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Safe and Efficient Local Anesthetic Continuous Injection in CPNB

Safe and Efficient Local Anesthetic Continuous Injection in CPNB. Xavier Capdevila M.D., Ph.D . Head of Department Department of Anesthesiology and Critical Care Medicine Lapeyronie University Hospital and Montpellier School of Medicine Montpellier , France.

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Safe and Efficient Local Anesthetic Continuous Injection in CPNB

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  1. Safe and Efficient Local Anesthetic Continuous Injection in CPNB Xavier Capdevila M.D.,Ph.D. Head of Department Department of Anesthesiology and Critical Care Medicine LapeyronieUniversityHospital and Montpellier School of Medicine Montpellier , France • Conflicts of interest: • Pajunk • B Braun • GE Healthcare • Baxter • Janssen • Abbott

  2. 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

  3. 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 readinessof 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

  4. « 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. » From Tou K, Abstract A168, ASRA 2010 et Nader A, J Ultrasound Med 2009

  5. Can we optimize the technique? « 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. »

  6. 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 was a 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).

  7. 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.§ Anesthesiology 2006 * * * * * * * 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

  8. The Effects of Varying Local Anesthetic Concentration and Volume on Continuous Popliteal Sciatic Nerve Blocks: A Dual-Center, Randomized, Controlled Study Brian 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) • Insensatelimbswere far more commonwithlarger volumes of relativelydiluteropivacaine. • Duringcontinuoussciatic nerve block in the poplitealfossa,arelativelyconcentrated solution in smaller volume thusappearspreferable.

  9. Effects of Local Anesthetic Concentration and Dose on Continuous Interscalene Nerve Blocks: A Dual-Center, Randomized, Observer-Masked, Controlled Study Linda 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

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

  11. 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.

  12. The current point of view on pumps: Elastomeric vs Electronic • 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

  13. Acute and non-acute complications associatedwithinterscalene block and shouldersurgery Borgeat A et al, Anesthesiology 2001 Incidence of neurological complications (%) Perineural catheters do not increase the risk of neurological complications

  14. Other quite important side effects 0,42% One unilateralepidural due to a CPCB Location of one catheter in the peritonealcavity

  15. 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, AnesthAnalg 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, RegAnesth Pain Med 2007 “ Lower-extremity–nerve blocks result in decreased leg stiffness and lateral instability, which may lead to difficulty with pivoting maneuvers”

  16. 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. Fall risks following PNB % 900 800 0.93% Total PNB Fall risk 0.67% 700 600 0.48% 500 400 300 200 100 0% 0 Year ASRA 2008:A4 Edelman A. et al

  17. 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.

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