Regional anesthesia and analgesia are associated with lower postoperative complications, shorter hospital stays, and better functional outcomes compared to general anesthesia alone. Regional techniques like neuraxial blocks and peripheral nerve blocks improve mobility and physical function after surgery. Newer regional techniques like adductor canal blocks aim to provide good pain relief while preserving quadriceps strength. A multimodal, multidisciplinary approach is needed to optimize perioperative care and functional recovery for patients.

1. @EMARIANOMD
Regional Anesthesia and
Perioperative Outcomes
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
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. @EMARIANOMD
Overview
 Regional Anesthesia and Postoperative
Complications
 Regional Analgesia and Functional
Outcomes
 Regional Analgesia and Perioperative
Medicine

4. @EMARIANOMD
Overview
 Regional Anesthesia and Postoperative
Complications
 Regional Analgesia and Functional
Outcomes
 Regional Analgesia and Perioperative
Medicine

5. @EMARIANOMD
Neuraxial Anesthesia
 30-day mortality was lower for neuraxial
and neuraxial/GA vs. GA alone for TKA
 Most in-hospital complications were lower
for neuraxial and neuraxial/GA vs. GA alone
 Transfusion requirements lowest for
neuraxial
Memtsoudis SG, et al. Anesth 2013;118:1046

6. @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

7. @EMARIANOMD
Overview
 Regional Anesthesia and Postoperative
Complications
 Regional Analgesia and Functional
Outcomes
 Regional Analgesia and Perioperative
Medicine

8. @EMARIANOMD
What About Function?

9. @EMARIANOMD
Selection of Outcomes
 Range of motion
(degrees)
 Timed ambulation
distance (meters)
– 6-MWT
– 2-MWT
 Muscle strength
(force)
 Timed performance
(min)
– TUG
 Western Ontario and
McMaster Univ
Osteoarthritis Index
(WOMAC)
 Knee Society Score
 Lower Extremity
Functional Scale
 Health-Related
Quality of Life
Choi S, et al. RAPM 2013;38:340
Bernucci & Carli. Curr Op Anaes 2012;25:621
Performance-Based Self-Reported
&

10. @EMARIANOMD
Epidural Analgesia
 Bupiv 0.25% at 6-15 ml/h vs. opioids1
– Epid group had lower pain scores but high
proportion had complete motor block
 Epid bupiv+MS vs. epid MS vs. IV opioids2
– Bupiv+MS: shorter time to achieve
ambulation distance and range of motion
goals
– Shorter hospital length of stay
1. Raj PP, et al. A&A 1987;66:401
2. Mahoney OM, et al. CORR 1990;Nov:30

11. @EMARIANOMD
Anticoagulation Guidelines
Horlocker TT, et al. RAPM 2010;35:64

12. @EMARIANOMD
CFNB vs. Epidural for TKA
 Comparable analgesia
 Better side effect profile with CFNB
– Less nausea and vomiting
– Less urinary retention (no need for foley)
– Sparing of non-operative limb
– No epidural hematoma (anticoagulation)
 Epidurals require hospitalization
Barrington MJ, et al. A&A 2005;101:1824
Zaric D, et al. A&A 2006;102:1240

13. @EMARIANOMD
Ropiv
Saline
CFNB: Faster Discharge Eligibility
 50 subjects, tricompartment TKA
 CFNB with 1 night infusion of ropivacaine:
randomized to ropiv vs. saline on POD1
Ilfeld & Mariano, et al. Anesth 2008;108:703
3 Discharge Criteria:
1. NRS (pain) < 4
2. IV opioid-free x 12 hours
3. Ambulating > 30 meters

14. @EMARIANOMD
CFNB and Range of Motion
Knee Flexion (Degrees)
PCA CFNB P Value
POD #1 33 ± 15 56 ± 22 0.009
POD #3 53 ± 17 74 ± 11 <0.001
6 weeks 103 ± 12 116 ± 12 0.03
3 months 116 ± 11 124 ± 12 NS
Singelyn FJ, et al. A&A 1998;87:88
Is this a possible long-term effect??
If so, what is the mechanism?

15. @EMARIANOMD
CFNB vs. Local Infiltration
 RCT (n=40) of CFNB vs. LIA
– At 6 weeks, the CFNB group showed greater
within-group improvement in 6-MWT, physical
activity (CHAMPS), KSS, and WOMAC
– Preop 6-MWT, walking on POD1, time spent
walking during POD1-3 were predictors of 6-
MWT at 6 weeks
Carli F, et al. BJA 2010;105:185

16. @EMARIANOMD
Long-Term Outcomes (So Far)
 1 yr Western Ontario and McMaster Univ
Osteoarthritis Index (WOMAC) scores
Ilfeld & Mariano, et al. A&A 2009;108:1320
Ilfeld & Mariano, et al. A&A 2009;109:586

17. @EMARIANOMD
Lower Extremity CPNB and Falls
 Pooled analysis of 3 published RCTs (knee
and hip arthroplasty) with CPNB x 4 days
– 85 subjects received ropivacaine 0.2%
– 86 subjects received saline
 No falls in the saline group vs. 7 falls in
the ropiv group (P=0.013)
Ilfeld BM, et al. A&A 2010;111:1552
Memtsoudis & Mariano, et al. Anesthesiology 2014;120:551
Premier Perspective Database; n=191,570
 PNB in 12.1% of cases; no association with falls
 Risk factors=higher age, greater comorbidity burden

18. @EMARIANOMD
Introducing Adductor Canal Block
Perlas A, et al. RAPM 2013;38:334

19. @EMARIANOMD
 Patients in the
adductor canal group
walked 37 (0-90)
meters vs. 6 (0-51)
meters in the femoral
catheter group
(p=0.003).
 Pain scores, opioid
consumption, and
hospital length of
stay were similar.
Adductor Canal vs. Femoral CPNB
Mudumbai & Mariano, et al. CORR 2014;472:1377

20. @EMARIANOMD
Evidence from RCTs
 TKA: continuous ACB vs. FNB1
– Greater preservation of quad MVIC in ACB
group (median 52% vs. 18%)
– No differences in pain, opioids, flexion, TUG
 TKA: repeated bolus ACB vs. FNB2
– ACB had better TUG, 10 meter walk time, and
30 sec chair test
– No differences in pain, opioids
1. Jaeger P, et al. RAPM 2013;38:526
2. Shah NA and Jain NP. J Arthro 2014;29:2224

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

22. @EMARIANOMD
Overview
 Regional Anesthesia and Postoperative
Complications
 Regional Analgesia and Functional
Outcomes
 Regional Analgesia and Perioperative
Medicine

23. @EMARIANOMD
One Size Does Not Fit All
REGIONAL ANESTHESIOLOGIST

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Era of “Precision” Medicine

25. @EMARIANOMD
Remember Multimodal
Anesthesiology 2012;116:248

26. @EMARIANOMD
Remember Multimodal
Anesthesiology 2012;116:248

27. @EMARIANOMD
Adductor Canal Block is Not Perfect

28. @EMARIANOMD
Anesth Clinics 2014;32:853

29. @EMARIANOMD
Perioperative Surgical Home
“a patient-centered, physician
anesthesiologist-led, multidisciplinary team-
based practice model that coordinates
surgical patient care throughout the
continuum from the decision to pursue
surgery through convalescence.
Mariano, et al. A&A 2015;120:1163
Kain, et al. A&A 2014;118:1126

30. @EMARIANOMD
Mariano, Walters, Kim, Kain. A&A 2015;120:1163
Walters, Mariano, Clark. Pain Med 2015;16:1666.

31. @EMARIANOMD
Sun, et al. A&A 2017 epub

32. @EMARIANOMD
Sun, et al. A&A 2017 epub

33. @EMARIANOMD
We Can Do Better
Lavand’homme, et al. CORR 2014;472:1409
TKA
Patients
Normal
Persistent Pain
Neuropathic Pain

34. @EMARIANOMD
2017 epub
http://www.edmariano.com/archives/1196
27%!
J Arthroplasty 2016

35. @EMARIANOMD
Summary
 We discussed:
– Regional Anesthesia and Postoperative
Complications
– Regional Analgesia and Functional
Outcomes
– Regional Analgesia and Perioperative
Medicine