RCOA nov '14 mccartney

Regional Anaesthesia Regional Anaesthesia Papers that are Changing My Papers that are Changing My

PracticePractice

Colin J.L. McCartney Colin J.L. McCartney MBChB PhD FCARCSI FRCA FRCPCMBChB PhD FCARCSI FRCA FRCPCProfessor and Chair of AnesthesiologyProfessor and Chair of Anesthesiology

University of Ottawa, ON, CanadaUniversity of Ottawa, ON, Canada@colinjmccartney@colinjmccartney

Conflicts of InterestConflicts of Interest

No education supportNo education support No industry research supportNo industry research support No honorariaNo honoraria No shares in related companiesNo shares in related companies

Overview:Overview:

Big Data: how do we use it?Big Data: how do we use it? US and impact on quality and safety: US and impact on quality and safety:

where are we now?where are we now? Best techniques for pain control after Best techniques for pain control after

TKA?TKA? Liposomal bupivacaine: place in TKALiposomal bupivacaine: place in TKA Adductor Canal Block: Better than FNB?Adductor Canal Block: Better than FNB? Teaching USGRATeaching USGRA

What is the optimal method of What is the optimal method of anesthesia for TKA?anesthesia for TKA?

BMJ 2000

Rodgers A et al BMJ 2000

Why so few patients having Why so few patients having neuraxial block?neuraxial block?

Reduced postoperative pain, opioid Reduced postoperative pain, opioid consumption, adverse effectsconsumption, adverse effects

No difference in blood loss or TE eventsNo difference in blood loss or TE events No difference in mortalityNo difference in mortality

382,000 patients382,000 patients 25% neuraxial25% neuraxial Neuraxial associated with less mortality, Neuraxial associated with less mortality,

length of stay, in-patient morbiditylength of stay, in-patient morbidity

Anesthesiology 2013

Evidence building that neuraxial block is Evidence building that neuraxial block is superior to GA for TKAsuperior to GA for TKA

Improved morbidity and mortalityImproved morbidity and mortality Evidence from RCTs, systematic review Evidence from RCTs, systematic review

and large database studiesand large database studies ? Further large pragmatic studies needed? Further large pragmatic studies needed

Neuman MD and Brummett C Anesthesiology 2013

Overview:Overview:

Big Data: how do we use it?Big Data: how do we use it? US and impact on quality and safety: US and impact on quality and safety:

where are we now?where are we now? Best techniques for pain control after Best techniques for pain control after

TKA?TKA? Liposomal bupivacaine: place in TKALiposomal bupivacaine: place in TKA Adductor Canal Block: Better than FNB?Adductor Canal Block: Better than FNB? Teaching USGRATeaching USGRA

Impact of US on quality and safety?Impact of US on quality and safety?

A&A 2007

McCartney and Choi 2014

SafetySafety

Prospective multicentre clinical registryProspective multicentre clinical registry Quality and safety of PNBsQuality and safety of PNBs 20,000 patients, 20 hospitals over 5 years20,000 patients, 20 hospitals over 5 years 22 episodes LAST: 0.87/1000 PNBs22 episodes LAST: 0.87/1000 PNBs US associated with reduced incidence LASTUS associated with reduced incidence LAST

Barrington MJ et al RAPM 2013

Barrington MJ et al RAPM 2013

Orebaugh SL et al RAPM 2012

Overview:Overview:

Big Data: how do we use it?Big Data: how do we use it? US and impact on quality and safety: US and impact on quality and safety:

where are we now?where are we now? Best techniques for pain control after Best techniques for pain control after

TKA?TKA? Liposomal bupivacaine: place in TKALiposomal bupivacaine: place in TKA Adductor Canal Block: Better than FNB?Adductor Canal Block: Better than FNB? Teaching USGRATeaching USGRA

Optimizing Pain and Function Optimizing Pain and Function after TKAafter TKA

Is Total Knee Replacement Painful?Is Total Knee Replacement Painful?

✓Poulakka P et al EJA 2010

Best technique?Best technique?

LIA vs FNB vs ACB: GA vs Neuraxial

RCT 120 patientsRCT 120 patients IT bupivacaine or TIVA for TKAIT bupivacaine or TIVA for TKA All patients had multimodal analgesiaAll patients had multimodal analgesia All patients had LIAAll patients had LIA No other RA techniques usedNo other RA techniques used No IT or other opioid in IT group No IT or other opioid in IT group

GA shorter LOS and less PONV (46 vs GA shorter LOS and less PONV (46 vs 52h; p<0.001)52h; p<0.001)

Pain significantly greater in spinal group Pain significantly greater in spinal group after 6h (p<0.001)after 6h (p<0.001)

Patients in GA group used less PCA Patients in GA group used less PCA morphine (12 vs 30 doses; p<0.001)morphine (12 vs 30 doses; p<0.001)

Harsten et al BJA 2013

Liposomal Bupivacaine in TKALiposomal Bupivacaine in TKA

Early experience with liposomal Early experience with liposomal bupivacaine: no increased duration of bupivacaine: no increased duration of analgesia compared to plain bupivacaine analgesia compared to plain bupivacaine alonealone

Three negative studies to dateThree negative studies to date Several more studies to comeSeveral more studies to come

Adductor Canal BlockAdductor Canal Block Block of saphenous Block of saphenous

nerve in adductor nerve in adductor canalcanal

Usually single Usually single injection techniqueinjection technique

Less motor block Less motor block than femoral nerve than femoral nerve blockblock

? Facilitates ? Facilitates ambulation with less ambulation with less painpain

Retrospective review of patients having Retrospective review of patients having ACB or cFNB for TKAACB or cFNB for TKA

Primary outcome: distance walked POD1Primary outcome: distance walked POD1 Secondary outcomes: walking POD2,3. Secondary outcomes: walking POD2,3.

Pain, Opioid dose and AEsPain, Opioid dose and AEs

RAPM 2013

Perlas A et al RAPM 2013

RCT 50 patients TKARCT 50 patients TKA Spinal anaesthesia. LIA. MultimodalSpinal anaesthesia. LIA. Multimodal ACB or FNB 30ml 0.2% ropivacaine after ACB or FNB 30ml 0.2% ropivacaine after

surgerysurgery Endpoints: muscle strength (MVIC), TUG Endpoints: muscle strength (MVIC), TUG

test, pain scorestest, pain scores 120 minutes assessment120 minutes assessment

ACB preserves strength more effectively than ACB preserves strength more effectively than ssFNBssFNB

Pain scores equivalentPain scores equivalent Need more data on longer term pain and Need more data on longer term pain and

function outcomesfunction outcomes Study underlines (again) poor pain control with Study underlines (again) poor pain control with

LIA technique alone as mean pain scores in LIA technique alone as mean pain scores in both groups 6/10 at baselineboth groups 6/10 at baseline

Overview:Overview:

Big Data: how do we use it?Big Data: how do we use it? US and impact on quality and safety: US and impact on quality and safety:

where are we now?where are we now? Best techniques for pain control after Best techniques for pain control after

TKA?TKA? Liposomal bupivacaine: place in TKALiposomal bupivacaine: place in TKA Adductor Canal Block: Better than FNB?Adductor Canal Block: Better than FNB? Teaching USGRATeaching USGRA

Teaching USGRATeaching USGRA

Teaching traditionally uses quantitative Teaching traditionally uses quantitative measuresmeasures

Problems include volume of clinical Problems include volume of clinical material and variability in achievement of material and variability in achievement of competence competence

A&A 1998

Konrad C et al 1998

20 residents randomized to two groups20 residents randomized to two groups Group 1: standard trainingGroup 1: standard training Group 2: Extra training in US guided Group 2: Extra training in US guided

needling (phantom)needling (phantom) Success assessed over 3 week regional Success assessed over 3 week regional

rotationrotation RAPM 2012

Niazi A et al RAPM 2012

Summary:Summary:

Big Data: how do we use it?Big Data: how do we use it? US and impact on quality and safety: US and impact on quality and safety:

where are we now?where are we now? Best techniques for pain control after Best techniques for pain control after

TKA?TKA? Liposomal bupivacaine: place in TKA: Liposomal bupivacaine: place in TKA: Adductor Canal Block: Better than FNB?Adductor Canal Block: Better than FNB? Teaching USGRATeaching USGRA

Acknowledgements

University of Ottawa Department of Anesthesiology and Pain Medicine

Key Faculty: Anne Lui, Desiree Persaud, Alan Lane, Jason McVicar, Patrick Wong, Catherine Smyth, Shona Nair, Colin McCartney

Contact cmccartney@toh.on.ca Twitter: @colinjmccartney