ho kok yuen - pump delivery for pain management

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CONTINUOUS PUMP DELIVERY SYSTEMS IN PAIN MANAGEMENT Dr Ho Kok Yuen MBBS, MMed (Anaes), FIPP, DAAPM Consultant Anaesthesiologist President, Pain Association of Singapore Clinical Director, Pain Management Service, Raffles Hospital

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Page 1: Ho Kok Yuen - Pump Delivery for Pain Management

CONTINUOUS PUMP DELIVERY SYSTEMS

IN PAIN MANAGEMENT

Dr Ho Kok YuenMBBS, MMed (Anaes), FIPP, DAAPM

Consultant AnaesthesiologistPresident, Pain Association of Singapore

Clinical Director, Pain Management Service, Raffles Hospital

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Early Indications• Prolonging intraoperative surgical anaesthesia• Sympathectomy and vasodilation to increase

blood flow– Limb salvage– Digital replantation– Raynaud’s disease

• Chronic pain– CRPS– Phantom pain

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Indications for Continuous Pump Delivery Systems

• Continuous peripheral nerve blocks– Perioperative analgesia– Postoperative analgesia– CRPS– Phantom pain

• Continuous intrathecal/epidural infusions– Cancer pain

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Continuous Peripheral Nerve Blocks (CPNB)

• Brachial plexus– Interscalene– Infraclavicular– Axillary

• Lumbar plexus– Femoral nerve sheath– Psoas compartment

• Sciatica nerve

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Nerve stimulation technique

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Ultrasound-Guided

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Ultrasound Guidance Improves Efficacy of PNB

• Higher rate of successful blocks• Less time to perform, less discomfort• Faster onset (29% shorter onset time)• Longer duration (25% longer)• Reduced risk of vascular puncture

Abrahams MS, et al. Br J Anaesth 2009;102:408-17

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Advantages of Continuous Peripheral Nerve Block

• Improved pain control during mobilisation• Decrease opioid use• Less nausea, vomiting, pruritus and sedation• Greater patient satisfaction• Improved functional outcomes• Outpatient use

Capdevila X, et al. Anesthesiology 1999;91:8-15Richman JM, et al. Anesth Analg 2006;102:248-57Bingham AE, et al. Reg Anesth Pain Med 2012

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1. 19 RCT’s (11 double-blind)2. Better analgesia for all time periods at 24, 48 and 72 h and all

catheters 3. Reduction in opioid use 4. Lower incidence of PONV (21 % vs. 49 %), sedation (27% vs.

52%), and pruritus (10 vs. 27 %) with PNB´s5. Improved patient satisfaction (4 RCT’s only)6. CPNB, regardless of catheter location, provided superior

postoperative analgesia and fewer opioid-related side effects when compared with opioid analgesia

Anesth Analg 2006;102:248-57

Richman JM, et al. Anesth Analg 2006;102:248-57

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DrugsLocal Anaesthetics

• Bupivacaine, levo-bupivacaine and ropivacaine– Cardiotoxicity ratio 3: 1.7: 1– Ropivacaine: less motor block

• Common concentrations: – Bupivacaine or L-bupivacaine 0.1-0.25%– Ropivacaine 0.2%

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DrugsAdjuvants

• Unknown analgesic combination for optimal pain relief

• E.g. adrenaline, clonidine, opioid

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Clonidine

• Meta-analysis of 20 RCTs• Prolongs analgesia and sensory by about 2 hrs• Increases risk of hypotension, fainting,

bradycardia and sedation• Prolongs motor block

Popping DM, et al. Anesthesiology 2009;111:406-15

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Determinants of CPNB Effect

• Dose (mass)• Volume (rate)• Concentration

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Infusion Strategies• Continuous infusion

– Greater use of LA– May produce dense block

• Infusion with patient-controlled (PCA) boluses– Comparable analgesia– 30% less LA

• Patient-controlled (PCA) boluses only– Higher pain scores– Greater opioid consumption

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Taboada M, et al. Anesth Analg 2008;107:1433-7

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Figure 1. Box plots of verbal rating pain scores (VRS) obtained from the two groups at 6, 8, 12, and 24 h postoperatively.

Taboada M et al. Anesth Analg 2008;107:1433-1437

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Taboada M, et al. Anaesthesiology 2009;110:150-4

• 50 patients randomized to 0.125% levobupivacaine infusion administered through a popliteal catheter as an automated regular bolus or as CI, both combined with PCA

• Both dosing regimens - similar postop analgesia• Consumption of LA and dose request from the PCA

lower in the automated bolus group

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60 patients received ISB:Gp 1: CI of 0.125% bupivacaine with sufentanil 0.1 microg/mL and

clonidine 1 microg/mL at 10 mL /hGp 2: 5 mL/h plus PCA bolusesGp 3: only PCA boluses

Sensory block more frequent and pain control was significantly higher in Groups 1 and 2 than in Group 3 (P < 0.01).

A basal infusion of 5 mL/h combined with PCA boluses most appropriate

Singelyn FJ, et al. Anesth Analg 1999;89:1216-20

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0.2% ropivacaine delivered as a CI combined with PCA bolus doses via an infraclavicular perineural catheter optimizes analgesia while minimizing oral analgesic use compared with basal- or bolus onlydosing regimens.

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Intermittent Bolus Superior?

• Intermittent bolus– higher pressure and more volume per time– may increase spread of LA in the popliteal fossa,

thus reaching the two trunks of the sciatic nerve more easily

• Intermittent bolus doses may reach the targeted nerve before they are taken up by perineural tissue or removed by blood vessels

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Advantage of PCA bolus

• Decreasing basal infusion rate and theoretically decreasing motor block

• Decreasing incidence of insensate extremity• Increasing duration of infusion/analgesia for

ambulatory patients discharged with a finite volume of LA

Borgeat A, et al. Anesth Analg 2001;92:218-23Ilfeld BM et al. Anesthesiology 2002;97:959-65Ilfeld BM, et al. Anesthesiology 2004;101;970-7

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Optimal Infusion Regimen

• Basal rate 4-10 ml/h– Lower rates for catheters of the lower extremity– Higher rates for catheters of the upper extremity

• Bolus volume 2-10 ml• Bolus lockout period 20-60 minutes

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Elastomeric Pumps• Lightweight, portable• Simple to set up• Disposable• Overinfusion

– Initial 3-6 hrs– Near reservoir exhaustion

• Infusion rate increases with increasing ambient temp and pump height

Ilfeld BM, et al. RAPM 2003;28:424-32

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Outpatient/Home Continuous Pump Infusions

• Advantages– Shortens hospital stay– Early discharge– Good pain control at home

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Outpatient/Home Continuous Pump Infusions

• Problems with nerve catheters– Accidental dislodgement– Excessive leakage at insertion site– Infection– Neurological injury

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Electronic Infusion Pumps

• Accurate and consistent infusion rates

• Adjustable infusion rate• Has PCA function• Variable bolus lockout

period• Limited to inpatient use

Ilfeld BM, et al. RAPM 2003;28:424-32

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Incisional Catheters• Simple, safe, inexpensive

• Catheter placed at correct position under direct vision

• Eliminates risk of inadvertent penetration of vascular or neural structures (vs. perineural)

• Only area of surgery affected allowing normal use of extremity and early rehabilitation (vs. perineural)

• Useful for ambulatory and inpatient surgery

Liu, Kehlet

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Lower Pain Scores

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Less Opioid Consumed

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Continuous Wound Infusion

• 58 patients undergoing LSCS• Randomized to:

– Wound infusion with ropivacaine 0.2% at 5ml/h– Epidural morphine 2mg 12H

• Better analgesia at 24 and 48 hrs, less nausea, vomiting, pruritus and urinary retention

O’Neill P, et al. Anesth Analg 2012;114:179-85

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Summary

• Effectiveness and safety of CPNB and continuous local wound infusion

• Basal infusion with PCA option• Types of pumps – elastomeric vs. electronic• Outpatient and home infusion pumps

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