New Kids on the Block:

Advances in Regional Anesthesia Practice

Melissa Byrne DO, MPH@dr_melissabyrne

“Precision” Acute Care Medicine

Chronic Pain

“Nurse, get on the internet, go to NYSORA.COM, scroll down and click on the ‘Are you totally lost?’ icon.”

Roadmap for Discussion

Fascial Plane Blocks

Lower Extremity

Blocks

NovelLocal

Anesthetics

Take Home Points

• Who can do it?

• What do you need?

• Where should you place them?

• Why bother?

Overview

Who Can Do It?

• Catheters / Needles– Single- or multi-orifice

catheters

– Stimulating or non-

stimulating

– Flexible springwound or

rigid plastic

– Through or over the

needle

What Do You Need?

• Who can do it?

• What do you need?

• Where should you place them?

• Why bother?

Overview

• Tactile “pops” and “clicks” + ultrasound fascial

plane blocks

• Fastest growing subset of blocks

Truncal Fascial Plane Blocks

“If we can see it, we can now block it.” (Elsharkawy et al., RAPM 2018)

The Rise of the Fascial Plane Block

El-Boghdadly & Pawa (Anaesthesia, 2017)

TAP

QLB

PECS

Serratus Anterior

Transversus Abdominis Plane (TAP) Blocks

• Recent meta-analysis of US-guided TAP blocks

– Baeriswyl et al, Anesth Analg 2015

– Statistically significant but clinically modest

analgesic benefit in adult patient undergoing

abdominal laparotomy, laparoscopy or

cesarean delivery

– 6 and 11 mg IV morphine at 6 and 24 hours,

respectively

TAP Blocks…Why Bother?

• Upper Abdominal Surgery: Subcostal TAP

block is a useful alternative when epidural

analgesia is contraindicated with fewer side

effects such as hypotension

• Colorectal Surgery: open and laparoscopic

• Open appendectomy

• Abdominoplasty

Beneficial

• Major open gynecological surgery including total

abdominal hysterectomy

• Laparoscopic total hysterectomy

• Open inguinal hernia surgery

• Laparoscopic donor nephrectomy

• Cesarean delivery

The Data is Out…

• Laparoscopic cholecystectomy

• Laparoscopic Roux-en-Y bypass surgery

• Laparoscopic appendectomy

• Open radical retropubic prostatectomy

• Reconstructive abdominal surgery

• Renal transplantation

No Benefit

Quadratus Lumborum (QL)

Quadratus Lumborum (QL)

• Sparse literature; most only case reports

QL Block – Why Bother?

PECs Blocks

PECS Blocks – PECS I

- Lateral and medial pectoral nerves blocked

- Suitable for surgeries involving pecs major muscle (e.g., breast expanders, traumatic chest injuries, Portocath, pacemaker insertion)

PECS Blocks – PECS II

- T2-4 spinal nerves (including intercostobrachial) and long thoracic nerve may be blocked

- Suitable for more extensive excisions (e.g., tumor resections, mastectomy, axillary clearance, sentinel node excision, tissue expanders)

• RCTs for mastectomy

– Decreased opioid consumption and pain

scores in first 24 hours compared to

paravertebral (PVB) blocks (Wahba and

Kamal, 2014)

– Lower pain scores and opioid use

(Bashandy and Abbas, 2015)

– Increased duration of analgesia compared

to PVB (Kulhari, 2016)

PECS Blocks – Why Bother?

• Case Reports

– Insertion of cardiac resynchronization device with

block and dexmedetomidine

– Mastectomy under PECS II with supplemental

infiltration

– Alternative to brachial plexus blockade for axilla,

proximal medial upper arm and posterior

shoulder

PECS Blocks – Why Bother?

Serratus Anterior

- Thoracodorsal, thoracic intercostal nerves may be blocked

- Suitable for latissimus dorsi flap reconstruction

• Early data

– Duration of paresthesia in intercostal nerve

distribution T2-9 was 752 minutes

• Case reports

– Rib fracture: enabled PT and ambulation

– Thoracotomy: pain and ventilation improvement

• RCTs

– Increased opioid consumption during radical

mastectomy compared to PVB

– Less hemodynamic change compared to

thoracic epidural in thoracotomy

Serratus Anterior – Why Bother?

Erector Spinae (ESP) Blocks

ESP

Is this a paravertebral block by proxy???

• Early data

– Case reports/series

• Rib fractures (single shot and catheters

employed)

• Pleuroscopy: minimized procedural

sedation (T5 level)

• Bariatric surgery

• Thoracotomy (as rescue analgesic)

– Pilot study

• Laparoscopic ventral hernia repair (T7

level)

ESP – Why Bother?

Roadmap for Discussion

Fascial Plane Blocks

Lower Extremity

Blocks

NovelLocal

Anesthetics

Take Home Points

• Indications: saphenous vein stripping,

supplementation for medial foot/ankle surgery,

analgesia for knee surgery

Adductor Canal

• TKA

– Similar pain scores to femoral nerve block

– Quad strength preserved and ambulation

retained (several studies) compared to FNB

– Analgesic and opioid-sparing benefits in TKA

– KEY COMPONENT OF MULTIMODAL

ANALGESIC PLAN

Adductor Canal – Why Bother?

• Minor knee arthroscopies

– Little benefit (i.e., multimodal with NSAIDs +

APAP = ACB)

– ACL reconstruction mixed data

Adductor Canal – Why Bother?

• iPACK = interspace between the popliteal artery

and capsule of the posterior knee

iPACK Blocks

• Early data

– iPACK + ACB equivalent analgesia +

improved PT + earlier hospital discharge

post-TKA (Thobhani et al, Ochsner Journal

2017)

– iPACK + ACB better analgesia + improved

ROM and number of steps walked post-TKA

than ACB alone (Reddy et al, Int J Orthop Sci

2017)

iPACK – Why Bother?

Roadmap for Discussion

Fascial Plane Blocks

Lower Extremity

Blocks

NovelLocal

Anesthetics

Take Home Points

Liposomal Bupivacaine (Exparel ®)

• Many efficacy studies in surgical infiltration

but compare only to placebo

– Hemorrhoidectomy

– Mammoplasty

– Bunionectomy

– Forefoot surgery

– TKA

Liposomal Bupivacaine – Why Bother?

• Single-injection PNB

– NOTE: only FDA-approved for interscalene &

TAP blocks

– Femoral blocks: dose-response study (Ilfeld

et al, Anesth Analg 2013)

• High degree of intersubject variability

• Peak effect at 24 hours in 75% of subjects

• MUCH less than predicted 72 hours by

manufacturer

Liposomal Bupivacaine – Why Bother?

• Robotic-assisted hysterectomy

– Decrease in LOS with TAP blocks

– Potentially long-term opioid-sparing benefit

• Laparoscopic prostatectomy

– No difference in median time to opioid use, pain

scores comparing 20 mL vs 40 mL

– No placebo group included

• Open abdominal umbilical hernia repair

– Pain severity, opioid-related adverse events

recorded

– No placebo group included

Liposomal Bupivacaine – Why Bother?

Liposomal Bupivacaine – Why Bother?

Liposomal Bupivacaine – Why Bother?

Final Words on Liposomal Bupivacaine…

SABER®

• Laparoscopic cholecystectomy

– Did not meet its primary efficacy for Phase 3

trial with 380 patients

– No statistical difference in pain reduction with

movement over first 48 hours post surgery

compared to bupivacaine HCl

• Open hernia repair

– Significantly lower AUC for mean pain intensity

from 1-72 hours compared to placebo

• Abdominal surgery

– Decreased pain for 3 days

SABER – Why Bother?

Roadmap for Discussion

Fascial Plane Blocks

Lower Extremity

Blocks

NovelLocal

Anesthetics

Take Home Points

• Continued emphasis on precision acute care

medicine and avoiding persistent postoperative

pain

• Multiple newer fascial plane blocks can be

employed in the perioperative period

• Research regarding outcomes demands further

investigation

• Novel long-acting formulations may provide

additional benefit

Take Home Points

References

• H. Elsharkawy, A. Pawa, E.R. Mariano. Interfascial Plane Blocks: Back to Basics. Regional Anesthesia and Pain Medicine 43(4):341-346, May

2018.

• El-Boghdadly K, Pawa A. The erector spinae plane block: plane and simple. Anaesthesia. 2017: 72;4:434-438.

• K.J. Chin, J.G. McDonnell, B. Carvalho, A. Sharkey, A. Pawa, J. Gadsden. Essentials of our current understanding: abdominal wall blocks. Reg

Anesth Pain Med. 2017; 42:133-183.

• Baeriswyl M, Kirkham KR, Kern C, Albrecht E. The analgesic efficacy of ultrasound-guided transversus abdominis plane block in adult patients: a

meta-analysis. Anesth Analg. 2015;121:1640–1654.

• Ganapathy S, Sondekoppam RV, Terlecki M, et al. Comparison of efficacy and safety of lateral-to-medial continuous transversus abdominis plane

block with thoracic epidural analgesia in patients undergoing abdominal surgery: a randomised, open-label feasibility study. Eur J Anaesthesiol.

2015;32:797–804.

• Niraj G, Kelkar A, Jeyapalan I, et al. Comparison of analgesic efficacy of subcostal transversus abdominis plane blocks with epidural analgesia

following upper abdominal surgery. Anaesthesia. 2011;66:465–471.

• Wahba SS, Kamal SM. Analgesic efficacy and outcome of transversus-abdominis plane block versus low thoracic-epidural analgesia after

laparotomy in ischemic heart disease patients. J Anesth. 2014;28:517–523.

• Wu Y, Liu F, Tang H, et al. The analgesic efficacy of subcostal transversus abdominis plane block compared with thoracic epidural analgesia and

intravenous opioid analgesia after radical gastrectomy. Anesth Analg. 2013;117:507–513.

• Blanco R, Ansari T, Girgis E. Quadratus lumborum block for postoperative pain after caesarean section: a randomised controlled trial. Eur J

Anaesthesiol. 2015;32:812–818.

• Murouchi T, Iwasaki S, Yamakage M. Quadratus lumborum block: analgesic effects and chronological ropivacaine concentrations after

laparoscopic surgery. Reg Anesth Pain Med. 2016;41:146–150.

• Parras T, Blanco R. Randomised trial comparing the transversus abdominis plane block posterior approach or quadratus lumborum block type I

with femoral block for postoperative analgesia in femoral neck fracture, both ultrasound-guided. Rev Esp Anestesiol Reanim. 2016;63:141–148.

• McCrum CL, Ben-David B, Shin JJ, Wright VJ. Quadratus lumborum block provdes improved immediate postoperative analgesia and decreased

opioid use compared with a multimodal pain regimen following hip arthroscopy. J Hip Preservation Surg. 2018; 5:3: 233-239.

• Chin KJ, Adhikary S, Sarwani N, Forero M. The analgesic efficacy of pre‐operative bilateral erector spinae plane (ESP) blocks in patients having

ventral hernia repair. Anaesthesia 2017; 72: 452–60.

• Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain.

RAPM 2016;41:621-627.

• Forero M, Rajarathinam M, Adhikary S, Chin KJ. Continuous erector spinae plane block for rescue analgesia in thoracotomy after epidural failure:

a case report. AA Case Rep 2017;8:254-256.

• Chin KJ, Adhikary S, Sarwani N, Forero M. The analgesic efficacy of pre-operative bilateral erector spinae plane (ESP) blocks in patients having

ventral hernia repair. Anaesthesia 2017;72:452-460.

• Chin KJ, Malhas L, Perlas A. The erector spinae plane block provides visceral abdominal analgesia in bariatric surgery: a report of 3 cases. RAPM

2017;42:372-376.

• https://www.asra.com/asra-news/article/39/how-i-do-it-erector-spinae-block-for-rib Accessed 11/25/2018.

References

• Jenstrup, MT, Jæger, P, Lund, J, Fomsgaard, JS, Bache, S, Mathiesen, O, Larsen, TK, Dahl, JB Effects of adductor-canal-blockade on pain and

ambulation after total knee arthroplasty: A randomized study.. Acta Anaesthesiol Scand. (2012). 56 357–64.

• A.V. Gururva Reddy, A. Jangale, R.C. Reddy, M. Sagi, A. Gaikwad, A. Reddy. To compare effect of combined block of ACB with IPACK and ACB

alone on total knee replacement in immediate postoperative rehabilitation. Int J Orthop Sci, 3 (2017), pp. 141-145.

• Thobhani S, Scalercio L, Elliott CE, Nossaman BD, Thomas LC, Yuratich D, Bland K, Osteen K, Patterson M. Novel regional techniques for total

knee arthroplasty promote reduced hospital length of stay: an analysis of 106 patients. Ochsner Journal 2017; 17:233-238.

• M.A. Mont, W.B. Beaver, S.H. Dysart, J.W. Barrington, D.J. Del Gaizo. Local infiltration analgesia with liposomal bupivacaine improves pain scores

and reduces opioid use after total knee arthroplasty: results of a randomized controlled trial. J Arthroplasty, 33 (2018), pp. 90-96.

• Hadzic’s Textbook of Regional Anesthesia and Acute Pain Management. Chapter 8: Controlled-Release Local Anesthetics.

https://accessanesthesiology.mhmedical.com/content.aspx?bookid=2070&sectionid=157599103#1141731079 Accessed 11/25/2018.