analgesia – Sleepy Time

Exparel

Liposomal bupivacaine (Exparel) is a longer acting form of traditional bupivacaine that delivers the drug by means of a multivesicular liposomal system.

Exparel FDA drug sheet

Max Dose: 266 mg or 4mg/kg (6yo-17yo). Interscalene NB max dose (adults) =133mg

Exparel dosing company info: Pocket Dosing Guide , Billing Guide

Liposomal bupivacaine: a review of a new bupivacaine formulation. J Pain Res. 2012; 5: 257–264.

Emerging roles of liposomal bupivacaine in anesthesia practice. J Anaesthesiol Clin Pharmacol. 2017 Apr-Jun; 33(2): 151–156.

Liposomal bupivacaine peripheral nerve block for the management of postoperative pain. Cochrane Database Syst Rev. 2016 Aug 25;2016(8):CD011476.

Liposomal bupivacaine infiltration at the surgical site for the management of postoperative pain. Cochrane Database Syst Rev. 2017 Feb; 2017(2): CD011419.

Novel Local Anesthetics in Clinical Practice: Pharmacologic Considerations and Potential Roles for the Future. Anesth Pain Med. 2022 Feb; 12(1): e123112.

Cardiac/Thoracic

The role of liposomal bupivacaine in thoracic surgery. J Thorac Dis. 2019 May; 11(Suppl 9): S1163–S1168.

Intercostal nerve blockade for thoracic surgery with liposomal bupivacaine: the devil is in the details. J Thorac Dis. 2019 May; 11(Suppl 9): S1202–S1205.

VATs: Dilute liposomal bupivacaine (266 mg, 20 cc) mixed with 20 cc injectable saline. We use two syringes to save time (refill syringe between injections).
For planned thoracotomy, we add 60 cc injectable saline for wider injection.
The efficacy of this strategy requires attention to specific details, such as timing and technique of injection, dilution with saline, and injection of multiple interspaces (typically interspaces 3–10 when technically possible).
Inject EXPAREL slowly and deeply (generally 1-2 mL per injection) into soft tissues using a moving needle technique (ie, inject while withdrawing the needle)
Infiltrate above and below the fascia and into the subcutaneous tissue
Aspirate frequently to minimize the risk of intravascular injection
Use a 25-gauge or larger-bore needle to maintain the structural integrity of the liposomal particles
Inject frequently in small areas (1-1.5 cm apart) to ensure overlapping analgesic coverage

Liposomal Bupivacaine Versus Bupivacaine for Intercostal Nerve Blocks in Thoracic Surgery: A Retrospective Analysis. Pain Physician. 2020 Jun;23(3):E251-E258.

Intercostal Blocks with Liposomal Bupivacaine in Thoracic Surgery: A Retrospective Cohort Study. J Cardiothorac Vasc Anesth. 2021 May;35(5):1404-1409.

Is liposomal bupivacaine superior to standard bupivacaine for pain control following minimally invasive thoracic surgery? Interactive CardioVascular and Thoracic Surgery, Volume 31, Issue 2, August 2020, Pages 199–203, https://doi.org/10.1093/icvts/ivaa083

Paravertebral Nerve Block With Liposomal Bupivacaine for Pain Control Following Video-Assisted Thoracoscopic Surgery and Thoracotomy. J Surg Res. 2020 Feb;246:19-25.

Rib fractures case report: ESP block

Evaluation of an Enhanced Recovery After Surgery Protocol Including Parasternal Intercostal Nerve Block in Cardiac Surgery Requiring Sternotomy. Am Surg. 2021 Dec;87(10):1561-1564.

Ultrasound-guided Modified Parasternal Intercostal Nerve Block: Role of Preemptive Analgesic Adjunct for Mitigating Poststernotomy Pain. Anesth Essays Res. 2020 Apr-Jun; 14(2): 300–304.

Comparison of preincisional and postincisional parasternal intercostal block on postoperative pain in cardiac surgery. J Card Surg. 2020 Jul;35(7):1525-1530.

Ultrasound-guided parasternal intercostal nerve block for postoperative analgesia in mediastinal mass resection by median sternotomy: a randomized, double-blind, placebo-controlled trial. BMC Anesthesiol. 2021; 21: 98.

Pain Relief Following Sternotomy in Conventional Cardiac Surgery: A Review of Non Neuraxial Regional Nerve Blocks. Ann Card Anaesth. 2020 Apr-Jun; 23(2): 200–208.

A Novel Use of Liposomal Bupivacaine in Erector Spinae Plane Block for Pediatric Congenital Cardiac Surgery. Case Rep Anesthesiol. 2021; 2021: 5521136.

Breast/Gen Surg

Evaluating the Efficacy of Two Regional Pain Management Modalities in Autologous Breast Reconstruction. Plast Reconstr Surg Glob Open. 2022 Jan 19;10(1):e4010.

Perioperative Blocks for Decreasing Postoperative Narcotics in Breast Reconstruction. Anesth Pain Med. 2020 Oct; 10(5): e105686.

Opioid-sparing Strategies in Alloplastic Breast Reconstruction: A Systematic Review. Plast Reconstr Surg Glob Open. 2021 Nov 16;9(11):e3932.

Comparison of the efficacy of erector spinae plane block performed with different concentrations of bupivacaine on postoperative analgesia after mastectomy surgery: ramdomized, prospective, double blinded trial. BMC Anesthesiol. 2019; 19: 31.

Efficacy of liposomal bupivacaine versus bupivacaine in port site injections on postoperative pain within enhanced recovery after bariatric surgery program: a randomized clinical trial. Surg Obes Relat Dis. 2019 Sep;15(9):1554-1562.

The use of extended release bupivacaine with transversus abdominis plane and subcostal anterior quadratus lumborum catheters: A retrospective analysis of a novel technique. J Anaesthesiol Clin Pharmacol. 2020 Jan-Mar; 36(1): 110–114.

Ortho

Pain Control and Functional Milestones in Total Knee Arthroplasty: Liposomal Bupivacaine versus Femoral Nerve Block. Clin Orthop Relat Res. 2017 Jan;475(1):110-117.

OB

Transversus Abdominis Plane Block With Liposomal Bupivacaine for Pain After Cesarean Delivery in a Multicenter, Randomized, Double-Blind, Controlled Trial. Anesth Analg. 2020 Dec; 131(6): 1830–1839.

Intraperitoneal Chloroprocaine

20-something year old primip came today with preeclampsia and was deemed a c/s candidate for her 26 week baby. She was 5’8″, 165lb and had no prior issue with previous surgeries. She was started on magnesium preop. The mag was held intraoperatively and would resume postoperatively. Pt was in sitting position for her spinal, which was placed at L4-5. Good clear CSF return. 0.75% bupi dosed at 13.5 mg with intrathecal fentanyl 15mcg and intrathecal morphine 0.2mg. BP decreased from 150s to 130s, which was appropriate. Patient stated she had increased tingling and decreased mobility in her legs. All symptoms and signs appropriate with her spinal. Patient passed the Allis clamp test prior to incision. She was quite anxious: propofol was given IV for anxiolysis. Patient was adamant about breastfeeding/pumping for her baby. No complications with delivery. Uterus was externalized and patient was sensitive to pressure and tugging/manipulation. IV fenatnyl and IV morphine were given along with IV propofol. When uterus was internalized, patient felt more pressure that seemed unbearable. More IV pain meds were given. Suggestion was made for intraperitoneal chloroprocaine. Patient able to tolerate fascial closure as well as staple skin closure.

Intraperitoneal chloroprocaine

Chloroprocaine. StatPearls.

Intraperitoneal chloroprocaine is a useful adjunct to neuraxial block during cesarean delivery: a case series. Int J Obstet Anesth. 2018 Aug;35:33-41. doi: 10.1016/j.ijoa.2018.01.007. Epub 2018 Mar 2.

Chloroprocaine Lavage to Improve Outcomes Related to Operative Cesarean Delivery (CLOR-PRO). Clinicaltrials.gov. 2018 ongoing.

Pain Control During Cesarean Delivery. Anesthesia Experts. Jan 2020.

From Essential Clinical Anesthesia: January 2012. Chapter 47

Failed epidural

Mechanisms and management of an incomplete epidural block for cesarean section. Anesthesiology Clinics. REVIEW ARTICLE| VOLUME 21, ISSUE 1, P39-57, MARCH 01, 2003

Dexmedetomidine

What is dexmedetomidine?

Current role of dexmedetomidine in clinical anesthesia and intensive care. Anesth Essays Res. 2011 Jul-Dec; 5(2): 128–133.

Dexmedetomidine: a novel sedative-analgesic agent. Proc (Bayl Univ Med Cent). 2001 Jan; 14(1): 13–21.

Update: April 2023

Dexmedetomidine for reduction of atrial fibrillation and delirium after cardiac surgery (DECADE): a randomised placebo-controlled trial. The Lancet: Volume 396, ISSUE 10245, P177-185, July 18, 2020.

Association of Dexmedetomidine With New-Onset Atrial Fibrillation in Patients With Critical Illness. JAMA Netw Open. 2023;6(4):e239955.

Resources:

Perioperative Dexmedetomidine Improves Outcomes of Cardiac Surgery. Circulation. 2013;127:1576–1584.

Dexmedetomidine sedation reduces atrial fibrillation after cardiac surgery compared to propofol: a randomized controlled trial. Critical Care volume 20, Article number: 298 (2016).

The effect of dexmedetomidine on outcomes of cardiac surgery in elderly patients. J Cardiothorac Vasc Anesth. 2016 Dec; 30(6): 1502–1508.

Prevalence of Delirium with Dexmedetomidine Compared with Morphine Based Therapy after Cardiac Surgery: A Randomized Controlled Trial (DEXmedetomidine COmpared to Morphine-DEXCOM Study). Anesthesiology 11 2009, Vol.111, 1075-1084.

Effects of Perioperative Dexmedetomidine on Postoperative Mortality and Morbidity: A Systematic Review and Meta-analysis. Clinical Therapeutics/Volume 41, Number 1, 2019.

Effect of Intravenous Acetaminophen vs Placebo Combined With Propofol or Dexmedetomidine on Postoperative Delirium Among Older Patients Following Cardiac SurgeryThe DEXACET Randomized Clinical Trial. JAMA. 2019;321(7):686-696.

Dexmedetomidine for reduction of atrial fibrillation and delirium after cardiac surgery (DECADE): a randomised placebo-controlled trial. The Lancet. VOLUME 396, ISSUE 10245, P177-185, JULY 18, 2020.

Role of dexmedetomidine infusion after coronary artery bypass grafting. The Cardiothoracic Surgeon volume 28, Article number: 4 (2020).

Dexmedetomidine as an Option for Opioid Refractory Pain in the Hospice Setting. J Palliat Med. 2019 Nov;22(11):1478-1481.

Dexmedetomidine as an adjunct in regional anesthesia

The comparison of the effects of dexmedetomidine, fentanyl and esmolol on prevention of hemodynamic response to intubation

Ketamine and Methadone: Is more of a good thing better?

I’ve done a good deal of research on the benefits of an ERAS and Cardiac ERAS protocol to help with decreased length of hospital stay as well as early extubations and perioperative adjuvant pain control with ketamine, methadone, regional anesthesia, adjuvants to regional, etc.

What about ketamine and methadone in combination to aid decreased postoperative narcotic use?

Perioperative Methadone and Ketamine for Postoperative Pain Control in Spinal Surgical Patients: A Randomized, Double-blind, Placebo-controlled Trial. Anesthesiology Newly Published on March 2021. doi: https://doi.org/10.1097/ALN.0000000000003743.

0.2 mg/kg of methadone (based on ideal body weight, up to a maximal dose of 20 mg)250 mg of ketamine was added to the dextrose 5% in water bag (total volume 500 ml). 500 ml bags were connected to a pump that was programed to deliver an infusion of ketamine dosed at ideal body weight (or an equal volume of dextrose 5% in water) at a rate of 0.3 mg · kg⁻¹ · h⁻¹ from induction of anesthesia until surgical closure, at which time the infusion was decreased to 0.1 mg · kg⁻¹ · h⁻¹. The infusion was maintained at a rate of 0.1 mg · kg⁻¹ · h⁻¹ in the postanesthesia care unit (PACU) and for the next 48 postoperative hours. Dosing of ketamine was based on recommendations in the literature^17,18 and from clinical experience at our institution.

From Perioperative Methadone and Ketamine for Postoperative Pain Control in Spinal Surgical Patients: A Randomized, Double-blind, Placebo-controlled Trial. *Anesthesiology* Newly Published on March 2021. doi: https://doi.org/10.1097/ALN.0000000000003743.

Management of Neuropathic Chronic Pain with Methadone Combined with Ketamine: A Randomized, Double Blind, Active-Controlled Clinical Trial. Pain Physician. 2017 Mar;20(3):207-215.

Role of Ketamine and Methadone as Adjunctive Therapy in Complex Pain Management: A Case Report and Literature Review. Indian J Palliat Care. 2017 Jan-Mar; 23(1): 100–103.

Ketamine: an introduction for the pain and palliative medicine physician. Pain Physician. 2007 May;10(3):493-500.

Prescription of Controlled Substances: Benefits and Risks. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan.2020 Jun 27.

The perioperative combination of methadone and ketamine reduces post-operative opioid usage compared with methadone alone. Acta Anaesthesiol Scand. 2012 Nov;56(10):1250-6.

Comparison of ketamine-dexmedetomidine-methadone and tiletamine-zolazepam-methadone combinations for short-term anaesthesia in domestic pigs. Vet J. 2015 Sep;205(3):364-8.

A Systematic Review of NMDA Receptor Antagonists for Treatment of Neuropathic Pain in Clinical Practice. Clin J Pain. 2018 May;34(5):450-467.

[Drugs for postoperative analgesia: routine and new aspects: Part 2: opioids, ketamine and gabapentinoids]. Anaesthesist. 2008 May;57(5):491-8.

Multimodal Analgesia Pain Management

Methadone: perioperative use; acute and chronic pain

Buprenorphine

Orthopedic Surgery

Updates on Multimodal Analgesia for Orthopedic Surgery. Anesthesiol Clin. 2018 Sep;36(3):361-373.

Enhanced Recovery After Surgery (ERAS)

ERAS for general surgery

Cardiac ERAS

Non-Opioid Analgesics

Postoperative Multimodal Analgesia Pain Management With Nonopioid Analgesics and Techniques: A Review. JAMA Surg. 2017 Jul 1;152(7):691-697.

Preemptive Analgesia Decreases Pain Following Anorectal Surgery: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Trial. Dis Colon Rectum. 2018 Jul;61(7):824-829.

Gabapentinoids

Ketamine

Lidocaine

Regional Anesthesia

TAP block

Regional for Cardiothoracic Anesthesia

PECS and serratus blocks

Thoracic blocks: ESP, PVB, TEA block

Paravertebral catheters

Regional Anesthesia catheters

Adjuncts to prolong regional anesthesia

Regional Anesthesia for Cardiac Surgery

Gathering data for Cardiac ERAS program for our hospital as well as the SCA. This page will be continuously updated as I find more information.

Resources:

Regional Anesthesia in Cardiac Surgery: An Overview of Fascial Plane Chest Wall Blocks. Anesthesia & Analgesia: July 2020 – Volume 131 – Issue 1 – p 127-135.

From Anesthesia & Analgesia131(1):127-135, July 2020.

Thoracic
- Ultrasound-Guided Serratus Anterior Plane Block Versus Thoracic Epidural Analgesia for Thoracotomy Pain. J Cardiothorac Vasc Anesth. 2017 Feb;31(1):152-158.
Medical pumps for delivery of programmable intermittent bolus:
- CADD medical Solis

What I’m using these days:

August 2020: None as we do not have programmable intermittent bolus pumps for regional.

Paravertebral Block and Catheters

Review: Thoracic Paravertebral Block. Anesthesiology. Sept 2001.

Ultrasound-Guided Paravertebral Block Anaesthesia Tutorial of the Week. April 2018. Tutorial #376.

YouTube: PVB catheter technique

YouTube: LSORA U/S-guided PVB

YouTube: U/S-guided PVB by Block Jocks

YouTube: nerveblocks U/S-guided PVB

YouTube: thoracic PVB and anatomy

YouTube: Ottawa Hospital PVB

Update:

Nov 2021:

https://www.sciencedirect.com/science/article/pii/S1053077020300987?via%3Dihub

Insertion of paravertebral block catheters intraoperatively to reduce incidence of block failure. Interact Cardiovasc Thorac Surg. 2012 May; 14(5): 648–649.

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)

From The mid‐point transverse process to pleura (MTP) block: a new end‐point for thoracic paravertebral block. https://onlinelibrary.wiley.com/doi/abs/10.1111/anae.14004

Table 3. Drug and Dosage for Thoracic Paravertebral Block

A Systematic Review of Randomized Trials Evaluating Regional Techniques for Postthoracotomy Analgesia. Anesthesia & Analgesia:September 2008 – Volume 107 – Issue 3 – p 1026-1040

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.

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.

Effects of perineural administration of dexmedetomidine in combination with bupivacaine in a femoral-sciatic nerve block. Saudi J Anaesth. 2016 Jan-Mar; 10(1): 18–24.
- 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 (Dex_P group), intravenously (Dex_IV group), or none (control group). Dex_IV was noninferior to Dex_P 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.

Review of Dexmedetomidine (Precedex) for Acute Pain and Analgesia. ASRA News, August 2018.

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.

**Updated May 2022**