Continuous paravertebral block using a thoracoscopic catheter-insertion technique for postoperative pain after thoracotomy: a retrospective case-control study. Journal of Cardiothoracic Surgery volume 12, Article number: 5 (2017)
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.
Prolonging blockade with adjuvants:
- IOSR J of Dental and Medical Sci; Dec 2015. Comparative study of bupiv with dexamethasone and bupi with clonidine through single space PVB for post op analgesia in thoracic and abdominal surgeries.
- 0.125% Bupiv + clonidine (1mcg/kg) vs 0.125% bupiv + dexamethasone (4mg): greater duration of analgesia in the dexamethasone group.
- 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.
Investigating the Efficacy of Dexmedetomidine as an Adjuvant to Local Anesthesia in Brachial Plexus Block: A Systematic Review and Meta-Analysis of 18 Randomized Controlled Trials. Regional Anesthesia and Pain Medicine: March/April 2017 – Volume 42 – Issue 2 – p 184–196.
- Effective Dose of Intravenous Dexmedetomidine to Prolong the Analgesic Duration of Interscalene Brachial Plexus Block: A Single-Center, Prospective, Double-Blind, Randomized Controlled Trial. Regional Anesthesia and Pain Medicine: July 2018 – Volume 43 – Issue 5 – p 488–495.
- Intravenous DEX at a dose of 2.0 μg/kg significantly increased the duration of ISBPB analgesia without prolonging motor blockade and reduced the cumulative opioid consumption at the first 24 hours in patients undergoing arthroscopic shoulder surgery.
- Dexmedetomidine prolongs the effect of bupivacaine in supraclavicular brachial plexus block. J Anaesthesiol Clin Pharmacol. 2014 Jan-Mar; 30(1): 36–40.
- 30 ml of 0.325% bupivacaine + 1 ml (100 μg) dexmedetomidine were given for supraclavicular brachial plexus block using the peripheral nerve stimulator.
- Below knee surgery under combined femoral-sciatic nerve block were randomly allocated into two groups to have their block performed using bupivacaine 0.5% alone (group B) or bupivacaine 0.5% combined with 100 μg bupivacaine-dexmedetomidine
- IV and Perineural Dexmedetomidine Similarly Prolong the Duration of Analgesia after Interscalene Brachial Plexus Block: A Randomized, Three-arm, Triple-masked, Placebo-controlled Trial. Anesthesiology 3 2016, Vol.124, 683-695.
- Randomized to receive ISB using 15 ml ropivacaine, 0.5%, with 0.5 μg/kg dexmedetomidine administered perineurally (DexP group), intravenously (DexIV group), or none (control group). DexIV was noninferior to DexP for these outcomes. Both dexmedetomidine routes reduced the pain and opioid consumption up to 8 h postoperatively and did not prolong the duration of motor blockade.
Evidence basis for using perineural dexmedetomidine to enhance the quality of brachial plexus nerve blocks: a systematic review and meta-analysis of randomized controlled trials. BJA: British Journal of Anaesthesia, Volume 118, Issue 2, 1 February 2017, Pages 167–181.
- Upper limb block. A 50-60µg dexmedetomidine dose maximized sensory block duration while minimizing haemodynamic side-effects.
Other useful links:
- Erector Spinae Plane Block
- Suprascapular Blocks
- Enhanced Recovery After Surgery (ERAS)
- PEC 1 & 2 Blocks, Serratus Anterior 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.
- Rib fractures
- Continuous Erector Spinae Plane Block for Rescue Analgesia in Thoracotomy After Epidural Failure: A Case Report. A & A Case Reports. 8(10):254–256, MAY 2017.
- The Erector Spinae Plane Block: A Novel Analgesic Technique in Thoracic Neuropathic Pain. Regional Anesthesia and Pain Medicine. Volume 41, Number 5, September-October 2016.
- The Ultrasound-Guided Continuous Erector Spinae Plane Block for Postoperative Analgesia in Video-Assisted Thoracoscopic Lobectomy. Regional Anesthesia and Pain Medicine: July/August 2017 – Volume 42 – Issue 4 – p 537.
Erector spinae plane block as an alternative to epidural analgesia for post-operative analgesia following video-assisted thoracoscopic surgery: A case study and a literature review on the spread of local anaesthetic in the erector spinae plane. Indian J Anaesth. 2018 Jan; 62(1): 75–78.
- Mastectomy/Breast reconstruction
- Abdominal surgery
- Continuous Erector Spinae Plane (ESP) Analgesia In Different Open Abdominal Surgical Procedures: A Case Series. Journal of Anesthesia and Surgery. https://doi.org/10.15436/2377-1364.18.1853.
Bilateral Continuous Erector Spinae Plane Block Contributes to Effective Postoperative Analgesia After Major Open Abdominal Surgery: A Case Report. A&A Practice: December 1, 2017 – Volume 9 – Issue 11 – p 319–321
- Cardiac surgery
- Continuous Erector Spinae Plane (ESP) Block for Postoperative Analgesia after Minimally Invasive Mitral Valve Surgery. October 2018Volume 32, Issue 5, Pages 2271–2274.
- Comparison of continuous thoracic epidural analgesia with bilateral erector spinae plane block for perioperative pain management in cardiac surgery. Ann Card Anaesth 2018;21:323-7.
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 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.
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)
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.
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.
Another project I’m working on is the effect of lidocaine infusions on intraoperative and postoperative pain.
- American Pregnancy Association: Epidural Anesthesia
- N Engl J Med 2010;362:1503-10. Epidural analgesia for labor and delivery.
What is a “walking” epidural?
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)
My other OB blog links:
Today, I’m on call covering OB.
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
To epidural or not to epidural. That is the question.
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
Neuraxial anesthesia in the non-pregnant patient
From my blog:
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.
- Regional Anesthesia & Pain Medicine – Aug 2013. Kwofie et al. The effects of ultrasound-guided ACB vs FNB on quadriceps strength and fall risk.
- Regional Anesthesia & Pain Medicine – Nov 2013. Jaeger et al. ACB vs FNB for analgesia after TKA: a randomized, double-blind study.
- Anesthesiology – Mar 2014. Kim et al. ACB vs FNB for TKA: a prospective, randomized, controlled trial.
- Clinical Orthopedics and Related Research – 1999. Mudumbai et al. Continuous ACBs are superior to continous FNBs in promoting early ambulation after TKAs.
- Clinical Anesthesiology – Feb 2014. O’Rourke. Study supports ACBs after TKAs.
- Clinical Trials. 2013-2015. ACBs in ACLs.
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