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Practice Details
Main OR
A60
Regional facilities
Main ORs
A variety of blocks performed by
BS
Infusion catheters
◦ Inpatients
Femoral, popliteal and
supraclavicular
◦ Outpatients
Supraclavicular and Popliteal
Ambit Pump
Kit includes….
◦ Preset pump
◦ Batteries
◦ Carrying case
◦ One liter bag of local
anesthetic
◦ Detailed instructions
◦ Contact number for our
APMS
Acute Pain Service
Nurses call the patient
daily
Patient will remove
catheters by
themselves
A 60
Most blocks are placed Block
Service (BS)
Day before surgery, surgeon or
anesthesia will contact BS for
blocks needed in A60
Most common blocks performed
◦ Supraclavicular
◦ Axillary
Rare to send patients home with
peripheral catheters
Regional Facilities
Beachwood
Strongsville
Hillcrest
Lutheran
Marymount
Lorain
Regional Facilities-No
Catheters
Beachwood
◦ Supraclavicular and popliteals
(started femoral blocks)
◦ Patient do not go home with
catheters
Strongsville
◦ All blocks
◦ Success with dexamethasone
◦ No catheters: had some
challenges with dizziness when
used
Regional Facilities
Hillcrest
◦ All blocks
◦ Home: Interscalene and popliteal catheters
(10-15 patients per month)
◦ Own nurses for follow-up (On-Q pump)
Lutheran
◦ All blocks
◦ Home: popliteal catheters (3-5 per month)
◦ Femoral catheters for inpatients
◦ Use our nurses for follow-up
Regional Facilities
Regional Anesthesia is
Much Better than General
Anesthesia
Benefits of Peripheral Nerve
Blocks
Improved post operative pain control
Less PONV
Earlier mobilization
Earlier discharge
Surgeries
Hadzic et al anesthesiology 2004;101:127-32
Infraclavicular nerve block vs. fast-track
GENA
Criteria INB(25) GENA(25) P value
infraclavicular 6
5
catheters and GA
Pain scale
4 ropivacaine
3 placebo
2
Post-operatively: 1
0
0 1 2 3
15 received POD
ropivacaine 0.2%
at 8 ml/hr Average pain at rest
15 received placebo
4
3.5
3
Pain scale
2.5
Infusion was 2
1.5
maintained for 3
1
0.5
0
days.
0 1 2 3
POD
Complications : There were no apparent local
anesthetic or catheter related complications
during infusion
Continuous Interscalene Analgesia for
Ambulatory Shoulder Surgery in a Private
Practice Setting Fredrickson et al. Reg Anesth
Pain Med 2008;33:122-128.
Fredrickson et al….
C o m p lica tio n s:
Nonsense!
All INB patients received
continuous IV propofol sedation
GA patients were not optimally
managed
◦ Only Dolasetron 12.5 mg
preoperatively (no dexamethasone)
◦ Desflurane as maintenance
◦ Only 25% of GA cases met fast-track
criteria!
◦ No NSAIDs
◦ No BIS
Still Myth #1
Devil is in the details
Recent meta-analysis compared
peripheral nerve block to GA showed a
“decrease in nausea”
◦ Only 3 of 7 studies used PONV prophylaxis-
only Dolasetron.
◦ Only 2 used propofol for maintenance!
◦ Data skewed
100 of the 359 patients came from
one study which used neither
prophylactic measures nor propofol!
◦ No difference in central nerve block
techniques with GA
Liu et al. AA 2005
Myth #2
Postoperative Pain
Hadzic re-visited
Only 3% of INB had VAS score
greater than 3 compared to
43% of those with GA
Details:
◦ No NSAIDs
◦ Intraoperatively, GA group
received 5 fold increase in
narcotics
◦ No difference in VAS scores or
quantity of analgesics at 24 or 48
hours
Hadzic et al Anesth. 2004
Myth #2
Postoperative Pain
McCartney et al hypothesized that
regional would provide improved
analgesia up to 2 weeks
postoperatively
Results: despite improved early VAS
scores there was no difference
◦ Pain
◦ Opioid consumption
◦ Incidence of nausea/vomiting
◦ Adverse effects i.e. paraesthesia
◦ Satisfaction at POD 1, 7, 14
And this is despite the lack of
multimodal analgesic techniques!
McCartney et al. Anesth 2004
VAS
Problems you are not suppose
to know about
Need for sedation
Need for conversion to GA
Dysrhythmias
Cardiovascular collapse
No control of airway
PDPH
CNS toxicity
Need for Conversion
McCartney et al
◦ 10% of patients were converted to
GA because of block failure
28% of patients with RA required
local anesthetic infiltration
Complications
A recent review shows that as
more regional anesthesia is
done more complications will be
seen
◦ Direct nerve injury
◦ Systemic local anesthetic toxicity
◦ Wrong-sided and wrong-site
procedures
More complications
Recent ASA closed claims
◦ 66 of 210 PNB claims were
permanent and 71% of those
were thought to be block related
◦ 4 claims were respiratory or
cardiovascular collapse
Neuraxial anesthesia .
blocks
PACU bypass rate of 94%
Unplanned admission rate of 3%
Estimated savings will be……
1.2 million $