Adjuvants to prolong regional anesthesia

For my single shot blocks, I’m always looking for ways to prolong my regional anesthetic effect.  For awhile, Exparel was the most talked about drug to have a 72 hour blockade.  We don’t have this medication available to us at the hospital.  Therefore, it’s time to get creative and hit the literature to see what has worked for prolonging our blocks.

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Prolonging blockade with adjuvants:

 

  • Facilitatory effects of perineural dexmedetomidine on neuraxial and peripheral nerve block: a systematic review and meta-analysis. British Journal of Anaesthesia 110 (6): 915–25 (2013).
    • Sensory block duration was prolonged by 150 min [95% confidence interval (CI): 96, 205, P,0.00001] with intrathecal dexmedetomidine. Perineural dexmedetomidine used in brachial plexus (BP) block may prolong the mean duration of sensory block by 284 min (95% CI: 1, 566, P¼0.05), but this difference did not reach statistical significance. Motor block duration and time to first analgesic request were prolonged for both intrathecal and BP block. Dexmedetomidine produced reversible bradycardia in 7% of BP block patients, but no effect on the incidence of hypotension. No patients experienced respiratory depression.
    • Considerable differences existed in the doses of perineural dexmedetomidine; doses varied between 3, 5, 10, or 15 mcg for the intrathecal route, and 30, 100, 0.75, 1 mcg/kg for the peripheral route.

 

 

 

 

 

 

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Other useful links:

 

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Erector Spinae Plane Block

After speaking to a colleague of mine regarding regional anesthesia for thoracotomy and mastectomy, I am reading up on Erector Spinae Plane (ESP) block.

 

Indications:

 

 

Other regional blocks

Continuous ESP block catheter (my current regimen and what I’m able to get at my institution):

  • Braun Periflex catheter through 17g epidural needle
  • Cranial-to-caudal approach @ T5 (mastectomy, vats, rib fractures)
  • 20ml 0.25% bupi + epi prior to catheter
  • Catheter 5cm in space
  • 5 ml 0.25% bupi + epi after catheter placed
  • Mix: 0.125% bupi + fentanyl @ 10 ml/hr
  • If PCEA available, bolus 15ml every 3 hours; continuous as mix above.

Ketamine for intraoperative and postoperative analgesia

Ketamine for improving intraop and postoperative pain. #ketamine #pain #anesthesia #analgesia #meded

I’m always looking for ways to improve myself. Lately, I’m looking at various clinical elements of my practice and select certain endpoints that will better my practice of medicine.

This time, I’ve focused on cutting back on opioids intraoperatively for pain. I’m looking specifically at ketamine, an old drug with multiple benefits (and some downsides). Not only does ketamine help with intraoperative pain, but it also helps with postoperative pain. I’d like to incorporate some type of ERAS model for all of my patients and surgeries.

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Ketamine: (different doses I’ve seen in the literature below)

• Induction: 0.2-0.5 mg/kg

• Infusion: 0.1mg/kg/hr before incision

◦ 2mcg/kg/hr x 24hr (spine)

◦ 0.1-0.15mg/kg/hr x 24-72hrs (UW)

◦ 2mcg/kg/min

◦ 2-8mcg/kg/min

What I’m using nowadays:

  • Oct 2017: Cardiac open hearts: induction bolus=0.5mg/kg; infusion=0.1mg/kg/hr and stopping when last stitch placed.  Patients seem to require less postoperative narcotics.  Looking at time to extubation to see if this is improved.

 

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Is intravenous ketamine effective for postoperative pain management in adults? Medwave2017;17(Suppl2):e6952 doi: 10.5867/medwave.2017.6952

Ketamine: Current applications in anesthesia, pain, and critical care.  Anesth Essays Res. 2014 Sep-Dec; 8(3): 283–290.

Effect of intraoperative infusion of low-dose ketamine on management of postoperative analgesia.  J Nat Sci Biol Med. 2015 Jul-Dec; 6(2): 378–382.

 

Ketamine for Perioperative Pain Management.  Anesthesiology 2005; 102:211–20. 

CLINICAL GUIDELINE FOR USE OF KETAMINE AS AN ADJUVANT ANALGESIC FOR USE BY ANAESTHETISTS ONLY.  NHS Royal Cornwall Guidelines June 2015.

Ketamine as an Adjunct to Postoperative Pain Management in Opioid Tolerant Patients After Spinal Fusions: A Prospective Randomized Trial.  HSS Journal: Volume 4, Number 1.  

The Use of Intravenous Infusion or Single Dose of Low-Dose Ketamine for Postoperative Analgesia: A Review of the Current Literature.  Pain Medicine Volume 16Issue 2pages 383–403February 2015. 

 

Role of Ketamine in Acute Postoperative Pain Management: A Narrative Review.  BioMed Research International. Volume 2015; Article ID 749837, 10 pages.

Ketamine in Pain Management.  CNS Neuroscience & Therapeutics 19 (2013) 396–402. 

Ketamine for the Management of Acute Pain and Agitation in the ICU: Future, Fiction or Just another Drug-Induced Hallucination? Ann Pharmacol Pharm. 2017; 2(11): 1059. 

Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: an international, multicentre, double-blind, randomised clinical trial. Lancet 2017; 390: 267–75.

A comparison between intravenous lidocaine and ketamine on acute and chronic pain after open nephrectomy: A prospective, double-blind, randomized, placebo-controlled study. Saudi J Anaesth 2017;11:177-84.

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Acute and Chronic Post-Thoracotomy Pain, modes of treatment

 

Another project I’m working on is the effect of lidocaine infusions on intraoperative and postoperative pain.

Walking labor epidurals

What is an epidural?

What is a “walking” epidural?

Anesthesiology 2 2000, Vol.92, 387. Walking with Labor Epidural Analgesia: The Impact of Bupivacaine Concentration and a Lidocaine–Epinephrine Test Dose.

MJAFI, Vol. 63, No. 1, 2007. Walking Epidural : An Effective Method of Labour Pain Relief. 

Int J Women’s Health, 2009, 1: 139-154. Advances in labor analgesia.

R. Can J Anesth/J Can Anesth (2010) 57: 103. Walking epidurals for labour analgesia: do they benefit anyone?

MOBILIZATION IN LABOUR AFTER REGIONAL ANALGESIA. Euroanesthesia May 2005. Royal Free Hospital. London, UK.

Impact of first-stage ambulation on mode of delivery among women with epidural analgesia. Australian and New Zealand Journal of Obstetrics and Gynaecology 2004; 44: 489–494

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From WebMD

Walking Epidural with Low Dose Bupivacaine Plus Tramadol on Normal Labour in Primipara. Journal of the College of Physicians and Surgeons Pakistan 2010, Vol. 20 (5): 295-298.

Clinical Guidelines: Labour Analgesia. Jan 2017. King Edward Memorial Hospital, Australia.

BJOG, Feb 2015. Neuraxial analgesia effects on labor progression: facts, fallacies, uncertainties and the future.

Position in the second stage of labour for women with epidural anaesthesia. Cochrane Database of Systematic Reviews. Feb 2017.

Ambulatory Epidural Analgesia in Obstetrics: Clinical Effectiveness, Safety, and Guidelines. Canadian Agency for Drugs and Technologies in Health. Rapid Response Reports. Nov 2010.

Contin Educ Anaesth Crit Care Pain (2004) 4 (4): 114-117. Epidural analgesia in labor.

CSE for Labour Analgesia. 

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From the ASA 2017 (October in Boston):

  • CSE: 1 cc 0.25% bupi + 15mcg fentanyl (good for primip)
  • 25g Dural Puncture without dosing sometimes (primips)

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My other OB blog links:

OB Anesthesia

Birth plans

Reflections

Fun on the job

OB Anesthesia

Today, I’m on call covering OB.

MGH: OB anesthesia Q&A for patients

BWH: OB anesthesia Q&A for patients

IARS 2010: OB anesthesia in the 21st century

IARS 2011: OB anesthesia update

A&A 2013: A Randomized Controlled Comparison of Epidural Analgesia and Combined Spinal-Epidural Analgesia in a Private Practice Setting: Pain Scores During First and Second Stages of Labor and at Delivery

Indian J Anesthesia 2006: Acute Pain – Labour Analgesia

Presentation on mobile epidural

2014: CONTINUOUS VERSUS PATIENT-CONTROLLED EPIDURAL ANALGESIA FOR LABOUR ANALGESIA AND THEIR EFFECTS ON MATERNAL MOTOR FUNCTION AND AMBULATION

June 2011: Update on rural OB anesthesia

Oct 2013: Presentation on Labor analgesia. Epidural vs CSE, bolus v infusions

To epidural or not to epidural. That is the question.

My Reddit Comment

A great YouTube video on what an epidural is and what it will feel like.

YouTube vid of a real epidural placement ** Needles are involved in this one**

Lately, I’ve been changing my regimen for pain control with PCEA.  It seems most of my partners use a 10ml/hr basal rate, 5ml bolus dose, 10 minute lockout, and 30 ml/hr max.

My current strategy for PCEA (0.0625% bupi + 2mcg/ml fentanyl):

  • 5ml/hr basal rate
  • 10ml bolus
  • 20 minute lockout
  • 35 ml/hr max

Anesth Analges 2007: A Comparison of a Basal Infusion with Automated Mandatory Boluses in Parturient-Controlled Epidural Analgesia During Labor.

ASA Nov 2001: PCEA during labor

Br J Anaesth 2010:Labour analgesia and obstetric outcomes.

Effect of Intrathecal Bupivacaine Dose on the Success of External Cephalic Version for Breech Presentation: A Prospective, Randomized, Blinded Clinical Trial

Neuraxial anesthesia in the non-pregnant patient

Anesthesiology Research and Practice 2012: Recent advances in epidural analgesia.

Br J Anaesth 2012: Failed epidural: causes and management.

From my blog:

Adductor Canal Blocks #adductor #regional #anesthesia #femoral #blocks

What is the adductor canal?

Why all this talk about an adductor canal block (ACB)?

For years, femoral nerve blocks (FNB) have been the gold standard for pain control in more invasive knee/lower leg surgeries (total knees, ACLs, etc.).  More recently, adductor canal blocks have been gaining in popularity over femoral nerve blocks because there seems to be less motor blockade from ACB than FNB.  This is important because it decreases fall risk and allows earlier patient ambulation while also providing adequate analgesia.

Anesthesiology Mar 2014. Kim et al. Adductor Canal Block versus Femoral Nerve Block for Total Knee Arthroplasty: A Prospective, Randomized, Controlled Trial.

From the ASA 2017:

Virtual Anatomy lab for regional:

  • Femoral nb: fem art, Top of iliacus muscle, within fasc iliaca. Flat nerve. Want local anesthesia (LA) spread going under femoral artery (FA). Does hip joint capsule > Adductor CB (hip fractures, not THA). Catheters to POD3. Fascia iliaca more cranial than inguinal crease to get hip jt nerves. Do inplane to avoid bowel.
  • Adductor Canal block: nerve sits on lateral side of FA. Want FA when dives under Sartorius muscle. Aim for bottom of FA to get under membrane. Block the Nerve to Vastus medialis nerve also (not effect motor). Nerve bt vastus med and sartorius. Looks like it’s in the membrane bt muscles. Want proximimal sartorius (pain and strength better)

 

How to place an adductor canal block

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Overview with quiz

Youtube video of ultrasound-guided ACB – Nov 2014

Youtube video of ultrasound-guided ACB – Apr 2014

Ultrasoundblock.com: Ultrasound-guided ACB with pics and video