13TH UPDATE IN ORTHOPAEDIC ANAESTHESIA

13TH UPDATE IN ORTHOPAEDICANAESTHESIA

Dr Sim West

Consultant Anaesthetist

University College Hospital London

PRESENTATION OUTLINE

• Anaesthesia for joint replacement

• Anaesthesia for hip fracture

• Regional anaesthesia

• Pain management

JOINT REPLACEMENTS

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Anesthesia and Analgesia Practice Pathway Options forTotal Knee Arthroplasty

An Evidence-Based Review by the American and European Societies ofRegional Anesthesia and Pain Medicine

Sandra L. Kopp, MD,* Jens Børglum, MD, PhD,† Asokumar Buvanendran, MD,‡Terese T. Horlocker, MD,§|| Brian M. Ilfeld, MD, MS (Clinical Investigation),**

Stavros G. Memtsoudis, MD, PhD, FCCP,†† Joseph M. Neal, MD,‡‡Narinder Rawal, MD, PhD, FRCA (Hon), EDRA,§§ and Jessica T. Wegener, MD, PhD, EDRA||||

Abstract: In 2014, the American Society of Regional Anesthesia andPain Medicine in collaboration with the European Society of Regional An-aesthesia and Pain Therapy convened a group of experts to compare path-ways for anesthetic and analgesic management for patients undergoingtotal knee arthroplasty in North America and Europe and to develop a prac-tice pathway. This review is intended to be an analysis of the current liter-ature to assist individuals and institutions in designing a pathway for totalknee arthroplasty that is based on existing evidence and expert recommen-dation and may be customized according to individual settings.

(Reg Anesth Pain Med 2017;42: 683–697)

Total knee arthroplasty (TKA) is one of the most commonlyperformed orthopedic procedures, with an estimated more

than 700,000 total knee replacements (TKRs) performed annuallyin the United States. The annual expected growth rate of TKA is7.9% in the United States and 5.3% to 14.7% in the main Europeancountries.1 Patients undergoing TKA report improved health-related quality of life and functional status.2–4 Unfortunately, itis known to cause moderate to severe pain in most patients andis therefore regarded as one of the most painful orthopedic proce-dures.5 In addition, patients who are identified as at risk of chronic

pain may benefit from aggressive perioperative pain managementin an attempt to prevent central sensitization.6 The extensive in-crease in the number of patients undergoing TKA requires spe-cific customized management of care. Clinical pathways are toolscreated to organize care of well-defined groups of patients whilemaintaining a high quality of efficient care during a well-defined,limited episode of care.2 An effective TKA pathway would linkthe current evidence to individual practices with the goal of havinga positive impact on perioperative outcomes (Fig. 1). In 2014, theAmerican Society of Regional Anesthesia and Pain Medicine(ASRA) in collaboration with the European Society of RegionalAnaesthesia and Pain Therapy (ESRA) convened a group of expertsto compare pathways for anesthetic and analgesic management forpatients undergoing TKA between North America and Europe anddevelop a practice pathway. It became immediately clear thatstandardized pathways are not ubiquitous in Europe or NorthAmerica. Rather, each practicewas using a combination of differenttechniques dictated by the orthopedic surgeons, anesthesiologists,or simply the needs of the site. The panel quickly determined thatit was going to be impossible to define or compare a specific path-way on either continent. Therefore, this review is intended to be ananalysis of the current literature to assist individuals and institutionsin designing a pathway for TKA that is based on existing evidenceand expert recommendation and may be customized according toindividual settings.

METHODSThe ASRA and ESRA panelists were chosen based on their

demonstrated expertise in various issues related to anesthetic(neuraxial vs general) and analgesic (eg, multimodal analgesia,peripheral nerve blocks [PNBs]) management for patients under-going TKA. Panelists received no compensation for their contri-butions; nor did any declare a conflict of interest pertinent to thetopic. Panelists were charged with performing an extensive reviewof the literature; summarizing and presenting their findings at the2014 American Society of Regional Anesthesiology and AcutePain Medicine Conference, Chicago, Illinois; and producing anarticle based on their scholarly work. A comprehensive reviewof the subtopics (anesthesia type and outcomes, PNBs, infiltrativetechniques, and multimodal oral analgesia) was performed, in-cluding publications involving comparative techniques, efficacy,and complications. In each section, the authors created their workwith a combination of literature review and experience-basedopinion. This document is not intended to define the standard ofcare and is not a formal systematic review. Rather, it is intendedto provide a scoping review of specific components of a regionalanesthesia pathway for TKA.7

From the *Department of Anesthesiology, Mayo Clinic, Rochester, MN; †De-partment of Anesthesiology and Intensive Care Medicine, Zealand UniversityHospital, University of Copenhagen, Copenhagen, Denmark; ‡Department ofAnesthesiology, Rush University Medical Center, Chicago, IL; Departmentsof §Anesthesiology and ||Orthopedics, Mayo Clinic, Rochester, MN; **Depart-ment of Anesthesiology, University of California, San Diego, CA; ††Depart-ment of Anesthesiology, Weill Cornell Medical College, Hospital for SpecialSurgery, New York, NY; ‡‡Department of Anesthesiology, Virginia MasonMedical Center, Seattle, WA; §§Department of Anaesthesiology and IntensiveCare, Örebro University, Örebro, Sweden; and ||||Department of Anaesthesiol-ogy, Pain Medicine and Palliative Care, University Hospital of Amsterdam,Amsterdam, the Netherlands.Accepted for publication June 12, 2017.Address correspondence to: Sandra L. Kopp, MD, Department of

Anesthesiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905(e‐mail: [email protected]).

B.M.I.'s institution has received funding for his research from several infusionpump manufacturers, including Baxter Healthcare, Smiths Medical,Infutronix, and Summit Medical; a perineural catheter manufacturer,Teleflex Medical; a manufacturer of a peripheral nerve stimulator, SPRTherapeutics; a manufacturer of a cryoneurolysis device, Myoscience; andmanufacturers of long-acting liposome bupivacaine formulations, PaciraPharmaceuticals, and Heron Therapeutics. The other authors declare noconflict of interest.

Copyright © 2017 by American Society of Regional Anesthesia and PainMedicine

ISSN: 1098-7339DOI: 10.1097/AAP.0000000000000673

REGIONAL ANESTHESIA AND ACUTE PAIN

SPECIAL ARTICLE

Regional Anesthesia and Pain Medicine • Volume 42, Number 6, November-December 2017 683

Copyright © 2017 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.

SOURCES OF INFORMATION

?

ERAS PROTOCOLS

• Many units already have an ERAS protocol for hips/knees.

• There are wide variations but:

• Most comprise of:

1. Prehab, blood management+/- other optimisation.

2. Anaesthetic technique: multimodal analgesia, spinal +/-opioid, ?nerve block, antifibrinolytic.

3. Surgical technique: LIA, no drains, antibiotic protocol

4. Post-op pain management

• Some units are routinely doing “day case” joint replacements in suitable patients.

From: Enhanced recovery after surgery for primary hip and knee arthroplasty: a review of the evidenceBr J Anaesth. 2016;117(suppl_3):iii62-iii72.

ERAS PROTOCOLS

ERAS PROTOCOLS

BALANCE OF PAIN AND MOBILISATION(THE ORTHO PRIORITY)

RegionalBlocks

PERIOPERATIVE OUTCOMES?

• Mortality

• Length of stay

• Morbidity

• Thromembolic events.

• Pulmonary complication.

• Ileus and urinary retention.

• Chronic pain.

• Functional Outcome (Risk of Falls).

• Patient Satisfaction.

• Postop cognitive dysfunction/Delerium.

From: Impact of Regional Anaesthesia on Perioperative Outcomes, Opperer et al. Current Anesthesiology Reports, 5(2), pp. 209-16.

SPINAL OR GA?

Renewed interest in the GA vs Spinal debate. Retrospective insurance database review, found mortality and morbidity outcome improvements with spinal vs. GA.Suffers heavily from selection bias given design.

SPINAL OR GA

SPINAL OR GA?

OPIOID OR NOT?

• Advantages of no opioid

• Reduction in post-operative urinary retention

• Reduction in pruritus

• Potential for improved mobilisation

• Avoidance of risk of delayed post op resp depression?

• Disadvantages

• Selective/additional post-operative analgesia

• Longevity of spinal

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Relative Contributions of Adductor Canal Block andIntrathecal Morphine to Analgesia and Functional Recovery

After Total Knee ArthroplastyA Randomized Controlled Trial

Abhijit Biswas, MBBS, FCARCSI, MSc, EDRA, Anahi Perlas, MD, FRCPC, Meela Ghosh, MBBS, BSc, FRCA,KiJinn Chin, MD, FRCPC, Ahtsham Niazi, MD, FCARCSI, FRCPC, Barjind Pandher, BSc,

and Vincent Chan, MD, FRCPC, FRCA

Background and Objectives: Effective postoperative analgesia mayenhance early rehabilitation after orthopedic surgery. This randomizeddouble-blind trial investigates the relative contributions of adductor canalblock and low-dose intrathecal morphine (ITM) to postoperative analgesiaand functional recovery after total knee arthroplasty.Methods: Two-hundred one patients undergoing elective unilateral totalknee arthroplasty under spinal anesthesia were randomized to 3 groups.All patients received standardized intraoperative local infiltration analgesiaand postoperative oral analgesics. Patients in group 1 received a “sham” ad-ductor canal block with 30 mL of normal saline. Patients in group 2 re-ceived an adductor canal block with 30 mL of ropivacaine 0.5% with1:400,000 epinephrine, whereas patients in group 3 received the adductorcanal block with the active drug and 100 μg of ITM. The primary outcomemeasure was the Timed Up and Go (TUG) test on the second postoperativeday. Secondary outcomes included postoperative pain scores and opioid re-quirements, distance walked, time to hospital discharge, and self-reportedfunctional outcomes at 3 months.Results: All 3 groups had similar values of TUG test on postoperativeday (POD) 2 (46 [36–62], 45 [33–61], and 52 [41–69]; P = 0.166) as wellas other short-term and 3-month functional outcomes. Patients in group 3showed a favorable analgesic profile as evidenced by 3 positive secondaryoutcomes. These positive outcomes were lower pain scores 12 hours post-operatively both at rest (4 [2–6.3], 4 [2.3–6], and 3 [1–4];P = 0.007) and onmovement (6 [4–8], 6 [3–8], and 4 [2–6]; P = 0.002), a lower incidence of“rescue” intravenous patient-controlled analgesia (42%, 34%, and 20%;P = 0.031), and the lowest cumulative opioid requirements for the first48 hours postoperatively (86 ± 71, 68 ± 46, and 59 ± 39; P < 0.005, group3 compared with group 1).Conclusions: Our data suggest that there is no difference in either theprimary outcome of TUG test on POD 2, other immediate functionalsecondary outcomes, or in global functional outcome at 3 months post-operatively across all 3 groups. Our data also suggest an improved anal-gesic profile in the first 48 hours postoperatively when both adductorcanal block and low-dose ITM (100 μg) are added to local infiltration

analgesia as evidenced by several positive secondary outcomes of lowerpain scores and opioid requirements.Clinical Trial Registration: This studywas registered at ClinicalTrials.gov,identifier NCT02411149.


Osteoarthritis of the knee is a common disease of the elderly,and total knee arthroplasty (TKA) is indicated in severe

cases to improve long-term pain and function. The number of kneearthroplasties in Canada increased by 20.3% between fiscal-yearperiods 2009 to 2010 and 2014 to 2015.1,2 The surgical proce-dure involves extensive bone resection (of both the distal femurand proximal tibia) as well as soft tissue excision and is fre-quently associated with moderate to severe postoperative pain.3

Inadequate perioperative pain control may hinder early rehabili-tation and prolong hospitalization, and is also a strong predictorof persistent pain beyond 3 months.4 Adequate analgesia afterTKA is therefore considered paramount to facilitate effective re-habilitation and timely hospital discharge.5

Several analgesic regimens are currently used to provideanalgesia after TKA. These regimens usually involve multimodalinterventions that include local anesthetics either in the form ofperipheral nerve blocks or intraoperative local infiltration, alsoknown as local infiltration analgesia (LIA).6–8 Although LIAhas been shown to be superior to placebo, several retrospectivestudies suggest improved analgesia and or improved functionaloutcomes when LIA is combined with adductor canal block.6,9,10

Intrathecal morphine (ITM) is also commonly used in the settingof neuraxial anesthesia, but it is not known whether it offers anyadditional advantage in the context of the previous interventions.11,12

Over the past few years, the adductor canal block (ACB) has gainedpreference over the femoral nerve block owing to its quadriceps-sparing effect and associated earlier functional recovery.13–15

Previous studies on the relative effectiveness of these differentinterventions are limited by small sample sizes and by the studyof individual interventions outside the context of systemicmultimodal analgesia.16–20

This prospective randomized double-blind study was per-formed to compare the relative contributions of ACB and ITMwith analgesia and functional outcomes after TKA in the settingof systemic multimodal analgesia and LIA.

METHODSThe study was approved by the University Health Network

Research Ethics Board (REB number 13-7106-A), and it was reg-istered at clinicaltrials.gov (NCT02411149). Patients undergoingunilateral TKA between January 2014 and September 2016 atthe TorontoWestern Hospital were considered for inclusion in this

From the Department of Anesthesia and Pain Management, Toronto WesternHospital, University Health Network, Toronto, Canada.Accepted for publication October 4, 2017.Address correspondence to: Anahi Perlas, MD, FRCPC, Department of

Anesthesia and Pain Medicine, Toronto Western Hospital, 399 Bathurst St,Toronto, Ontario, Canada M5T2S8 (e‐mail: [email protected]).

V.C. has received honoraria from SonoSite, Braun, and Aspen Pharma. He isalso a member of the Medical Advisory Board for Smiths Medical. Theauthors declare no conflict of interest.

Presented at the 42nd Annual Regional Anesthesia and Acute Pain MedicineMeeting, American Society of Regional Anesthesia and Pain Medicine,April 7, 2017, San Francisco, CA.


ISSN: 1098-7339DOI: 10.1097/AAP.0000000000000724


ORIGINAL ARTICLE

154 Regional Anesthesia and Pain Medicine • Volume 43, Number 2, February 2018


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Relative Contributions of Adductor Canal Block andIntrathecal Morphine to Analgesia and Functional Recovery

After Total Knee ArthroplastyA Randomized Controlled Trial

Abhijit Biswas, MBBS, FCARCSI, MSc, EDRA, Anahi Perlas, MD, FRCPC, Meela Ghosh, MBBS, BSc, FRCA,KiJinn Chin, MD, FRCPC, Ahtsham Niazi, MD, FCARCSI, FRCPC, Barjind Pandher, BSc,

and Vincent Chan, MD, FRCPC, FRCA

Background and Objectives: Effective postoperative analgesia mayenhance early rehabilitation after orthopedic surgery. This randomizeddouble-blind trial investigates the relative contributions of adductor canalblock and low-dose intrathecal morphine (ITM) to postoperative analgesiaand functional recovery after total knee arthroplasty.Methods: Two-hundred one patients undergoing elective unilateral totalknee arthroplasty under spinal anesthesia were randomized to 3 groups.All patients received standardized intraoperative local infiltration analgesiaand postoperative oral analgesics. Patients in group 1 received a “sham” ad-ductor canal block with 30 mL of normal saline. Patients in group 2 re-ceived an adductor canal block with 30 mL of ropivacaine 0.5% with1:400,000 epinephrine, whereas patients in group 3 received the adductorcanal block with the active drug and 100 μg of ITM. The primary outcomemeasure was the Timed Up and Go (TUG) test on the second postoperativeday. Secondary outcomes included postoperative pain scores and opioid re-quirements, distance walked, time to hospital discharge, and self-reportedfunctional outcomes at 3 months.Results: All 3 groups had similar values of TUG test on postoperativeday (POD) 2 (46 [36–62], 45 [33–61], and 52 [41–69]; P = 0.166) as wellas other short-term and 3-month functional outcomes. Patients in group 3showed a favorable analgesic profile as evidenced by 3 positive secondaryoutcomes. These positive outcomes were lower pain scores 12 hours post-operatively both at rest (4 [2–6.3], 4 [2.3–6], and 3 [1–4];P = 0.007) and onmovement (6 [4–8], 6 [3–8], and 4 [2–6]; P = 0.002), a lower incidence of“rescue” intravenous patient-controlled analgesia (42%, 34%, and 20%;P = 0.031), and the lowest cumulative opioid requirements for the first48 hours postoperatively (86 ± 71, 68 ± 46, and 59 ± 39; P < 0.005, group3 compared with group 1).Conclusions: Our data suggest that there is no difference in either theprimary outcome of TUG test on POD 2, other immediate functionalsecondary outcomes, or in global functional outcome at 3 months post-operatively across all 3 groups. Our data also suggest an improved anal-gesic profile in the first 48 hours postoperatively when both adductorcanal block and low-dose ITM (100 μg) are added to local infiltration

analgesia as evidenced by several positive secondary outcomes of lowerpain scores and opioid requirements.Clinical Trial Registration: This studywas registered at ClinicalTrials.gov,identifier NCT02411149.


Osteoarthritis of the knee is a common disease of the elderly,and total knee arthroplasty (TKA) is indicated in severe

cases to improve long-term pain and function. The number of kneearthroplasties in Canada increased by 20.3% between fiscal-yearperiods 2009 to 2010 and 2014 to 2015.1,2 The surgical proce-dure involves extensive bone resection (of both the distal femurand proximal tibia) as well as soft tissue excision and is fre-quently associated with moderate to severe postoperative pain.3

Inadequate perioperative pain control may hinder early rehabili-tation and prolong hospitalization, and is also a strong predictorof persistent pain beyond 3 months.4 Adequate analgesia afterTKA is therefore considered paramount to facilitate effective re-habilitation and timely hospital discharge.5

Several analgesic regimens are currently used to provideanalgesia after TKA. These regimens usually involve multimodalinterventions that include local anesthetics either in the form ofperipheral nerve blocks or intraoperative local infiltration, alsoknown as local infiltration analgesia (LIA).6–8 Although LIAhas been shown to be superior to placebo, several retrospectivestudies suggest improved analgesia and or improved functionaloutcomes when LIA is combined with adductor canal block.6,9,10

Intrathecal morphine (ITM) is also commonly used in the settingof neuraxial anesthesia, but it is not known whether it offers anyadditional advantage in the context of the previous interventions.11,12

Over the past few years, the adductor canal block (ACB) has gainedpreference over the femoral nerve block owing to its quadriceps-sparing effect and associated earlier functional recovery.13–15

Previous studies on the relative effectiveness of these differentinterventions are limited by small sample sizes and by the studyof individual interventions outside the context of systemicmultimodal analgesia.16–20

This prospective randomized double-blind study was per-formed to compare the relative contributions of ACB and ITMwith analgesia and functional outcomes after TKA in the settingof systemic multimodal analgesia and LIA.

METHODSThe study was approved by the University Health Network

Research Ethics Board (REB number 13-7106-A), and it was reg-istered at clinicaltrials.gov (NCT02411149). Patients undergoingunilateral TKA between January 2014 and September 2016 atthe TorontoWestern Hospital were considered for inclusion in this

From the Department of Anesthesia and Pain Management, Toronto WesternHospital, University Health Network, Toronto, Canada.Accepted for publication October 4, 2017.Address correspondence to: Anahi Perlas, MD, FRCPC, Department of

Anesthesia and Pain Medicine, Toronto Western Hospital, 399 Bathurst St,Toronto, Ontario, Canada M5T2S8 (e‐mail: [email protected]).

V.C. has received honoraria from SonoSite, Braun, and Aspen Pharma. He isalso a member of the Medical Advisory Board for Smiths Medical. Theauthors declare no conflict of interest.

Presented at the 42nd Annual Regional Anesthesia and Acute Pain MedicineMeeting, American Society of Regional Anesthesia and Pain Medicine,April 7, 2017, San Francisco, CA.


ISSN: 1098-7339DOI: 10.1097/AAP.0000000000000724


ORIGINAL ARTICLE

154 Regional Anesthesia and Pain Medicine • Volume 43, Number 2, February 2018


LIA/ADDUCTOR CANAL IN TKR

Author/Year Study Type OutcomeCohen/Kerr 2008 Case series LIA Pain score ≤3/10 for >80% of patients up to

POD 2

Fu 2009 RCT LIA vs Placebo Decreased pain at rest and with activity on POD 1; no difference on POD 2

Parvataneni 2007 RCT LIA vs ssFNB No difference in pain at rest or with activity on POD 1 or POD 2

Anderson 2013 RCT LIA (intraop) + ACB catheter vs LIA alone ACB catheter + LIA produces improved pain control, ambulation, and sleep compared with LIA alone

Sawhney 2016 RCT LIA (intraop) vs LIA + ACB vs ACB alone ACB + LIA produces lower pain scores with ambulation on POD 1 and 2. ACB (without LIA) has higher pain score at rest or with knee exionon POD 1.

Runge 2016 RCT LIA vs FTB vs FTB/OTB FTB/OTB reduces morphine consumption tenfold in first 24h, whilst decreasing dizziness during mobilisation (TUG)

Reddy 2017 RCT ACB+IPACK vs ACB Improved pain and ambulation. No LIA in either group. Suspicious study…..

NERVE SUPPLY TO KNEE

LIA/ADDUCTOR CANAL

• 78 patients randomised to OTB/FTB, FTB or LIA alone.

• Primary outcome 24h Morphine consumption.

• OTB/FTB tenfold reduction at 24h. Twofold at 48h. Minimal difference between LIA/FTB.

• No apparent downside apart from hip adductor strength, but no difference in TUG at 24h

TRANEXAMIC ACID

• ASRA recommendations published Jan 2019. Based on meta-analysis and expert opinion.

• Summary:

• TXA should be given to all total joint replacements.

• Single IV dose of 20mg/kg reduces transfusion risk by 81% in TKA, and 60-70% in THR.

• Second dose unnecessary.

• Pre-incision administration increases efficacy.

• TXA does not increase risk of VTE/ATE in those without history, and likely should also be given to those with a history of VTE (moderate weight evidence).

Tranexamic acid in total joint arthroplasty: the endorsed clinical practice guides of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of OrthopaedicSurgeons, Hip Society, and Knee Society FillinghamYA, et al. Reg Anesth Pain Med 2019;44:7–11. doi:10.1136/rapm-2018-000024

SHOULDER ARTHROPLASTY

• Gold standard for pain remain CISB, ideally with basal and bolus regime.*

• First ever metaanalysis published last year and supports this, but the data is old and largely irrelevant (most recent studies aren’t even arthroplasty).

• Other outcomes have not been extensively tested e.g sleep, patient satisfaction, morbidity/mortality.

• Catheter techniques remain challenging and so uptake still remains low, ultrasound guidance, modified catheters and increased availability of elastomeric pumps may improve this.

• Liposomal bupivacaine has been touted as an alternative to catheters.

*Postoperative analgesia for shoulder surgery: a critical appraisal and review of current techniques. Frederickson et al.Anaesthesia, 65(6), 608-24.

Should continuous rather than single-injection

interscalene block be routinely offered for major

shoulder surgery? A meta-analysis of the analgesic

and side-effects profilesL. Vorobeichik1, R. Brull1,2, R. Bowry1,3, J. G. Laffey1,4,5,6 andF. W. Abdallah1,4,5,7,*1Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada, 2Department of Anesthesia,

Women’s College Hospital, Toronto, Ontario, Canada, 3Department of Anesthesia, North York GeneralHospital, Toronto, Ontario, Canada, 4Department of Anesthesia, St Michael’s Hospital, Toronto, Ontario,

Canada, 5The Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada, 6Department of Anesthesia,School of Medicine, National University of Ireland Galway, Galway, Ireland and 7Department ofAnesthesiology and Pain Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa,

Ontario, Canada

*Corresponding author. Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada. E-mail: [email protected].

Abstract

Background: Major shoulder surgery is associated with moderate-to-severe pain, but consensus on the optimal analgesicapproach is lacking. Continuous catheter-based interscalene block (CISB) prolongs the analgesic benefits of its single-injection counterpart (SISB), but concerns over CISB complications and difficulties in interpreting comparative evidenceexamining major and minor shoulder procedures simultaneously, despite their differences in postoperative pain, havelimited CISB popularity. This meta-analysis evaluates the CISB analgesic role and complications compared with SISB formajor shoulder surgery.Methods: We retrieved randomised controlled trials (RCTs) comparing the effects of CISB to SISB on analgesic outcomesand side-effects after major shoulder surgery. Postoperative opioid consumption at 24 h was designated as the primaryoutcome. Secondary outcomes included 24e48 h opioid consumption, postoperative rest and dynamic pain scores up to72 h, time-to-first analgesic, recovery room and hospital stay durations, patient satisfaction, postoperative nausea andvomiting, respiratory function, and block-related complications.Results: Data from 15 RCTs were pooled using random-effects modelling. Compared with SISB, CISB reduced 24- and 48-horalmorphineconsumptionbyaweightedmeandifference [95%confidence interval] of 50.9mg [e81.6,e20.2], (P¼0.001) and44.7mg [e80.9,e8.7], (P<0.0001), respectively.Additionally, CISBprovided superior rest anddynamicpain control beyond48h, prolonged time-to-first analgesic, enhanced satisfaction, and reduced postoperative nausea and vomiting withoutcomplications.CISBcausedan11.0e11.7%decrease in respiratory indices. Resultheterogeneitywassuccessfully explained.

Editorial decision: November 4, 2017; Accepted: November 4, 2017

© 2017 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

For Permissions, please email: [email protected]

679

British Journal of Anaesthesia, 120 (4): 679e692 (2018)

doi: 10.1016/j.bja.2017.11.104

Advance Access Publication Date: 13 February 2018

Review Article

Should continuous rather than single-injection

interscalene block be routinely offered for major

shoulder surgery? A meta-analysis of the analgesic

and side-effects profilesL. Vorobeichik1, R. Brull1,2, R. Bowry1,3, J. G. Laffey1,4,5,6 andF. W. Abdallah1,4,5,7,*1Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada, 2Department of Anesthesia,

Women’s College Hospital, Toronto, Ontario, Canada, 3Department of Anesthesia, North York GeneralHospital, Toronto, Ontario, Canada, 4Department of Anesthesia, St Michael’s Hospital, Toronto, Ontario,

Canada, 5The Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada, 6Department of Anesthesia,School of Medicine, National University of Ireland Galway, Galway, Ireland and 7Department ofAnesthesiology and Pain Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa,

Ontario, Canada

*Corresponding author. Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada. E-mail: [email protected].

Abstract

Background: Major shoulder surgery is associated with moderate-to-severe pain, but consensus on the optimal analgesicapproach is lacking. Continuous catheter-based interscalene block (CISB) prolongs the analgesic benefits of its single-injection counterpart (SISB), but concerns over CISB complications and difficulties in interpreting comparative evidenceexamining major and minor shoulder procedures simultaneously, despite their differences in postoperative pain, havelimited CISB popularity. This meta-analysis evaluates the CISB analgesic role and complications compared with SISB formajor shoulder surgery.Methods: We retrieved randomised controlled trials (RCTs) comparing the effects of CISB to SISB on analgesic outcomesand side-effects after major shoulder surgery. Postoperative opioid consumption at 24 h was designated as the primaryoutcome. Secondary outcomes included 24e48 h opioid consumption, postoperative rest and dynamic pain scores up to72 h, time-to-first analgesic, recovery room and hospital stay durations, patient satisfaction, postoperative nausea andvomiting, respiratory function, and block-related complications.Results: Data from 15 RCTs were pooled using random-effects modelling. Compared with SISB, CISB reduced 24- and 48-horalmorphineconsumptionbyaweightedmeandifference [95%confidence interval] of 50.9mg [e81.6,e20.2], (P¼0.001) and44.7mg [e80.9,e8.7], (P<0.0001), respectively.Additionally, CISBprovided superior rest anddynamicpain control beyond48h, prolonged time-to-first analgesic, enhanced satisfaction, and reduced postoperative nausea and vomiting withoutcomplications.CISBcausedan11.0e11.7%decrease in respiratory indices. Resultheterogeneitywassuccessfully explained.

Editorial decision: November 4, 2017; Accepted: November 4, 2017

© 2017 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

For Permissions, please email: [email protected]

679

British Journal of Anaesthesia, 120 (4): 679e692 (2018)

doi: 10.1016/j.bja.2017.11.104

Advance Access Publication Date: 13 February 2018

Review Article

WHAT’S NEW IN HIP FRACTURES?

• Cochrane review published Feb 2016*

• No difference found between GA and Spinal, though wide trial heterogeneity

• Recommended large RCT

• Despite this, as a result of the ASAP publicity there is a drive towards spinal anaesthesia for all and low dose.

• It may be that mortality is the wrong outcome measure to base this decision on, however it is fair to say that (despite my own preferences), there is little to choose between a “good” GA and a ”good” spinal.

*Guay J, Anaesthesia for hip fracture surgery in adults. Cochrane Database of Systematic Reviews 2016, Issue 2. Art. No.: CD000521.

ASAP “STANDARDS”

National Hip Fracture Database: Anaesthesia Sprint Audit of Practice 2014

6 © Healthcare Quality Improvement Partnership 2014. All rights reserved

Anaesthetic Sprint Audit of Practice standards

Based on the guideline The Management of Proximal Femoral Fracture, Association of Anaesthetists of Great Britain and Ireland, 2012

Standard 1 Patients should be anaesthetised by a consultant or specialist with similar clinical experience.

Standard 2 Spinal/epidural anaesthesia should be considered for all patients

Standard 3 Spinal anaesthetics should be administered using hyperbaric bupivacaine (< 10mg) with the patient positioned laterally (bad hip down)

Standard 4 Co-administration of intrathecal opioids should be restricted to fentanyl

Standard 5 If sedation is required this should be midazolam or propofol

Standard 6 Supplemental oxygen should always be provided

Standard 7 Inhalational agents should be considered for the induction of general anaesthesia

Standard 8 Spontaneous ventilation should be used in preference to mechanical ventilation

Standard 9 Consider intraoperative nerve blocks for all patients undergoing surgery

Standard 10 Neuraxial and general anaesthesia should not be combined

Standard 11 Hypotension should be avoided

Standard 12 Patients should be routinely assessed for the occurrence of Bone Cement Implantation Syndrome

Key findings

Where the seniority of both the surgeon and the anaesthetist present in theatre was recorded, it is encouraging to find that in over 90% of cases both were consultants or specialists, and that in only 0.4% of cases were both unsupervised trainees. However, we cannot exclude the possibility of an element of reporting bias here and there certainly remains substantial inter-hospital variation in the seniority of staff dealing with these high-risk cases.

Pain relieving nerve blocks were administered to 56% of patients. This indicates an impressive adoption of this technique during recent years, particularly since its recommendation in the 2011 NICE Guidance on Hip Fracture2. However in this audit, nearly half of patients still do not receive a nerve block. The marked variation in provision of nerve blocks between different hospitals could suggest that this is more a reflection of organisational differences, than of individual patient need or preference.

There was striking inter-hospital variation in the proportion of patients being given spinal and general anaesthesia. Some units administered spinal anaesthesia in over 80% of cases, while others used this approach in less than 10%. This would suggest that the mode of anaesthesia is often determined by local departmental or individual anaesthetist preference, rather than being a response to the needs, comorbidities and preferences of individual patients.

ASAP 2

pressures. Lower intra-operative blood pressures wereweakly associated with higher volumes of intrathecallocal anaesthetic.

This study has several strengths in comparison toprevious observational studies [2–6]: it was conductedprospectively; it captured data about large numbers ofpatients (~ one-fifth of all hip fractures in England,Wales and Northern Ireland annually); and data-pointcompletion rates were high (> 90% for most fields).Importantly, data about anaesthesia were collected byanaesthetists and so are likely to provide a far moreaccurate indication of actual interventions than retro-spective data about anaesthesia collected by non-anaes-thetists [19]. Such discrepancy in data accuracy issuggested by a concordance of only 35–88% betweenthe type of anaesthesia as recorded by NHFD data col-lectors and that contemporaneously collected by ASAPanaesthetists.

There are weaknesses with the study that need tobe borne in mind when interpreting the results. Datawere only collected for 67.5% of patients who fracturedtheir hip(s) during the three-month study period, andthe primary outcome for these, 30-day mortality, was

36% lower than the annual 2014 figure reported by theNHFD (5.1% vs. 8.0%) [7]. Although there appears tobe some seasonal variation affecting mortality, we cal-culated that the 23 (12.5%) eligible hospitals who didnot participate in ASAP had a 75% higher overall 30-day mortality rate (8.9% vs. 5.1%) during the studyperiod, data from which would have been very usefulin determining the risks and benefits of various anaes-thetic interventions more accurately. Similarly, incom-plete patient data submitted to ASAP may haveaffected the statistical significance of some findings,although the proportion of these was small (e.g. 1.8%for mortality by type of anaesthesia). More impor-tantly, it should be remembered that this is an obser-vational study and so any statistically significantfindings can only indicate association rather than cau-sation. In this vein, although there was any number ofcomparisons that could have been analysed, weavoided small subgroup analysis and potentially unreli-able interpretations of significance based on these.

Anaesthesia Sprint Audit of Practice-2 confirmsthat there appears to be no significant differencebetween ‘general anaesthesia’ and ‘spinal anaesthesia’

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Figure 2 The reduction in systolic blood pressure following intrathecal injections of different volumes of (a) hyper-baric and (b) isobaric bupivacaine 0.5% in Anaesthesia Sprint Audit of Practice-2 patients having surgical repair ofhip fracture.

© 2016 The Association of Anaesthetists of Great Britain and Ireland 511

White et al. | Anaesthesia Sprint Audit of Practice-2 Anaesthesia 2016, 71, 506–514

White et al. Outcomes after anaesthesia for hip fracture surgery. Secondary analysis of prospective observational data from 11 085 patients included in the UK AnaesthesiaSprint Audit of Practice (ASAP 2). Anaesthesia 2016; 71: 506-14.

mortalities: five-day mortality 64/3,062 (2.1%) vs. 78/7,427 (1.1%) respectively, p = 0.017; 30-day mortality181/3,062 (5.9%) vs. 338/7,427 (4.6%) respectively,p = 0.013. An intra-operative mean arterial blood pres-sure below 75 mmHg compared with higher pressureswas similarly associated with higher mortalities: five-daymortality 120/8,163 (1.5%) vs. 19/2,139 (0.9%) respec-tively, p = 0.049; 30-day mortality 415/8,163 (5.1%) vs.94/2,139 (4.4%) respectively, p = 0.0029. Mortalities atfive and 30 postoperative days were increased in5 mmHg strata of blood pressure compared with higherpressures. The five-day and 30-day mortality rates forthe 71–75 mmHg systolic blood pressure stratum were18/908 (2.0%) and 53/908 (5.8%) compared with96/8,375 (1.1%) and 384/8,471 (4.5%) for higher sys-tolic pressures, p = 0.038 and 0.00020, respectively. Thefive-day and 30-day mortality rates for the 51–55 mmHg mean blood pressure stratum were 31/1,702(1.8%) and 95/1,733 (5.5%) compared with 76/6,908(1.1%) and 314/6,670 (4.7%) for higher mean pressures,p = 0.023 and 0.087, respectively. The 30-day mortalityfor the lowest stratum of mean blood pressure(< 51 mmHg) was significantly more than for highermean blood pressures, 100/1,585 (6.3%) vs. 409/8,717(4.7%), p = 0.0080.

We calculated the association of relative changesin systolic blood pressure with volumes of spinalbupivacaine 0.5% (hyperbaric for 2,972 patients andisobaric for 956 patients). The relative fall in systolicblood pressure was weakly correlated with more sub-arachnoid bupivacaine: r2 !0.10 and !0.16 for hyper-baric and isobaric bupivacaine, respectively. A 20%relative fall in systolic blood pressure correlated with1.4 ml hyperbaric bupivacaine 0.5% (Fig. 2a) and1.5 ml isobaric bupivacaine 0.5% (Fig. 2b). Quantileregression analysis, offset for variation not associatedwith spinal injectate, confirmed a significant associa-tion between the median relative reduction in systolicblood pressure and the dose of spinal hyperbaric bupi-vacaine 0.5%: the median (95% CI) relative fall inblood pressure was 31% (10–53%) after 1.5 ml and36% (12–55%) after 2.5 ml.

DiscussionWe found no association between anaesthetic tech-nique and mortality after surgery for hip fracture. Wefound no association between day of the week, time ofday or grade of surgical or anaesthetic personnel withmortality. Mortalities five days and 30 days postopera-tively were associated with lower intra-operative blood

(a) (b)

(c) (d)

Figure 1 The association of lowest intra-operative systolic (a and b) and mean (c and d) arterial blood pressureswith mortality five (a and c) and 30 (b and d) days after hip fracture surgery. The overall mortality is shown for ref-erence. The individual point areas are proportional to group size.

510 © 2016 The Association of Anaesthetists of Great Britain and Ireland

Anaesthesia 2016, 71, 506–514 White et al. | Anaesthesia Sprint Audit of Practice-2

www.hipfractureanaesthesia.com

NHFD CHANGES APRIL 2017

Current BPT criteria Criteria from 1 April

Time to surgery within 36 hours Time to surgery within 36 hours (no change)

Assessed by a geriatrician within 72 hours of admission

Assessed by a geriatrician within 72 hours of admission (no change)

Pre-op AMTS Pre-op AMTS (no change)

Bone protection medication Bone protection medication (no change)

Specialist falls assessment Specialist falls assessment (no change)

Joint assessment protocol(removed from BPT 1 April 2017)

Nutritional assessment during the admission(new)

Post-op AMTS2(removed from BPT 1 April 2017)

Delirium assessment using the 4AT screening tool during the admission (new)

Rehabilitation Assessment completed(removed from BPT 1 April 2017)

Assessed by a physiotherapist the day of or day following surgery (new).

Additional non-mandatory info: preoperative nerve block administered in A&E.

• 2 cohorts 2008-10 and 2012-4 (after introduction of BPT).

• No difference in 30 day mortality or LOS between cohorts. Reduction in time to theatre noted.

• Subgroup analysis of later cohort

• Those achieving BPT had lower mortality and 1 year survival, most significantly influenced by AMT and expedited surgery.

DOES ACHIEVING BPT IMPROVE OUTCOMES

BCIS

• Around 1/3 all hips are cemented, and 45% of those done for #NOF (NJR data 2014).

• Overall mortality from cemented vs. uncemented = 2.3% vs. 1.6%

• Risk of cement is BCIS. Undefined syndrome of hypoxia, hypotension and /or unexpected loss of consciousness at cementation, prosthesis insertion, joint reduction or tourniquet deflation.

• Risk is estimated to be 1 in 2900 for hip fracture*

• Another study showed risk of death during cemented arthroplasty to be 0.06-0.1%. There is no equivalent rate for uncemented prostheses.

• A multimodal of embolic event plus histamine release/complement activation.

*Rutter PD, Panesar SS, Darzi A, et alWhat is the risk of death or severe harm due to bone cement implantation syndrome among patients undergoing hip hemiarthroplasty for fractured neck of femur? A patient safety surveillance studyBMJ Open 2014;4:e004853

BCIS

• Safety guideline produced in 2015

• Risks: Increasing age, significant CVS disease, diuretics, male sex.

• Recommendations:

• Surgically: inform cementing, caution with pressurisationdevices.

• Anaesthetics: maintain hydration, vigilance, BP and have drug ready.

TIMING OF SURGERY/NOACS

• Many patients on NOACs (advantages of simplified dosing, no testing, predicatable response).

• Lack of specific tests lead to fears over timing of surgery.

• Northern hip collaboration found delays in TTS, LOS and achieving BPT in matched patient groups.

• New recommendations awaited from AoA in September. Likely to include:

• Anti Xa: 24 h from last ingested dose (check CrCl).

• Anti Iia: check TT, consider Praxbind.

Original Article

Use of Anticoagulants Remains a SignificantThreat to Timely Hip Fracture Surgery

Razvan Taranu, MRCSEd, MSc1, Chelsea Redclift, MBChB1,Patrick Williams, MRCS2, Marina Diament, MRCSEd2,Anne Tate, BSc(Hons)1, Jamie Maddox, MRCP1,Faye Wilson, MBBS, MSc, MRCP3, andWill Eardley, MSc, MD1, Northern Hip Fracture Collaboration

AbstractIntroduction: Hip fracture remains the biggest single source of morbidity and mortality in the elderly trauma population, and anyintervention focused on quality improvement and system efficiency is beneficial for both patients and clinicians. Two of thevariables contributory to improving care and efficiency are time to theater and length of stay, with the overall goal being toimprove care as reflected within the achievement of best practice tariff. One of the biggest barriers to optimizing these variables ispreinjury anticoagulation. Method: Building on our previous work with warfarin in this population, we utilized a regional hipfracture collaborative network collecting prospective data through the National Hip Fracture Database with custom fieldspertaining to all agents, including novel oral anticoagulants. Results: In all, 1965 hip fracture patients median age 83 years (1639not anticoagulated) were admitted to the 5 centers over 12 months. Median length of stay was 20.71 days; time to theater 23.09hours, and the populations (anticoagulated vs control) were evenly matched for injury. Anticoagulated patients were delayed totheater (P ! .001), were inpatients for longer (P ! .001) and gained less best practice tariff (P ! .05). All variables per agent werenoted and the impact of each assessed. Conclusions: Despite the widespread use of newer anticoagulants, popular due tounmonitored reversal and administration, patients stay longer in hospital and wait longer for surgery than nonanticoagulatedpatients of the same age and injury. Contemporary perioperative practices impact negatively on the ability to perform timelysurgery on hip fracture patients. We propose a guideline specific to the management of anticoagulation in the hip fracturepopulation to aid the optimum preparation of patients for theater, achievement of timely surgery, and potentially reducelength of stay.

Keywordsgeriatric trauma, trauma surgery, geriatric medicine, anesthesia, pharmacology, hip, coagulation

Submitted December 11, 2017. Accepted January 22, 2018.

The hip fracture continues to grow in health-care importance.For older patients, it is the commonest serious injury and is themost common reason for them to undergo emergency anesthe-sia and surgery. With one-third of patients dead within a year ofinjury, it also represents the most frequent cause of accidentaldeath in the elderly population.1 It is one of the most expensiveand resource-intensive health episodes, associated with a sig-nificant cost to health and social services. With 65 000 frac-tures added each year to the United Kingdom National HipFracture Database (NHFD), this injury alone accounts for 1%of the nation’s health-care budget or around £1 billion per yearto the National Health Service (NHS).1 A substantial part ofthis cost is due to length of stay (LOS) with one and a half

million bed days being used each year, equivalent to the con-tinuous occupation of over 4000 beds across the United King-dom. This situation of significant patient impact and

1 James Cook University Hospital, Middlesbrough, United Kingdom2 ST5 Trauma and Orthopaedics, James Cook University Hospital, Mid-dlesbrough, United Kingdom3 City Hospitals Sunderland NHS Foundation Trust, Sunderland, UnitedKingdom

Corresponding Author:Marina Diament, ST5 Trauma and Orthopaedics, James Cook UniversityHospital, Marton Road, Middlesbrough TS4 3BW, United Kingdom.Email: [email protected]

Geriatric Orthopaedic Surgery& RehabilitationVolume 9: 1-6ª The Author(s) 2018Reprints and permission:sagepub.com/journalsPermissions.navDOI: 10.1177/2151459318764150journals.sagepub.com/home/gos

Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License(http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permissionprovided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).

Original Article












Original Article












WHAT’S NEW IN REGIONAL ANAESTHESIA? – SUPRAINGUINAL FICB

• New (ish) approach to an old block.

• Needle and transducer direction cephalad. Spread more promximal??

• Sensory block testing: 80% volunteers had block of anterior, lateral and medial thigh c/w 30% in infrainguinal approach.

• Spread according to MRI studies consistently ON in FIC, not seen with infrainguinal.

483Vermeylen K, et al. Reg Anesth Pain Med 2019;44:483–491. doi:10.1136/rapm-2018-100092

Original article

Supra-inguinal injection for fascia iliaca compartment block results in more consistent spread towards the lumbar plexus than an infra-inguinal injection: a volunteer studyKris Vermeylen,1 Matthias Desmet,2 Ine Leunen,1 Filiep Soetens,1 Arne Neyrinck,3 Dirk Carens,4 Ben Caerts,5 Patrick Seynaeve,6 Admir Hadzic,7 Marc Van de Velde8

To cite: Vermeylen K, Desmet M, Leunen I, et al. Reg Anesth Pain Med 2019;44:483–491.

1Department of Anesthesia, AZ Turnhout, Turnhout, Belgium2Department of Anesthesia, AZ Groeninge, Kortrijk, Belgium3Department of Anesthesiology, UZ Leuven, Katholieke Universiteit Leuven, Leuven, Belgium4FIKS Groepspraktijk (private practice), Antwerp, Belgium5Department of Radiology, AZ Turnhout, Turnhout, Belgium6Department of Radiology, AZ Groeninge, Kortrijk, Belgium7Department of Anesthesia, Consultant, ZOL, Genk, Belgium8Department of Cardiovascular Sciences, KU Leuven, Katholieke Universiteit Leuven, Leuven, Belgium

Correspondence toDr Kris Vermeylen, Department of Anesthesia, AZ Turnhout, Turnhout 2300, Belgium; kris. vermeylen@ gmail. com

KV and MD contributed equally.

KV and MD are joint first authors.

Received 10 September 2018Revised 22 October 2018Accepted 28 October 2018Published Online First 22 February 2019

© American Society of Regional Anesthesia & Pain Medicine 2019. No commercial re-use. See rights and permissions. Published by BMJ.

ABSTRACTBackground and objectives Lumbar plexus block has been used to provide postoperative analgesia after lower limb surgery. The fascia iliaca compartment block (FICB) has been proposed as an anterior approach of the lumbar plexus targeting the femoral, obturator and lateral femoral cutaneous nerve. However, both radiological and clinical evidence demonstrated that an infra-inguinal approach to the fascia iliaca compartment does not reliably block the three target nerves.We hypothesized that a supra-inguinal approach of the fascia iliaca compartment results in a more consistent block of the three target nerves than an infra-inguinal approach.Methods We performed a randomized controlled, double-blind trial in 10 healthy volunteers. Both an infra-inguinal FICB (I-FICB) and a supra-inguinal FICB (S-FICB) were performed on the left or the right side in each volunteer. Forty milliliters of lidocaine 0.5% was injected with each approach. Sensory and motor block and spread of local anesthetics (LA) on MRI were assessed.Results After an S-FICB, 80% of the volunteers had a complete sensory block of the medial, anterior and lateral region of the thigh, compared with 30% after an I-FICB (p=0.035). There was an insignificant effect on motor function with both approaches. After an S-FICB, in 8 out of 10 volunteers there was spread of LA in the expected anatomic location of the obturator nerve on MRI compared with 1 out of 10 volunteers after an I-FICB (p=0.0017). The cranial spread of LA after an S-FICB on MRI was higher than after an I-FICB (p=0.007), whereas there was a more caudal spread of LA on MRI after an I-FICB than after an S-FICB (p=0.005).Conclusions An S-FICB produces a more complete sensory block of the medial, anterior and lateral region of the thigh, compared with an I-FICB. Our study demonstrates that an S-FICB with 40 mL of LA more reliably spreads LA to the anatomical location of the three target nerves of the lumbar plexus on MRI than an I-FICB. An S-FICB also leads to a more consistent spread in a cranial direction under the fascia iliaca and around the psoas muscle.Clinical trial registration This work was registered with the European clinical trial registry: Identifier Eudra CT 2015-004607-24.

INTRODUCTIONDifferent techniques for lumbar plexus blockade have been described providing postoperative anal-gesia after hip surgery.1–3 Posterior approaches to the lumbar plexus are associated with complications, such as spinal and epidural anesthesia, nerve injury, risk of local anesthetic systemic toxicity (LAST) and retroperitoneal hemorrhage.4 Moreover, posterior approaches to the lumbar plexus require the lateral or sitting position, which may be uncomfortable for patients with a hip fracture. Therefore, an ante-rior approach of the lumbar plexus, like the fascia iliaca compartment block (FICB), which can be performed in the supine position and has minimal associated risk, may be advantageous.

The fascia iliaca (FI) is the connective tissue layer that covers the anterior surface of the iliacus and psoas muscles. The FI is attached to the inner aspect of the iliac crest and blends medially with the psoas fascia, which surrounds the psoas muscle. The virtual space between the FI and the iliac muscle (IM) and psoas muscle (PM) forms the FI compartment (FIC). Therefore, it is theo-retically possible to block the femoral nerve (FN), the obturator nerve (ON), and lateral femoral cutaneous nerve (LFCN) by a single injection into the FIC. Studies to date, however, suggest that an infra-inguinal injection of LA under the FI (I-FICB) does not reliably block these nerves.5 6 Moreover, in at least one study, an I-FICB failed to provide adequate analgesia and did not decrease opioid consumption in patients after total hip arthroplasty.5 Marhofer et al evaluated the spread of local anesthetics (LA) after an I-FICB using sensory block (pinprick) and MRI and concluded that the ON could not be blocked.7

To improve the spread of LA and the success of FICB’s, Hebbard et al described a ‘longitudinal supra-inguinal approach’ (S-FICB), where LA is injected cranial to the inguinal ligament (IL).8 In a cadaver study, Hebbard observed staining of FN and LFCN after injection of 20 mL of dye. A limitation of Hebbard’s study is that he did not examine the ON.8 A recent clinical study demonstrated that an S-FICB with a larger volume (40 mL of LA) resulted in a significant reduction of morphine consumption after total hip arthroplasty.1

on 16 June 2019 by guest. Protected by copyright.http://rapm

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483Vermeylen K, et al. Reg Anesth Pain Med 2019;44:483–491. doi:10.1136/rapm-2018-100092

Original article

Supra-inguinal injection for fascia iliaca compartment block results in more consistent spread towards the lumbar plexus than an infra-inguinal injection: a volunteer studyKris Vermeylen,1 Matthias Desmet,2 Ine Leunen,1 Filiep Soetens,1 Arne Neyrinck,3 Dirk Carens,4 Ben Caerts,5 Patrick Seynaeve,6 Admir Hadzic,7 Marc Van de Velde8

To cite: Vermeylen K, Desmet M, Leunen I, et al. Reg Anesth Pain Med 2019;44:483–491.

1Department of Anesthesia, AZ Turnhout, Turnhout, Belgium2Department of Anesthesia, AZ Groeninge, Kortrijk, Belgium3Department of Anesthesiology, UZ Leuven, Katholieke Universiteit Leuven, Leuven, Belgium4FIKS Groepspraktijk (private practice), Antwerp, Belgium5Department of Radiology, AZ Turnhout, Turnhout, Belgium6Department of Radiology, AZ Groeninge, Kortrijk, Belgium7Department of Anesthesia, Consultant, ZOL, Genk, Belgium8Department of Cardiovascular Sciences, KU Leuven, Katholieke Universiteit Leuven, Leuven, Belgium

Correspondence toDr Kris Vermeylen, Department of Anesthesia, AZ Turnhout, Turnhout 2300, Belgium; kris. vermeylen@ gmail. com

KV and MD contributed equally.

KV and MD are joint first authors.

Received 10 September 2018Revised 22 October 2018Accepted 28 October 2018Published Online First 22 February 2019

© American Society of Regional Anesthesia & Pain Medicine 2019. No commercial re-use. See rights and permissions. Published by BMJ.

ABSTRACTBackground and objectives Lumbar plexus block has been used to provide postoperative analgesia after lower limb surgery. The fascia iliaca compartment block (FICB) has been proposed as an anterior approach of the lumbar plexus targeting the femoral, obturator and lateral femoral cutaneous nerve. However, both radiological and clinical evidence demonstrated that an infra-inguinal approach to the fascia iliaca compartment does not reliably block the three target nerves.We hypothesized that a supra-inguinal approach of the fascia iliaca compartment results in a more consistent block of the three target nerves than an infra-inguinal approach.Methods We performed a randomized controlled, double-blind trial in 10 healthy volunteers. Both an infra-inguinal FICB (I-FICB) and a supra-inguinal FICB (S-FICB) were performed on the left or the right side in each volunteer. Forty milliliters of lidocaine 0.5% was injected with each approach. Sensory and motor block and spread of local anesthetics (LA) on MRI were assessed.Results After an S-FICB, 80% of the volunteers had a complete sensory block of the medial, anterior and lateral region of the thigh, compared with 30% after an I-FICB (p=0.035). There was an insignificant effect on motor function with both approaches. After an S-FICB, in 8 out of 10 volunteers there was spread of LA in the expected anatomic location of the obturator nerve on MRI compared with 1 out of 10 volunteers after an I-FICB (p=0.0017). The cranial spread of LA after an S-FICB on MRI was higher than after an I-FICB (p=0.007), whereas there was a more caudal spread of LA on MRI after an I-FICB than after an S-FICB (p=0.005).Conclusions An S-FICB produces a more complete sensory block of the medial, anterior and lateral region of the thigh, compared with an I-FICB. Our study demonstrates that an S-FICB with 40 mL of LA more reliably spreads LA to the anatomical location of the three target nerves of the lumbar plexus on MRI than an I-FICB. An S-FICB also leads to a more consistent spread in a cranial direction under the fascia iliaca and around the psoas muscle.Clinical trial registration This work was registered with the European clinical trial registry: Identifier Eudra CT 2015-004607-24.

INTRODUCTIONDifferent techniques for lumbar plexus blockade have been described providing postoperative anal-gesia after hip surgery.1–3 Posterior approaches to the lumbar plexus are associated with complications, such as spinal and epidural anesthesia, nerve injury, risk of local anesthetic systemic toxicity (LAST) and retroperitoneal hemorrhage.4 Moreover, posterior approaches to the lumbar plexus require the lateral or sitting position, which may be uncomfortable for patients with a hip fracture. Therefore, an ante-rior approach of the lumbar plexus, like the fascia iliaca compartment block (FICB), which can be performed in the supine position and has minimal associated risk, may be advantageous.

The fascia iliaca (FI) is the connective tissue layer that covers the anterior surface of the iliacus and psoas muscles. The FI is attached to the inner aspect of the iliac crest and blends medially with the psoas fascia, which surrounds the psoas muscle. The virtual space between the FI and the iliac muscle (IM) and psoas muscle (PM) forms the FI compartment (FIC). Therefore, it is theo-retically possible to block the femoral nerve (FN), the obturator nerve (ON), and lateral femoral cutaneous nerve (LFCN) by a single injection into the FIC. Studies to date, however, suggest that an infra-inguinal injection of LA under the FI (I-FICB) does not reliably block these nerves.5 6 Moreover, in at least one study, an I-FICB failed to provide adequate analgesia and did not decrease opioid consumption in patients after total hip arthroplasty.5 Marhofer et al evaluated the spread of local anesthetics (LA) after an I-FICB using sensory block (pinprick) and MRI and concluded that the ON could not be blocked.7

To improve the spread of LA and the success of FICB’s, Hebbard et al described a ‘longitudinal supra-inguinal approach’ (S-FICB), where LA is injected cranial to the inguinal ligament (IL).8 In a cadaver study, Hebbard observed staining of FN and LFCN after injection of 20 mL of dye. A limitation of Hebbard’s study is that he did not examine the ON.8 A recent clinical study demonstrated that an S-FICB with a larger volume (40 mL of LA) resulted in a significant reduction of morphine consumption after total hip arthroplasty.1

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ADDUCTOR CANAL, WHERE TO BLOCK?

• An ongoing question in the literature, provoking ever more discussion of the minutiae by the Danish.

• This study seems to suggest a single injection point at the Adductor Hiatus may negate need for obturator block and have all the benefits of a higher ACB

• Needs proving in clinical trial.

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06/14/2018


The Spread of Ultrasound-Guided Injectate From theAdductor Canal to the Genicular Branch of the Posterior

Obturator Nerve and the Popliteal PlexusA Cadaveric Study

Charlotte Runge, MD,* Bernhard Moriggl, MD, PhD,†Jens Børglum, MD, PhD,‡ and Thomas Fichtner Bendtsen, MD, PhD§

Background and Objectives: The popliteal nerve plexus contributesto afferent knee-pain conduction. It is mainly formed by genicular branchesfrom the posterior obturator and the tibial nerves, innervating the intra-articular and posterior knee region. A subinguinal obturator nerve block al-leviates pain after total knee arthroplasty. Reduced hip adductor motorfunction could be avoided by a posterior obturator nerve block inside thepopliteal fossa.The aim of this study was to evaluate the spread of dye after a distal ad-

ductor canal (AC) injection to the popliteal fossa and coloring of the pop-liteal plexus and the genicular branch of the posterior obturator nerve bydissection. We also assessed the spread of dye into the popliteal fossa aftera distal femoral triangle injection.Methods: Ten milliliters of dye was injected into the distal part of the ACin 10 cadaver sides and into the distal part of the femoral triangle in 3 sides.Dissection was used to assess the spread of the injectate and coloring of thepopliteal plexus and the genicular branch of the posterior obturator nerve,as well as the saphenous and medial vastus nerves.Results: The popliteal plexus and the genicular branch of the posteriorobturator nerve were dyed in all 10 dissections after AC injections. Nodye spread into the popliteal fossa after femoral triangle injections.Conclusions: Injection of 10 mL of dye into the distal part of the ACspreads into the popliteal fossa and colors the popliteal plexus and thegenicular branch of the posterior obturator nerve.


When aiming at alleviating severe pain after total kneearthroplasty (TKA) with peripheral nerve blocks, the chal-

lenge is to provide efficient analgesia while simultaneously pre-serving the ability to ambulate early after surgery.1,2 A femoraltriangle block generates anesthesia of the saphenous nerve, themedial vastus nerve, and the medial femoral cutaneous nerve,3,4

alleviating pain from the anteromedial region of the knee5–7

without clinically affecting the ability to ambulate or increasingthe risk of fall.8,9 The obturator nerve block has been demon-strated to play an important role in alleviating pain afterTKA.3 The popliteal plexus is mainly formed by the genicularbranches of the tibial and posterior obturator nerves, entwiningthe popliteal artery, and vein within the popliteal fossa.5,6 Theterminal branches from the popliteal plexus reach the posteriorcapsule and innervate the posterior part and the intra-articularstructures of the knee joint.5 Paralysis of the hip adductor mus-cles could be avoided by blocking the posterior branch of the ob-turator nerve inside the popliteal fossa instead of blocking theobturator nerve inside the subinguinal region.

We hypothesized that an injection into the distal part of theadductor canal (AC) would spread alongside the femoral arteryand vein through the adductor hiatus and into the popliteal fossa,thereby reaching the popliteal plexus and the genicular branch ofthe posterior obturator nerve.

The primary aims of the study were to assess the spread ofthe injectate from the distal end of the AC into the popliteal fossaon a cadaver model and to assess if the posterior branch of the ob-turator nerve and the popliteal plexus were reached by the dye.The secondary aims of the study were to evaluate the possiblespread of the injectate from the AC proximally into the femoral tri-angle and to assess if the saphenous andmedial vastus nervesweredyed. Furthermore, we aimed to assess whether the dye injectedinto the femoral triangle at the midthigh level (midpoint betweenthe base of the patella and anterior superior iliac spine [ASIS])would spread throughout the AC and into the popliteal fossa todye the popliteal plexus and the genicular branch of the posteriorobturator nerve.

METHODSSeven cadavers were donated to the Division of Clinical

and Functional Anatomy of the Medical University of Innsbruckby men and women who had given their written informed con-sent premortem to use their bodies after death for scientific andeducational purposes.

Ultrasound-guided injections of methylene blue were carriedout bilaterally in the 7 cadavers (4 females and 3 males) except in1 cadaver side that was not usable for ultrasound-guided injection(ie, 14 sides altogether). Ten cadaver sides had an injection into theAC, and 3 had an injection into the femoral triangle. Preservationof the cadavers was carried out by arterial injection of an ethanol-glycerol solution followed by 1 to 3 months of immersion in phe-nolic acid in water.10,11 The ultrasound-guided injections wereperformed using a high-frequency 15-6 MHz linear array probe(X-Porte, Fujifilm; Sonosite, Inc, Bothell, Washington).

All the injections were performed by one of the authors(T.F.B.). Another author (B.M.), who was not present during the

From the *Elective Surgery Centre, Silkeborg Regional Hospital, Silkeborg,Denmark; †Division of Clinical and Functional Anatomy, Medical Universityof Innsbruck, Innsbruck, Austria; and ‡Department of Anesthesiology and In-tensive CareMedicine, Zealand UniversityHospital, University of Copenhagen,Copenhagen; and §Department of Anesthesiology, Aarhus University Hospital,Aarhus, Denmark.Accepted for publication June 25, 2017.Address correspondence to: Thomas Fichtner Bendtsen, MD, PhD, Department

of Anesthesiology, Aarhus University Hospital, Noerrebrogade 44,DK-8000 Aarhus, Denmark (e‐mail: [email protected]).

The study was supported by the A.P. Møller and Chastine Mc-Kinney MøllerFoundation. The content is solely the responsibility of the authors.

The authors declare no conflict of interest.Copyright © 2017 by American Society of Regional Anesthesia and Pain

MedicineISSN: 1098-7339DOI: 10.1097/AAP.0000000000000675


ORIGINAL ARTICLE



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The Spread of Ultrasound-Guided Injectate From theAdductor Canal to the Genicular Branch of the Posterior

Obturator Nerve and the Popliteal PlexusA Cadaveric Study

Charlotte Runge, MD,* Bernhard Moriggl, MD, PhD,†Jens Børglum, MD, PhD,‡ and Thomas Fichtner Bendtsen, MD, PhD§

Background and Objectives: The popliteal nerve plexus contributesto afferent knee-pain conduction. It is mainly formed by genicular branchesfrom the posterior obturator and the tibial nerves, innervating the intra-articular and posterior knee region. A subinguinal obturator nerve block al-leviates pain after total knee arthroplasty. Reduced hip adductor motorfunction could be avoided by a posterior obturator nerve block inside thepopliteal fossa.The aim of this study was to evaluate the spread of dye after a distal ad-

ductor canal (AC) injection to the popliteal fossa and coloring of the pop-liteal plexus and the genicular branch of the posterior obturator nerve bydissection. We also assessed the spread of dye into the popliteal fossa aftera distal femoral triangle injection.Methods: Ten milliliters of dye was injected into the distal part of the ACin 10 cadaver sides and into the distal part of the femoral triangle in 3 sides.Dissection was used to assess the spread of the injectate and coloring of thepopliteal plexus and the genicular branch of the posterior obturator nerve,as well as the saphenous and medial vastus nerves.Results: The popliteal plexus and the genicular branch of the posteriorobturator nerve were dyed in all 10 dissections after AC injections. Nodye spread into the popliteal fossa after femoral triangle injections.Conclusions: Injection of 10 mL of dye into the distal part of the ACspreads into the popliteal fossa and colors the popliteal plexus and thegenicular branch of the posterior obturator nerve.


When aiming at alleviating severe pain after total kneearthroplasty (TKA) with peripheral nerve blocks, the chal-

lenge is to provide efficient analgesia while simultaneously pre-serving the ability to ambulate early after surgery.1,2 A femoraltriangle block generates anesthesia of the saphenous nerve, themedial vastus nerve, and the medial femoral cutaneous nerve,3,4

alleviating pain from the anteromedial region of the knee5–7

without clinically affecting the ability to ambulate or increasingthe risk of fall.8,9 The obturator nerve block has been demon-strated to play an important role in alleviating pain afterTKA.3 The popliteal plexus is mainly formed by the genicularbranches of the tibial and posterior obturator nerves, entwiningthe popliteal artery, and vein within the popliteal fossa.5,6 Theterminal branches from the popliteal plexus reach the posteriorcapsule and innervate the posterior part and the intra-articularstructures of the knee joint.5 Paralysis of the hip adductor mus-cles could be avoided by blocking the posterior branch of the ob-turator nerve inside the popliteal fossa instead of blocking theobturator nerve inside the subinguinal region.

We hypothesized that an injection into the distal part of theadductor canal (AC) would spread alongside the femoral arteryand vein through the adductor hiatus and into the popliteal fossa,thereby reaching the popliteal plexus and the genicular branch ofthe posterior obturator nerve.

The primary aims of the study were to assess the spread ofthe injectate from the distal end of the AC into the popliteal fossaon a cadaver model and to assess if the posterior branch of the ob-turator nerve and the popliteal plexus were reached by the dye.The secondary aims of the study were to evaluate the possiblespread of the injectate from the AC proximally into the femoral tri-angle and to assess if the saphenous andmedial vastus nervesweredyed. Furthermore, we aimed to assess whether the dye injectedinto the femoral triangle at the midthigh level (midpoint betweenthe base of the patella and anterior superior iliac spine [ASIS])would spread throughout the AC and into the popliteal fossa todye the popliteal plexus and the genicular branch of the posteriorobturator nerve.

METHODSSeven cadavers were donated to the Division of Clinical

and Functional Anatomy of the Medical University of Innsbruckby men and women who had given their written informed con-sent premortem to use their bodies after death for scientific andeducational purposes.

Ultrasound-guided injections of methylene blue were carriedout bilaterally in the 7 cadavers (4 females and 3 males) except in1 cadaver side that was not usable for ultrasound-guided injection(ie, 14 sides altogether). Ten cadaver sides had an injection into theAC, and 3 had an injection into the femoral triangle. Preservationof the cadavers was carried out by arterial injection of an ethanol-glycerol solution followed by 1 to 3 months of immersion in phe-nolic acid in water.10,11 The ultrasound-guided injections wereperformed using a high-frequency 15-6 MHz linear array probe(X-Porte, Fujifilm; Sonosite, Inc, Bothell, Washington).

All the injections were performed by one of the authors(T.F.B.). Another author (B.M.), who was not present during the

From the *Elective Surgery Centre, Silkeborg Regional Hospital, Silkeborg,Denmark; †Division of Clinical and Functional Anatomy, Medical Universityof Innsbruck, Innsbruck, Austria; and ‡Department of Anesthesiology and In-tensive CareMedicine, Zealand UniversityHospital, University of Copenhagen,Copenhagen; and §Department of Anesthesiology, Aarhus University Hospital,Aarhus, Denmark.Accepted for publication June 25, 2017.Address correspondence to: Thomas Fichtner Bendtsen, MD, PhD, Department

of Anesthesiology, Aarhus University Hospital, Noerrebrogade 44,DK-8000 Aarhus, Denmark (e‐mail: [email protected]).

The study was supported by the A.P. Møller and Chastine Mc-Kinney MøllerFoundation. The content is solely the responsibility of the authors.

The authors declare no conflict of interest.Copyright © 2017 by American Society of Regional Anesthesia and Pain

MedicineISSN: 1098-7339DOI: 10.1097/AAP.0000000000000675


ORIGINAL ARTICLE



WHAT’S NEW IN REGIONAL ANAESTHESIA?-NERVE STIMULATION

• Novel method to prolong nerve blocks without additional drugs.

• Proof of concept study in humans. Non-randomised.

• Peripheral stimulating catheters sited in the brachial plexus of volunteers undergoing rotator cuff surgery.

• Authors reported stimulation was inadequate for immediate post op pain relief, leading to a high number of rescue blocks with LA.

• Post op pain was reportedly reduced dramatically c/w normal post op course for up to 14 days (again, no comparitor).

• Leads 1-2cm away from nerve ?safety, however, 10% fracture rate during removal.

310 Ilfeld BM, et al. Reg Anesth Pain Med 2019;44:310–318. doi:10.1136/rapm-2018-100121

Original article

Ultrasound-guided percutaneous peripheral nerve stimulation: neuromodulation of the suprascapular nerve and brachial plexus for postoperative analgesia following ambulatory rotator cuff repair. A proof-of-concept studyBrian M Ilfeld,1,2 John J Finneran,1,2 Rodney A Gabriel,1,2 Engy T Said,1 Patrick L Nguyen,1 Wendy B Abramson,1 Bahareh Khatibi,1 Jacklynn F Sztain,1 Matthew W Swisher,1,2 Pia Jaeger,1,2,3 Dana C Covey,4 Matthew J Meunier,4 Eric R Hentzen,4 Catherine M Robertson4

To cite: Ilfeld BM, Finneran JJ, Gabriel RA, et al. Reg Anesth Pain Med 2019;44:310–318.

1Department of Anesthesiology, University of California San Diego, San Diego, California, USA2The Outcomes Research Consortium, Cleveland, Ohio, USA3Department of Anesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark4Departments of Orthopaedic Surgery, University of California San Diego, San Diego, California, USA

Correspondence toDr Brian M Ilfeld, Department of Anesthesiology, University of California San Diego, San Diego, CA 92093, USA; bilfeld@ ucsd. edu

Received 17 September 2018Accepted 4 November 2018

© American Society of Regional Anesthesia & Pain Medicine 2019. Re-use permitted under CC BY-NC. No commercial re-use. Published by BMJ.

ABSTRACTBackground and objectives Percutaneous peripheral nerve stimulation (PNS) is an analgesic modality involving the insertion of a lead through an introducing needle followed by the delivery of electric current. This modality has been reported to treat chronic pain as well as postoperative pain following knee and foot surgery. However, it remains unknown if this analgesic technique may be used in ambulatory patients following upper extremity surgery. The purpose of this proof-of-concept study was to investigate various lead implantation locations and evaluate the feasibility of using percutaneous brachial plexus PNS to treat surgical pain following ambulatory rotator cuff repair in the immediate postoperative period.Methods Preoperatively, an electrical lead (SPR Therapeutics, Cleveland, Ohio) was percutaneously implanted to target the suprascapular nerve or brachial plexus roots or trunks using ultrasound guidance. Postoperatively, subjects received 5 min of either stimulation or sham in a randomized, double-masked fashion followed by a 5 min crossover period, and then continuous stimulation until lead removal postoperative days 14–28.Results Leads (n=2) implanted at the suprascapular notch did not appear to provide analgesia, and subsequent leads (n=14) were inserted through the middle scalene muscle and placed to target the brachial plexus. Three subjects withdrew prior to data collection. Within the recovery room, stimulation did not decrease pain scores during the first 40 min of the remaining subjects with brachial plexus leads, regardless of which treatment subjects were randomized to initially. Seven of these 11 subjects required a single-injection interscalene nerve block for rescue analgesia prior to discharge. However, subsequent average resting and dynamic pain scores postoperative days 1–14 had a median of 1 or less on the Numeric Rating Scale, and opioid requirements averaged less than 1 tablet daily with active stimulation. Two leads dislodged during use and four fractured on withdrawal, but no infections, nerve injuries, or adverse sequelae were reported.Conclusions This proof-of-concept study demonstrates that ultrasound-guided percutaneous PNS of the brachial

plexus is feasible for ambulatory shoulder surgery, and although analgesia immediately following surgery does not appear to be as potent as local anesthetic-based peripheral nerve blocks, the study suggests that this modality may provide analgesia and decrease opioid requirements in the days following rotator cuff repair. Therefore, it suggests that a subsequent, large, randomized clinical trial with an adequate control group is warranted to further investigate this therapy in the management of surgical pain in the immediate postoperative period. However, multiple technical issues remain to be resolved, such as the optimal lead location, insertion technique, and stimulating protocol, as well as preventing lead dislodgment and fracture.Trial registration number NCT02898103.

INTRODUCTIONRotator cuff repair frequently results in pain that is difficult to control with current analgesic options, particularly when it is performed as an outpatient procedure.1 One potential analgesic technique used historically to relieve chronic pain is neuromodu-lation involving the delivery of electric current to a target nerve,2 3 suggesting that this modality may also provide analgesia in the acute pain setting. Since conventional systems for peripheral nerve stimulation (PNS) usually require invasive surgery to both implant and remove multiple electrodes in close proximity to the peripheral nerve,4 5 the intrusiveness and cost of applying neuromodulation have been a major barrier to use of this modality to treat acute pain syndromes.6

However, a percutaneous lead (figure 1A) and wearable stimulator (figure 1B) were recently cleared by the US Food and Drug Administration to treat both chronic and acute postoperative pain with a lead implantation period of up to 60 days,7 8 affording the possibility of providing a non-opioid analgesic that outlasts surgical procedure-related pain.6 This system has been reported in small series of patients used to target the femoral and sciatic nerves following surgical procedures of the knee

copyright. on 16 June 2019 by guest. Protected by

http://rapm.bm

j.com/

Regional Anesthesia & Pain M

edicine: first published as 10.1136/rapm-2018-100121 on 15 February 2019. D

ownloaded from

310 Ilfeld BM, et al. Reg Anesth Pain Med 2019;44:310–318. doi:10.1136/rapm-2018-100121

Original article

Ultrasound-guided percutaneous peripheral nerve stimulation: neuromodulation of the suprascapular nerve and brachial plexus for postoperative analgesia following ambulatory rotator cuff repair. A proof-of-concept studyBrian M Ilfeld,1,2 John J Finneran,1,2 Rodney A Gabriel,1,2 Engy T Said,1 Patrick L Nguyen,1 Wendy B Abramson,1 Bahareh Khatibi,1 Jacklynn F Sztain,1 Matthew W Swisher,1,2 Pia Jaeger,1,2,3 Dana C Covey,4 Matthew J Meunier,4 Eric R Hentzen,4 Catherine M Robertson4

To cite: Ilfeld BM, Finneran JJ, Gabriel RA, et al. Reg Anesth Pain Med 2019;44:310–318.

1Department of Anesthesiology, University of California San Diego, San Diego, California, USA2The Outcomes Research Consortium, Cleveland, Ohio, USA3Department of Anesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark4Departments of Orthopaedic Surgery, University of California San Diego, San Diego, California, USA

Correspondence toDr Brian M Ilfeld, Department of Anesthesiology, University of California San Diego, San Diego, CA 92093, USA; bilfeld@ ucsd. edu

Received 17 September 2018Accepted 4 November 2018

© American Society of Regional Anesthesia & Pain Medicine 2019. Re-use permitted under CC BY-NC. No commercial re-use. Published by BMJ.

ABSTRACTBackground and objectives Percutaneous peripheral nerve stimulation (PNS) is an analgesic modality involving the insertion of a lead through an introducing needle followed by the delivery of electric current. This modality has been reported to treat chronic pain as well as postoperative pain following knee and foot surgery. However, it remains unknown if this analgesic technique may be used in ambulatory patients following upper extremity surgery. The purpose of this proof-of-concept study was to investigate various lead implantation locations and evaluate the feasibility of using percutaneous brachial plexus PNS to treat surgical pain following ambulatory rotator cuff repair in the immediate postoperative period.Methods Preoperatively, an electrical lead (SPR Therapeutics, Cleveland, Ohio) was percutaneously implanted to target the suprascapular nerve or brachial plexus roots or trunks using ultrasound guidance. Postoperatively, subjects received 5 min of either stimulation or sham in a randomized, double-masked fashion followed by a 5 min crossover period, and then continuous stimulation until lead removal postoperative days 14–28.Results Leads (n=2) implanted at the suprascapular notch did not appear to provide analgesia, and subsequent leads (n=14) were inserted through the middle scalene muscle and placed to target the brachial plexus. Three subjects withdrew prior to data collection. Within the recovery room, stimulation did not decrease pain scores during the first 40 min of the remaining subjects with brachial plexus leads, regardless of which treatment subjects were randomized to initially. Seven of these 11 subjects required a single-injection interscalene nerve block for rescue analgesia prior to discharge. However, subsequent average resting and dynamic pain scores postoperative days 1–14 had a median of 1 or less on the Numeric Rating Scale, and opioid requirements averaged less than 1 tablet daily with active stimulation. Two leads dislodged during use and four fractured on withdrawal, but no infections, nerve injuries, or adverse sequelae were reported.Conclusions This proof-of-concept study demonstrates that ultrasound-guided percutaneous PNS of the brachial

plexus is feasible for ambulatory shoulder surgery, and although analgesia immediately following surgery does not appear to be as potent as local anesthetic-based peripheral nerve blocks, the study suggests that this modality may provide analgesia and decrease opioid requirements in the days following rotator cuff repair. Therefore, it suggests that a subsequent, large, randomized clinical trial with an adequate control group is warranted to further investigate this therapy in the management of surgical pain in the immediate postoperative period. However, multiple technical issues remain to be resolved, such as the optimal lead location, insertion technique, and stimulating protocol, as well as preventing lead dislodgment and fracture.Trial registration number NCT02898103.

INTRODUCTIONRotator cuff repair frequently results in pain that is difficult to control with current analgesic options, particularly when it is performed as an outpatient procedure.1 One potential analgesic technique used historically to relieve chronic pain is neuromodu-lation involving the delivery of electric current to a target nerve,2 3 suggesting that this modality may also provide analgesia in the acute pain setting. Since conventional systems for peripheral nerve stimulation (PNS) usually require invasive surgery to both implant and remove multiple electrodes in close proximity to the peripheral nerve,4 5 the intrusiveness and cost of applying neuromodulation have been a major barrier to use of this modality to treat acute pain syndromes.6

However, a percutaneous lead (figure 1A) and wearable stimulator (figure 1B) were recently cleared by the US Food and Drug Administration to treat both chronic and acute postoperative pain with a lead implantation period of up to 60 days,7 8 affording the possibility of providing a non-opioid analgesic that outlasts surgical procedure-related pain.6 This system has been reported in small series of patients used to target the femoral and sciatic nerves following surgical procedures of the knee

copyright. on 16 June 2019 by guest. Protected by

http://rapm.bm

j.com/

Regional Anesthesia & Pain M

edicine: first published as 10.1136/rapm-2018-100121 on 15 February 2019. D

ownloaded from

WHAT’S NEW IN REGIONAL ANAESTHESIA? -NEEDLE TO NERVE DISTANCE

• Following on from previous work showing the maximum effective needle to nerve distance in ISB is 8mm.

• Study comparing an extrafascial needle tip position (4mm from C5/6) and an intrafascial position (between C5/6).

• Primary outcome was incidence of hemidiaphragmaticparesis as assessed by US, 21% vs. 90% at 30 mins post block. Also analgesic equivalence.

Palhais et al. Extrafascial injection for interscalenebrachial plexus block reduces respiratory complications compared with a conventional intrafascial injection: a randomized, controlled, double-blind trial. British Journal of Anaesthesia; 2016;116(4):531-537.

WHAT’S NEW IN REGIONAL ANAESTHESIA:KIT

• Catheter-over-needle kits, reduce leak, ?quicker to use.

• Fixed rate mechanical delivery systems. ?more consistent than elastomeric pumps, longer shelf life. Higher cost/weight, fewer rate options.

• App/subscription based models for POC US e.g Philips Lumify.

CONCLUSIONS

• ERAS/Fast track for joint arthroplasty is beneficial. Best “recipes” are still in flux.

• Spinal may confer benefits with LIA. ?Opioid free.

• RA is still the mainstay in upper limb.

• Good BP control key for hip fracture may confer mortality benefit, this may be optimally done with spinal.

• BCIS is a rare but catastrophic complication of cement, whole team needs high vigilance.

• Learn a knee block and catheter technique for upper limb, no magic bullets on the horizon.

QUESTIONS?

Documents

13TH UPDATE IN ORTHOPAEDIC ANAESTHESIA