Safe and Efficient Local Anesthetic Continuous Injection in CPNB

Xavier Capdevila M.D.,Ph.D.Head of Department

Department of Anesthesiology and Critical Care MedicineLapeyronie University Hospital and Montpellier School of Medicine

Montpellier , France

Conflicts of interest: •Pajunk•B Braun•GE Healthcare•Baxter•Janssen•Abbott

A Comprehensive Anesthesia Protocol that Emphasizes Peripheral Nerve Blockade for Total Knee and Total Hip Arthroplasty

JAMES R. HEBL, SANDRA L. KOPP, MIR H. ALI, TERESE T. HORLOCKER, JOHN A. DILGER, MD, ROBERT L. LENNON, BRENT A. WILLIAMS, ARLEN D. HANSSEN AND MARK W. PAGNANO

THE JOURNAL OF BONE & JOINT SURGERY ·VOLUME 87-A · SUPPLEMENT 2 · 2005

Ilfeld et al Anesthesiology 2008

Patients given 4 days of perineural ropivacaine attained the 3 discharge criteria in a median (25th-75th centiles) of 25 ( 21-47)h compared with 71 (46-89)h in the selected center. Decrease in time until discharge readiness of 46h

Ilfeld et al Pain 2010

Patients given 4 days of perineural ropivacaine attained the 3 discharge criteria in a median (25th-75th centiles) of 47 ( 29-69)h compared with 62 (45-79)h in that multicentric trial. Decrease in time until discharge readiness of 15h

From Tou K, Abstract A168, ASRA 2010 et Nader A, J Ultrasound Med 2009

• « Although more technically demanding, the in- plane placement of a continuous femoral nerve catheter resulted in fewer failed catheters for post-operative analgesia following total knee arthroplasty.

• The posterior location of the catheter relative to the femoral nerve may result in a higher success rate of catheter function. »

« In CFNB under ultrasound guidance, using the catheter perpendicular to the nerve technique can shorten the time of catheter insertion while providing a similar quality of analgesia after total knee arthroplasty as compared with the catheter parallel to the nerve technique. »

Can we optimize the technique?

Average pain scores the day after surgery for subjects of the 0- to 1-cm group were a median of 2.5 (interquartile range, 0.0-5.0), compared with 2.0 (interquartile range, 0.0-4.0) for subjects of the 5- to 6-cm group (P = 0.42). Worst pain scores during the same period for subjects of the 0- to 1-cm group wasa median of 6.0 (interquartile range, 3.0-9.0), compared with 7.0 (interquartile range, 3.0-8.0) for subjects of the 5- to 6-cm group (P = 0.37).

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100 PCA morphPerf ContBolus+cont

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* Anesthesiology 2006

Patient-controlled Perineural Analgesia at Home Decreases Postoperative Pain and Enhances Patient's Functional Exercice Capacity and Daily Activity after Ambulatory Orthopedic Surgery

Results of a Multicenter Randomized Trial Xavier Capdevila, M.D.,Ph.D.#, Christophe Dadure, M.D.*, Sophie Bringuier-Branchereau, Pharm.D., M.Sc.&, ,

Nathalie Bernard, M.D.*, Philippe Biboulet, M.D.*, Elisabeth Gaertner, M.D.°, Philippe Macaire, M.D.§

The time for the 10-minutes walking test: PCA morphine group: 40.5(16-44 ) h, continuous infusion group: 20.5 (17-42 )h, and basal-bolus group: 12.5 ( 4.5-20 )h respectively

The Effects of Varying Local Anesthetic Concentration and Volume on Continuous Popliteal Sciatic Nerve Blocks: A Dual-Center, Randomized, Controlled StudyBrian M. Ilfeld et al Anesth Analg. 2008 ; 107(2): 701–707

Either 0.2% (basal 8 mL/h, bolus 4 mL) or 0.4% (basal 4 mL/h, bolus 2 mL)

• Insensate limbs were far more common with larger volumes of relatively dilute ropivacaine.

• During continuous sciatic nerve block in the popliteal fossa,a relatively concentrated solution in smaller volume thus appears preferable.

Effects of Local Anesthetic Concentration and Dose on Continuous Interscalene Nerve Blocks: A Dual-Center, Randomized, Observer-Masked, Controlled StudyLinda T. Le et al Reg Anesth Pain Med. 2008 ; 33(6): 518–525

Either 0.2% ropivacaine (basal 8 mL/h, bolus 4 mL) or 0.4% ropivacaine (basal 4 mL/h, bolus 2 mL)

Pain (p=0.020) and dissatisfaction (p=0.011) were greater in patients given 0.4% ropivacaine

Ropivacaine 0.1% (basal 12 ml/h; bolus 4 ml) or 0.4% (basal3 ml/h; bolus 1 ml)

Each subject’s dominant side was randomized to either one of the two ropivacaine 0.1% treatments—a continuous 5 ml/h basal infusion for 6 h or 6 hourly 5-ml bolus doses—and the nondominant side received the opposite treatment.

• No variation with temperature and pump position

• More difficult for the patients

• Batteries

• Variations with T° and position

• Variation of 15%

• Very well accepted by the patients

The current point of view on pumps: Elastomeric vs Electronic

Incidence of neurological complications (%)

Perineural catheters do not increase the risk of neurological complications

Borgeat A et al, Anesthesiology 2001

Acute and non-acute complications associated with interscalene block and shoulder surgery

Other quite important side effects 0,42%

Side effects CPNB LA Due to PNB

1 Seizure Fascia iliaca bupi NO

3 epidurals CPCB ropi YES

1 Intra peritoneum CPCB ropi YES

One unilateral epidural due to a

CPCB

Location of one catheter in the

peritoneal cavity

The risk of falls?

Postoperative Analgesia After Knee Surgery: A Comparison of Three Different Concentrations of Ropivacaine for Continuous Femoral Nerve Blockade

Brodner G. et al, Anesth Analg 2007

Ropivacaine 0.1% provided ineffective analgesia

Ropivacaine 0.2% and 0.3% were similar in terms of analgesic quality.

“Initial infusion rates should be adjusted to 15 ml/h!!!!!! to obtain effective analgesia”

Falls Associated with Lower-Extremity–Nerve Blocks: A Pilot Investigation of Mechanisms Muraskin S.I. et al, Reg Anesth Pain Med 2007

“ Lower-extremity–nerve blocks result in decreased leg stiffness and lateral instability, which may lead to difficulty with pivoting maneuvers”

We implemented a policy that all patients who receive LE PNB are evaluated by a physical therapist prior to discharge. Physical therapists review their home living environment (stairs, bathroom access, and family assistance), preoperative functional capacity, cognitif status and a sit-to-stand test along with their ability to ambulate. If evaluation reveals high fall risk or inadequate home care, the patient will be admitted for overnight stay.

ASRA 2008:A4 Edelman A. et al

Total PNBFall risk

9008007006005004003002001000

Year

% Fall risks following PNB

0.93%

0.48%

0.67%

0%

• Continuous peripheral nerve blocks may be provided in the hospital setting, but the use of lightweight, portable pumps permits ambulatory infusion as well.

• This technique’s most common application is providing analgesia after surgical procedures. • Catheter insertion may be accomplished using including nerve stimulation or ultrasound

guidance

• Administered infusate generally includes exclusively long-acting, dilute, local anesthetic delivered as a bolus only, basal only, or basal-bolus combination.

• Documented benefits appear to be dependent on successfully improving analgesia, and include decreasing baseline/breakthrough/dynamic pain, supplemental analgesic requirements, opioid-related side effects, and sleep disturbances, patient satisfaction and ambulation and the time until discharge

• Lastly, postoperative joint inflammation and inflammatory markers may be decreased.