1.
To Block or Not to Block:
Prevention of Persistent
Postoperative Pain
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
@EMARIANOMD

2.
Persistent Postsurgical Pain
Financial Disclosures
 Halyard Health, 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.
Persistent Postsurgical Pain
Chronic Pain after Surgery

4.
Persistent Postsurgical Pain
Kehlet H, et al. Lancet 2006;367:1618

5.
Persistent Postsurgical Pain
Overview
 Risk Factors for Persistent Postsurgical
Pain (PPSP)
 Potential Role of Regional Anesthesia and
Analgesia
 Pharmacologic Interventions for PPSP

6.
Persistent Postsurgical Pain
Overview
 Risk Factors for Persistent Postsurgical
Pain (PPSP)
 Potential Role of Regional Anesthesia and
Analgesia
 Pharmacologic Interventions for PPSP

7.
Persistent Postsurgical Pain
Risk Factors for PPSP
 Patient phenotypic factors
– Preexisting pain before surgery
– High consumption of analgesic medications
preoperatively
– Catastrophizing
– Severe acute postoperative pain
 Patient genetic factors (~45%)
 Nerve injury during surgery, inflammation,
and neuronal plasticity
Richebe P, et al. CJA 2015;62:1329
Clarke H, et al. CJA 2015;62:294

8.
Persistent Postsurgical Pain
Bayman EO, et al. Anesth 2017 epub

9.
Persistent Postsurgical Pain
Catastrophizing as a Risk Factor
157 Knee
Replacement
Patients
Pain
Catastrophizing
Scale
≥16 considered
high score
Riddle DL, et al. CORR 2010;468:798

10.
Persistent Postsurgical Pain
Catastrophizing as a Risk Factor
Riddle DL, et al. CORR 2010;468:798

11.
Persistent Postsurgical Pain
Opioid-Induced Hyperalgesia
Angst MS, et al. Pain 2003;106:49

12.
Persistent Postsurgical Pain
Overview
 Risk Factors for Persistent Postsurgical
Pain (PPSP)
 Potential Role of Regional Anesthesia and
Analgesia
 Pharmacologic Interventions for PPSP

13.
Persistent Postsurgical Pain
Kehlet H, et al. Lancet 2006;367:1618
How Can Regional
Anesthesia Help?

14.
Persistent Postsurgical Pain
What Regional Anesthesia Does
 Mitigates maximal pain intensity after
surgery1
 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

15.
Persistent Postsurgical Pain
Preventing PPSP
 Primary prevention: avoid injury/surgery
 Secondary prevention: early intervention
to prevent transition from acute to chronic
Gilron & Kehlet. CJA 2014;61:101

16.
Persistent Postsurgical Pain
Chronic Pain after Thoracotomy
 Incidence is approximately 50%
– 3-16% report pain as moderate-severe
 Heterogeneity in study designs
 Many contributing factors: patients,
surgical technique, pre- and postop pain
 To date, no convincing evidence that PVB
decreases chronic pain after thoracotomy
Wildgaard & Kehlet. Eur J CTS 2009;36:170

17.
Persistent Postsurgical Pain
Chronic Pain after Breast Surgery
 Survey of 479 women who underwent
breast surgery over a 4-year period
 59% response rate
 Prevalence of pain after >1 year postop:
– Mastectomy/reconstruction = 49%
– Mastectomy alone = 31%
– Augmentation = 38%
– Reduction = 22%
Wallace MS, et al. Pain 1996;66:195

18.
Persistent Postsurgical Pain
Chronic Pain after Breast Surgery
 Secondary outcome of previously-published RCT
– Immediate postop pain less in PVB group (p<0.01)
 Less pain in PVB group at 6 (p=0.029; n=60) and
12 mos (p=0.003; n=59)
Kairaluoma P, et al. A&A 2004;99:1837

19.
Persistent Postsurgical Pain
Chronic Pain after Breast Surgery
 Meta-analysis: 3 studies assessed this
outcome (n=167)
 All PVB-GA vs. GA
 At 6 mos, RR=0.16, 95%CI (0.02-1.13)
– No difference (crosses 1)
 At 12 mos, RR=0.61, 95%CI (0.08-4.90)
– No difference (crosses 1)
Schnabel A, et al. BJA 2010;105:842

20.
Persistent Postsurgical Pain
 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

21.
Persistent Postsurgical Pain
Is the Infusion Long Enough?
Lavand’homme, et al. CORR 2014;472:1409
TKA
Patients
Normal
Persistent Pain
Neuropathic Pain

22.
Persistent Postsurgical Pain
Overview
 Risk Factors for Persistent Postsurgical
Pain (PPSP)
 Potential Role of Regional Anesthesia and
Analgesia
 Pharmacologic Interventions for PPSP

23.
Persistent Postsurgical Pain
Think Multimodal
Anesthesiology 2012;116:248

24.
Persistent Postsurgical Pain
Ketamine

25.
Persistent Postsurgical Pain
Where Ketamine Works
Himmelseher & Durieux. Anesth 2005;102:211

26.
Persistent Postsurgical Pain
When to Administer Ketamine
Himmelseher & Durieux. Anesth 2005;102:211

27.
Persistent Postsurgical Pain
Ketamine and OIH
Angst MS, et al. Pain 2003;106:49

28.
Persistent Postsurgical Pain
Pregabalin
1. Lavand’homme, et al. CORR 2014;472:1409
2. Buvanendran A, et al. A&A 2010;110:199
 For TKA, incidence of PPSP may be as
high as 58% with 11% reporting
neuropathic symptoms1
 Pregabalin may decrease neuropathic
PPSP after TKA2
– 0% vs. 9% (placebo) at 3 months (p=0.001)
– 0% vs. 5% (placebo) at 6 months (p=0.014)

29.
Persistent Postsurgical Pain
Gabapentin
Clarke H, et al. A&A 2012;115:428

30.
Persistent Postsurgical Pain
Framework for Approaching PPSP
Gilron & Kehlet. CJA 2014;61:101

31.
Persistent Postsurgical Pain
Overview
 We discussed:
– Risk Factors for Persistent Postsurgical
Pain (PPSP)
– Potential Role of Regional Anesthesia
and Analgesia
– Pharmacologic Interventions for PPSP