Fentanyl for labour pain management: a scoping review. BMC Pregnancy Childbirth. 2022; 22: 846.
Drugs and Lactation Database (LactMed®) [Internet]. Last Revision: February 15, 2023.
Tag: analgesia
Exparel
Liposomal bupivacaine (Exparel) is a longer acting form of traditional bupivacaine that delivers the drug by means of a multivesicular liposomal system.
- 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.
Cardiac/Thoracic
- 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
Rib fractures case report: ESP block
Breast/Gen Surg
Ortho
OB
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
Pain Control During Cesarean Delivery. Anesthesia Experts. Jan 2020.
Failed epidural
Dexmedetomidine
What is dexmedetomidine?
Update: April 2023
Resources:
Perioperative Dexmedetomidine Improves Outcomes of Cardiac Surgery. Circulation. 2013;127:1576–1584.
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?
- 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 literature17,18 and from clinical experience at our institution.
Multimodal Analgesia Pain Management
Methadone: perioperative use; acute and chronic pain
Orthopedic Surgery
Updates on Multimodal Analgesia for Orthopedic Surgery. Anesthesiol Clin. 2018 Sep;36(3):361-373.
Enhanced Recovery After Surgery (ERAS)
Non-Opioid Analgesics
Regional Anesthesia
Regional for Cardiothoracic 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 for cardiac surgery. Current Opinion in Anaesthesiology: October 2019 – Volume 32 – Issue 5 – p 674-682.
- Regional Analgesia in Cardiothoracic Surgery: A Changing Paradigm Toward Opioid-Free Anesthesia? Ann Card Anaesth. 2018 Jul-Sep; 21(3): 225–227.
- New approaches and old controversies to postoperative pain control following cardiac surgery. Eur J Anaesthesiol. 2006 Jul;23(7):539-50.
- Effect of postoperative analgesia on major postoperative complications: a systematic update of the evidence. Anesth Analg. 2007 Mar;104(3):689-702.
- Optimising pain management protocols following cardiac surgery: A protocol for a national quality improvement study. Int J Surg Protoc. 2019 Jan 11;14:1-8.
- Assessment and pathophysiology of pain in cardiac surgery. J Pain Res. 2018; 11: 1599–1611.
- The role of intraoperative interventions to minimise chronic postsurgical pain. Br J Pain. 2017 Nov;11(4):186-191.
- Impact of Enhanced Recovery After Surgery and Opioid-Free Anesthesia on Opioid Prescriptions at Discharge From the Hospital: A Historical-Prospective Study. Anesth Analg. 2017 Nov;125(5):1784-1792.
- Comparison of continuous thoracic epidural analgesia with bilateral erector spinae plane block for perioperative pain management in cardiac surgery. Ann Card Anaesth. Jul-Sep 2018;21(3):323-327.
- 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.
- Efficacy of bilateral pectoralis nerve block for ultrafast tracking and postoperative pain management in cardiac surgery. Ann Card Anaesth. Jul-Sep 2018;21(3):333-338.
- Bilateral thoracic paravertebral block combined with general anesthesia vs. general anesthesia for patients undergoing off-pump coronary artery bypass grafting: a feasibility study. BMC Anesthesiology volume 19, Article number: 101 (2019).
- A novel approach for pain management in cardiac surgery via median sternotomy: bilateral single-shot paravertebral blocks. Heart Surg Forum. 2007;10(5):E357-62.
- Regional Anesthesia Cardiothoracic Enhanced Recovery (RACER): A New Era. ASRA News. August 2019 Issue
- Neuraxial Analgesia for Cardiac Surgery. ASRA News. November 2017 Issue
- Regional anesthesia considerations for cardiac surgery. Best Practice & Research Clinical Anaesthesiology. Volume 33, Issue 4, December 2019, Pages 387-406.
- Thoracic
- Medical pumps for delivery of programmable intermittent bolus:
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: U/S-guided PVB by Block Jocks
YouTube: nerveblocks U/S-guided PVB
YouTube: thoracic PVB and anatomy
Update:
Nov 2021:
https://www.sciencedirect.com/science/article/pii/S1053077020300987?via%3Dihub
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)
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.
- 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.
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- 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.
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- 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
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**
Indications:
The erector spinae plane block: a narrative review. Korean J Anesthesiol. 2019 Jun; 72(3): 209–220.
- Rib fractures
- Thoracotomy/VATs
- 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.
- Esophagectomy
- Mastectomy/Breast reconstruction
- Abdominal surgery
- 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.
- Spine (ortho/neuro):
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.
Sleepy Time 