Regional anesthesia and analgesia are associated with lower postoperative complications, shorter hospital stays, and better functional outcomes compared to general anesthesia alone. Regional techniques like neuraxial blocks and peripheral nerve blocks improve mobility and physical function after surgery. Newer regional techniques like adductor canal blocks aim to provide good pain relief while preserving quadriceps strength. A multimodal, multidisciplinary approach is needed to optimize perioperative care and functional recovery for patients.
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Regional anesthesia and perioperative outcomes
1. @EMARIANOMD
Regional Anesthesia and
Perioperative Outcomes
Edward R. Mariano, M.D., M.A.S.
Professor of Anesthesiology, Perioperative & Pain Medicine
Stanford University School of Medicine
Chief, Anesthesiology and Perioperative Care
Veterans Affairs Palo Alto Health Care System
2. @EMARIANOMD
Financial Disclosures
Halyard Health, B Braun – Unrestricted
educational program funding paid to my
institution
The contents of the following presentation
are solely the responsibility of the speaker
without input from any of the above
companies.
5. @EMARIANOMD
Neuraxial Anesthesia
30-day mortality was lower for neuraxial
and neuraxial/GA vs. GA alone for TKA
Most in-hospital complications were lower
for neuraxial and neuraxial/GA vs. GA alone
Transfusion requirements lowest for
neuraxial
Memtsoudis SG, et al. Anesth 2013;118:1046
6. @EMARIANOMD
Peripheral Nerve Blocks
>1 million patients, 12.5% received PNB
PNB associated with:
– Lower rates of complications
– Decrease length of stay
– Lower rates of transfusion
– Lower rate of ICU admission (THA only)
Memtsoudis SG, et al. Anesth 2013;118:1046
9. @EMARIANOMD
Selection of Outcomes
Range of motion
(degrees)
Timed ambulation
distance (meters)
– 6-MWT
– 2-MWT
Muscle strength
(force)
Timed performance
(min)
– TUG
Western Ontario and
McMaster Univ
Osteoarthritis Index
(WOMAC)
Knee Society Score
Lower Extremity
Functional Scale
Health-Related
Quality of Life
Choi S, et al. RAPM 2013;38:340
Bernucci & Carli. Curr Op Anaes 2012;25:621
Performance-Based Self-Reported
&
10. @EMARIANOMD
Epidural Analgesia
Bupiv 0.25% at 6-15 ml/h vs. opioids1
– Epid group had lower pain scores but high
proportion had complete motor block
Epid bupiv+MS vs. epid MS vs. IV opioids2
– Bupiv+MS: shorter time to achieve
ambulation distance and range of motion
goals
– Shorter hospital length of stay
1. Raj PP, et al. A&A 1987;66:401
2. Mahoney OM, et al. CORR 1990;Nov:30
12. @EMARIANOMD
CFNB vs. Epidural for TKA
Comparable analgesia
Better side effect profile with CFNB
– Less nausea and vomiting
– Less urinary retention (no need for foley)
– Sparing of non-operative limb
– No epidural hematoma (anticoagulation)
Epidurals require hospitalization
Barrington MJ, et al. A&A 2005;101:1824
Zaric D, et al. A&A 2006;102:1240
13. @EMARIANOMD
Ropiv
Saline
CFNB: Faster Discharge Eligibility
50 subjects, tricompartment TKA
CFNB with 1 night infusion of ropivacaine:
randomized to ropiv vs. saline on POD1
Ilfeld & Mariano, et al. Anesth 2008;108:703
3 Discharge Criteria:
1. NRS (pain) < 4
2. IV opioid-free x 12 hours
3. Ambulating > 30 meters
14. @EMARIANOMD
CFNB and Range of Motion
Knee Flexion (Degrees)
PCA CFNB P Value
POD #1 33 ± 15 56 ± 22 0.009
POD #3 53 ± 17 74 ± 11 <0.001
6 weeks 103 ± 12 116 ± 12 0.03
3 months 116 ± 11 124 ± 12 NS
Singelyn FJ, et al. A&A 1998;87:88
Is this a possible long-term effect??
If so, what is the mechanism?
15. @EMARIANOMD
CFNB vs. Local Infiltration
RCT (n=40) of CFNB vs. LIA
– At 6 weeks, the CFNB group showed greater
within-group improvement in 6-MWT, physical
activity (CHAMPS), KSS, and WOMAC
– Preop 6-MWT, walking on POD1, time spent
walking during POD1-3 were predictors of 6-
MWT at 6 weeks
Carli F, et al. BJA 2010;105:185
16. @EMARIANOMD
Long-Term Outcomes (So Far)
1 yr Western Ontario and McMaster Univ
Osteoarthritis Index (WOMAC) scores
Ilfeld & Mariano, et al. A&A 2009;108:1320
Ilfeld & Mariano, et al. A&A 2009;109:586
17. @EMARIANOMD
Lower Extremity CPNB and Falls
Pooled analysis of 3 published RCTs (knee
and hip arthroplasty) with CPNB x 4 days
– 85 subjects received ropivacaine 0.2%
– 86 subjects received saline
No falls in the saline group vs. 7 falls in
the ropiv group (P=0.013)
Ilfeld BM, et al. A&A 2010;111:1552
Memtsoudis & Mariano, et al. Anesthesiology 2014;120:551
Premier Perspective Database; n=191,570
PNB in 12.1% of cases; no association with falls
Risk factors=higher age, greater comorbidity burden
19. @EMARIANOMD
Patients in the
adductor canal group
walked 37 (0-90)
meters vs. 6 (0-51)
meters in the femoral
catheter group
(p=0.003).
Pain scores, opioid
consumption, and
hospital length of
stay were similar.
Adductor Canal vs. Femoral CPNB
Mudumbai & Mariano, et al. CORR 2014;472:1377
20. @EMARIANOMD
Evidence from RCTs
TKA: continuous ACB vs. FNB1
– Greater preservation of quad MVIC in ACB
group (median 52% vs. 18%)
– No differences in pain, opioids, flexion, TUG
TKA: repeated bolus ACB vs. FNB2
– ACB had better TUG, 10 meter walk time, and
30 sec chair test
– No differences in pain, opioids
1. Jaeger P, et al. RAPM 2013;38:526
2. Shah NA and Jain NP. J Arthro 2014;29:2224
29. @EMARIANOMD
Perioperative Surgical Home
“a patient-centered, physician
anesthesiologist-led, multidisciplinary team-
based practice model that coordinates
surgical patient care throughout the
continuum from the decision to pursue
surgery through convalescence.
Mariano, et al. A&A 2015;120:1163
Kain, et al. A&A 2014;118:1126
35. @EMARIANOMD
Summary
We discussed:
– Regional Anesthesia and Postoperative
Complications
– Regional Analgesia and Functional
Outcomes
– Regional Analgesia and Perioperative
Medicine
Notes de l'éditeur
A post-hoc power calculation revealed 89% power to detect this difference.