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Regional Anaesthesia Techniques for Day-Surgery CSM 2011

Regional Anaesthesia Techniques for Day-Surgery CSM 2011. Dr Michael Barrington Department of Anaesthesia St Vincent’s Hospital, Melbourne. Attributes of the ideal anaesthetic for day-surgery. High quality analgesia low pain score low incidence of side-effects long duration Efficient

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Regional Anaesthesia Techniques for Day-Surgery CSM 2011

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  1. Regional Anaesthesia Techniques for Day-SurgeryCSM 2011 • Dr Michael Barrington • Department of Anaesthesia • St Vincent’s Hospital, Melbourne

  2. Attributes of the ideal anaesthetic for day-surgery • High quality analgesia • low pain score • low incidence of side-effects • long duration • Efficient • Patient acceptance

  3. Range of techniques available • Central neural blockade (CNB) • Peripheral nerve blockade (PNB) • Local infiltration analgesia (LIA)

  4. CNB and PNB result in: • decreased pain scores in PACU • decreased requirement for PACU analgesia • CNB was not associated • with decreased PACU time • with reduced nausea • Ambulatory Surgical Unit (ASU) discharge was increased by 35 mins

  5. Peripheral Nerve Blockade • increased ability to bypass PACU (OR14) • decreased PACU time (24 mins) • decreased risk of nausea (OR 0.17) • increased patient satisfaction • not associated with decreased discharge ASU

  6. Entire diamond lies to the right of line, RR = 1, indicating that ultrasound guided blocks are more likely to be successful

  7. Shoulder surgery

  8. Ambulatory shoulder surgery Ultrasound-guided techniques: interscalene (n = 515) supraclavicular (n = 654) blocks

  9. Pain score (VAS) in PACU 0/10 Need for IV analgesia in PACU 0.6% Time in PACU 168 mins

  10. Body mass index 22 kg/m2 Volume of local anaesthetic 50 mls Hospital for Special Surgery

  11. Side-effects/complications Hoarseness 26% Dyspnoea 8% Pneumothorax 0% LA toxicity 0%

  12. The role of Ultrasound Low dose efficacy studies (both single shot and continuous infusions)

  13. Dose reduction

  14. Severe hypotension following interscalene block Bilateral upper limb block in PACU Differential diagnosis: Bezold-Jarisch reflex Anaphylaxis Intrathecal spread Epidural spread

  15. Hand surgery

  16. Infraclavicular block (ICB), chloroprocaine compared with GA (LMA, desflurane) and wound infiltration in RCT • PACU nurses “blinded” to technique scored patients for readyness for PACU discharge

  17. 76% of patients who received ICB met criteria for PACU bypass compared to 25% in the GA group • None of the patients in the ICB group requested pain medication in hospital compared to 48% in the GA group • Patients receiving ICB were able to ambulate earlier 82 min vs 145 min with GA

  18. Results from St Vincent’s Hospital, Melbourne

  19. Breast surgery

  20. Unilateral breast surgery without reconstruction Randomised to single-shot paravertebral block (PVB) or continuous (PVB) 0.1 %, 0.2% or saline infusion for 48 hrs

  21. Validated pain assessment instruments including McGill Pain Questionnaire

  22. No clinically significant difference in: degree of postoperative pain Nausea Mood state Level of symptom distress Return to normal activity

  23. Patients having unilateral breast surgery without reconstruction were randomised to receive either GA alone or combined GA and PVB • Multilevel blocks T1 - T6 PVB • Ropivacaine 5mg/kg + Adrenaline (350mg maximum) was used

  24. Pain was study endpoint • Pain scores were lower following PVB at one hour and at three hours, but not at later time points • Pain scores were higher in PVB at 24 hrs compared to GA alone

  25. Hernea surgery

  26. Inguinal hernea repair Randomised to GA or paravertebral blockade

  27. Patients randomised to paravertebral blockade had improved outcomes including analgesia and recovery

  28. Inguinal hernea repair Randomised to transversus abdominis plane block or conventional ilioinguinal/ileohypogastric nerve blocks (n= 273)

  29. Ultrasound techniques: Reduced pain scores at 4, 12 and 24 hours No difference in PACU, Postoperative day 1 or thereafter

  30. Wound infiltration

  31. 1. Single injection wound • 2. Continuous local anaesthetic wound infusions • 3. High volume local anaesthetic wound infiltration • Need for procedure specific randomised controlled trials

  32. 1. Single injection wound • 2. Continuous local anaesthetic wound infusions • 3. High volume local anaesthetic wound infiltration • Need for procedure specific randomised controlled trials

  33. Wound infiltration • Efficacy should be procedure specific • Single injection of local anaesthetic at completion of surgery reduce analgesia - short duration only • Choice of local anaesthetic important • Catheter type • Adjuvants • Note anatomical location of infiltration

  34. Sites of wound catheter placement • Intraperitoneal • Intraarticular • Subfascial • Subcutaneous • Intrapleural • Substernal

  35. Knee Arthroscopy • One of the most common lower limb ambulatory surgical procedures • Multitude of intraarticular agents used for postoperative analgesia (opiates, NSAID, local anaesthetics) • Peripheral blocks

  36. Four groups: 0.9 % saline, bupivacaine 0.25%, ropivacaine 0.2%, ropivacaine 0.75% No difference within LA groups 40% of patients receiving placebo had motor block

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