Pain 2010;150:477 4. Ohmichi Y, et al. Eur J Pain 2012;16:338 5. Guo TZ, et al. J Pain 2014;15:1033
  20. 20. @EMARIANOMD “We Can Place a Catheter… © Mike Mariano
  21. 21. @EMARIANOMD …But Single-Injection is Fine” Heard at every anesthesiology residency program everywhere!
  22. 22. @EMARIANOMD 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
  23. 23. @EMARIANOMD Liposomal Bupivacaine Viscusi ER. RAPM 2005;30:491 1-3 Days? Not Titratable
  24. 24. @EMARIANOMD Liposomal Bupivacaine Ohri R, et al. RAPM 2012;37:607 Boogaerts JG, et al. CJA 1993;40:1201  Is 96h of block always good? 96 hrs
  25. 25. @EMARIANOMD Liposomal Bupivacaine
  26. 26. @EMARIANOMD Need for Titratability  Dose reductions based on muscle weakness or subjective numbness  10/25 (43%) ropivacaine subjects required reduction in dose on POD11  10/24 (42%) ropivacaine subjects required reduction in dose on POD12  10/39 (26%) ropivacaine subjects required reduction in dose on POD13 1. Ilfeld & Mariano, et al. Anesth 2008;108:703 2. Ilfeld & Mariano, et al. Anesth 2008;109:491 3. Ilfeld & Mariano, et al. Pain 2010;150:477
  27. 27. @EMARIANOMD Overview  Increasing access  Personalizing pain medicine  Improving outcomes that matter
  28. 28. @EMARIANOMD
  29. 29. @EMARIANOMD How Long Does Pain Last? Lavand’homme, et al. CORR 2014;472:1409 TKA Patients Normal Persistent Pain Neuropathic Pain
  30. 30. @EMARIANOMD Newer Interventions Ilfeld, et al. J Orthop Surg Res 2017;12:4
  31. 31. @EMARIANOMD Preventing Chronic Pain  Primary prevention: avoid injury/surgery  Secondary prevention: early intervention to prevent transition from acute to chronic Gilron & Kehlet. CJA 2014;61:101
  32. 32. @EMARIANOMD Prevention of Chronic Pain Protocol Gilron & Kehlet. CJA 2014;61:101
  33. 33. @EMARIANOMD  3 day infusion of ropivacaine vs. saline  At 12 months: – 13% pain-induced dysfunction for ropivacaine vs. 47% for saline (p=0.011) – Mean BPI 1.6 ± 4.6 for ropivacaine vs. 5.9 ± 11.3 for saline (p=0.007) Ilfeld BM, et al. Ann Surg Onc 2015;22:2017
  34. 34. @EMARIANOMD Deliver Highly Reliable Care

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