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?
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. @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

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Problem: The Opioid Epidemic
https://www.nytimes.com/interactive/2016/01/07/us/drug-overdose-deaths-in-the-us.html?_r=0

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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

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Problem: Chronic Pain after Surgery

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Overview
 Increasing access
 Personalizing pain medicine
 Improving outcomes

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Overview
 Increasing access
 Personalizing pain medicine
 Improving outcomes

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Kurtz S, et al. JBJS 2007 Apr;89(4):780
Arthroplasties Are Increasing

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Kurtz S, et al. JBJS 2007 Apr;89(4):780
Arthroplasties Are Increasing
Now Over 1,000,000 THA
and TKA Cases Annually

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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

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2017;42:368
http://www.edmariano.com/archives/1196
27%!
J Arthroplasty 2016

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We Can Be Change Agents

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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?

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Masaracchia MM, et al. Acta Anaes Scand 2017;61:224

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Patient Care Pathways
Hebl JR, et al. JBJS 2005;87 Suppl 2:63

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Overview
 Increasing access
 Personalizing pain medicine
 Improving outcomes

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“Precision” Pain Medicine

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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

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“We Can Place a Catheter…
© Mike Mariano

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…But Single-Injection is Fine”
Heard at every anesthesiology residency
program everywhere!

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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

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Liposomal Bupivacaine
Viscusi ER. RAPM 2005;30:491
1-3
Days?
Not
Titratable

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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

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Liposomal Bupivacaine

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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

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Overview
 Increasing access
 Personalizing pain medicine
 Improving outcomes that matter

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How Long Does Pain Last?
Lavand’homme, et al. CORR 2014;472:1409
TKA
Patients
Normal
Persistent Pain
Neuropathic Pain

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Newer Interventions
Ilfeld, et al. J Orthop Surg Res 2017;12:4

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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

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Prevention of Chronic Pain Protocol
Gilron & Kehlet. CJA 2014;61:101

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 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

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Deliver Highly Reliable Care