regional anesthesia and perioperative outcomes

Regional Anesthesia and Perioperative Outcomes

@EMARIANOMD@EMARIANOMD

Edward R. Mariano, M.D., M.A.S.Edward R. Mariano, M.D., M.A.S.Professor of Anesthesiology, Perioperative & Pain MedicineProfessor of Anesthesiology, Perioperative & Pain Medicine

Stanford University School of MedicineStanford University School of MedicineChief, Anesthesiology and Perioperative CareChief, Anesthesiology and Perioperative CareVeterans Affairs Palo Alto Health Care SystemVeterans Affairs Palo Alto Health Care System

Regional Anesthesia OutcomesRegional Anesthesia Outcomes

Financial DisclosuresFinancial Disclosures Halyard Health, B Braun – Halyard Health, B Braun –

Unrestricted educational program Unrestricted educational program funding paid to my institutionfunding paid to my institution

The contents of the following The contents of the following presentation are solely the presentation are solely the responsibility of the speaker without responsibility of the speaker without input from any of the above input from any of the above companies.companies.


DisclaimerDisclaimer This presentation is intended for This presentation is intended for

educational purposes only and is not educational purposes only and is not meant to be reproduced or meant to be reproduced or redistributed for commercial redistributed for commercial purposespurposes


Learning ObjectivesLearning Objectives Discuss the benefits of regional Discuss the benefits of regional

anesthesia on pain and rehabilitative anesthesia on pain and rehabilitative outcomesoutcomes

Identify applications of “big data” in Identify applications of “big data” in outcomes assessmentoutcomes assessment

Critically evaluate the evidence Critically evaluate the evidence related to regional anesthesia and related to regional anesthesia and long-term outcomeslong-term outcomes


OverviewOverview Continuous peripheral nerve blocks Continuous peripheral nerve blocks

(CPNB) and acute pain(CPNB) and acute pain Other short-term outcomesOther short-term outcomes Long-term outcomesLong-term outcomes


What is CPNB?What is CPNB?

Ilfeld & Mariano. RAPM 2010;35:123Ilfeld & Mariano. RAPM 2010;35:123


CPNB and Acute PainCPNB and Acute Pain RCT: 32 patients scheduled for RCT: 32 patients scheduled for

outpatient shoulder surgery with an US-outpatient shoulder surgery with an US-guided interscalene nerve blockguided interscalene nerve block

All subjects received a nerve block All subjects received a nerve block catheter and one-time ropivacaine bolus catheter and one-time ropivacaine bolus

After surgery, subjects discharged home After surgery, subjects discharged home with portable infusion devicewith portable infusion device– Half received Half received ropivacaineropivacaine infusion for 2 infusion for 2

daysdays– Half received Half received salinesaline infusion for 2 days infusion for 2 days

Mariano ER, et al. A&A 2009;108:1688Mariano ER, et al. A&A 2009;108:1688


CPNB and Acute PainCPNB and Acute Pain



ResultsResults Subjects who received ropivacaine Subjects who received ropivacaine

suffered suffered fewer sleep disturbances fewer sleep disturbances and consumed and consumed less oral opioid less oral opioid medicationmedication

Subjects who received ropivacaine Subjects who received ropivacaine reported reported higher satisfachigher satisfaction tion with with recoveryrecovery



Meta-analysis: CPNB vs. Meta-analysis: CPNB vs. OpioidsOpioids

Richman JM, et al. A&A 2006;102:248Richman JM, et al. A&A 2006;102:248

Mean VASMean VAS24h24h 48h48h

InfraclaInfraclavv

1.0 vs. 1.0 vs. 4.34.3

p<0.00p<0.0011

0.6 vs. 0.6 vs. 4.04.0

p<0.00p<0.0011

InterscaInterscall

1.4 vs. 1.4 vs. 3.63.6

p<0.00p<0.0011

0.5 vs. 0.5 vs. 2.32.3

p<0.00p<0.0011

Fem/LPFem/LP 2.1 vs. 2.1 vs. 4.04.0

p<0.00p<0.0011

1.6 vs. 1.6 vs. 3.23.2

p<0.00p<0.0011

SciaticSciatic 0.9 vs. 0.9 vs. 4.64.6

p<0.00p<0.0011

0.9 vs. 0.9 vs. 3.53.5

p<0.00p<0.0011


How Do We Study Rare How Do We Study Rare Outcomes?Outcomes?


Anesthesia Type and Anesthesia Type and MortalityMortality

30-day mortality was lower30-day mortality was lower for neuraxial and for neuraxial and neuraxial/GA vs. GA alone for TKAneuraxial/GA vs. GA alone for TKA

Most in-hospital complications were lower for Most in-hospital complications were lower for neuraxial and neuraxial/GA vs. GA aloneneuraxial and neuraxial/GA vs. GA alone

Transfusion requirements lowest for neuraxialTransfusion requirements lowest for neuraxial

Memtsoudis SG, et al. Anesth Memtsoudis SG, et al. Anesth 2013;118:10462013;118:1046



No difference in 30-day mortality No difference in 30-day mortality between between regional anesthesia and GAregional anesthesia and GA

Regional anesthesia patients are more likely Regional anesthesia patients are more likely to have shorter operative time and next-day to have shorter operative time and next-day dischargedischarge

Schechter MA, et al. Surgery Schechter MA, et al. Surgery 2012;152:3092012;152:309



N=6009; N=6009; no difference in 30-day mortality no difference in 30-day mortality based on anesthesia typebased on anesthesia type

Increased pulmonary complications and Increased pulmonary complications and length of stay for GA vs. spinal or local/MAClength of stay for GA vs. spinal or local/MAC

Edwards MS, et al. J Vasc Surg Edwards MS, et al. J Vasc Surg 2011;54:12732011;54:1273


Ultrasound and Patient Ultrasound and Patient SafetySafety

22 cases of LAST in 25,336 blocks (overall 22 cases of LAST in 25,336 blocks (overall incidence=0.87 per 1000)incidence=0.87 per 1000)

LAST cases: 12/20,401 blocks with US vs. LAST cases: 12/20,401 blocks with US vs. 10/4745 blocks without US (10/4745 blocks without US (p=0.004p=0.004))

Barrington MJ, et al. RAPM Barrington MJ, et al. RAPM 2013;38:2892013;38:289


Lower Extremity CPNB and Lower Extremity CPNB and FallsFalls

Pooled analysis of 3 published RCTs Pooled analysis of 3 published RCTs (knee and hip arthroplasty) with (knee and hip arthroplasty) with CPNB x 4 daysCPNB x 4 days– 85 subjects received ropivacaine 0.2%85 subjects received ropivacaine 0.2%– 86 subjects received saline86 subjects received saline

NoNo falls in the saline group vs. falls in the saline group vs. 77 falls falls in the ropiv group (P=0.013)in the ropiv group (P=0.013)

Ilfeld BM, et al. A&A Ilfeld BM, et al. A&A 2010;111:15522010;111:1552

Memtsoudis & Mariano, et al. Anesthesiology 2014;120:551Memtsoudis & Mariano, et al. Anesthesiology 2014;120:551Premier Perspective Database; n=191,570Premier Perspective Database; n=191,570PNB in 12.1% of cases; no association with fallsPNB in 12.1% of cases; no association with fallsRisk factors=higher age, greater comorbidity burdenRisk factors=higher age, greater comorbidity burden


We Can Be More SelectiveWe Can Be More Selective Injectate administered Injectate administered

distal to the femoral distal to the femoral triangle in triangle in adductor adductor canalcanal

Many variations on Many variations on technique technique

Effective vs. placebo Effective vs. placebo injectioninjection

Decreases quad strength Decreases quad strength but less than FNBbut less than FNB

Tsui & Ozelsel. RAPM 2009;34:178Tsui & Ozelsel. RAPM 2009;34:178Ishiguro S, et al. A&A Ishiguro S, et al. A&A 2012;115:14672012;115:1467Jaeger P, et al. Acta Anaes Jaeger P, et al. Acta Anaes 2012;56:10132012;56:1013Jaeger P, et al. Anesth Jaeger P, et al. Anesth 2013;118:4092013;118:409

Lund J, et al. Acta Anaes 2011;55:14Lund J, et al. Acta Anaes 2011;55:14Manickam B, et al. RAPM Manickam B, et al. RAPM 2009;34:5782009;34:578Krombach & Gray. RAPM Krombach & Gray. RAPM 2007;32:3692007;32:369

LATE

RAL

SFA

N

SARTORIUS


We Changed Our Clinical We Changed Our Clinical PathwayPathway

In April 2012, clinical pathway changed In April 2012, clinical pathway changed from CFNB to continuous adductor canal from CFNB to continuous adductor canal blocks due to concern over quad weaknessblocks due to concern over quad weakness

Hypothesis for retrospective cohort study: Hypothesis for retrospective cohort study: patients with continuous adductor canal patients with continuous adductor canal blocks blocks ambulate further ambulate further than those with than those with continuous femoral nerve blocks on continuous femoral nerve blocks on postoperative day (POD) 1 without postoperative day (POD) 1 without reduction in analgesiareduction in analgesia

Mudumbai & Mariano, et al. CORR Mudumbai & Mariano, et al. CORR 2014;472:13772014;472:1377


Patients in the adductor Patients in the adductor canal group walked canal group walked 3737 (0-90) meters vs. (0-90) meters vs. 66 (0- (0-51) meters in the 51) meters in the femoral catheter group femoral catheter group ((p=0.003p=0.003). ).

Pain scores, opioid Pain scores, opioid consumption, and consumption, and hospital length of stay hospital length of stay were similar. were similar.

ResultsResults

Mudumbai & Mariano, et al. CORR Mudumbai & Mariano, et al. CORR 2014;472:13772014;472:1377


Functional Outcomes at 6 Functional Outcomes at 6 WeeksWeeks

RCT (n=40) of CFNB vs. LIARCT (n=40) of CFNB vs. LIA– At 6 weeks, the CFNB group showed greater At 6 weeks, the CFNB group showed greater

within-group improvement in 6-MWT, physical within-group improvement in 6-MWT, physical activity (CHAMPS), KSS, and WOMACactivity (CHAMPS), KSS, and WOMAC

– Preop 6-MWT, walking on POD1, time spent Preop 6-MWT, walking on POD1, time spent walking during POD1-3 were predictors of 6-MWT walking during POD1-3 were predictors of 6-MWT at 6 weeksat 6 weeks

Carli F, et al. BJA Carli F, et al. BJA 2010;105:1852010;105:185


Long-Term OutcomesLong-Term Outcomes 1 yr Western Ontario and McMaster Univ 1 yr Western Ontario and McMaster Univ

Osteoarthritis Index (WOMAC) scoresOsteoarthritis Index (WOMAC) scores

Ilfeld BM, et al. A&A Ilfeld BM, et al. A&A 2009;108:13202009;108:1320Ilfeld BM, et al. A&A Ilfeld BM, et al. A&A 2009;109:5862009;109:586


Long-Term OutcomesLong-Term Outcomes Retrospective review of patients with Retrospective review of patients with

palpable breast lesions who palpable breast lesions who underwent mastectomy and axillary underwent mastectomy and axillary clearance with paravertebral CPNB x clearance with paravertebral CPNB x 48h vs. opioid IV PCA48h vs. opioid IV PCA

Primary outcome: metastases or Primary outcome: metastases or cancer recurrence over 2.5-4 year cancer recurrence over 2.5-4 year follow-up (fixed time point)follow-up (fixed time point)

Exadaktylos AK, et al. Anesth Exadaktylos AK, et al. Anesth 2006;105:6602006;105:660


Long-Term OutcomesLong-Term Outcomes 129 patients met inclusion criteria129 patients met inclusion criteria

– 50 patients received PVB (2 failures)50 patients received PVB (2 failures)– 79 patients received IV PCA79 patients received IV PCA

No demographic, tumor quality, or No demographic, tumor quality, or therapeutic differences between groupstherapeutic differences between groups

Recurrence/metastasis rates:Recurrence/metastasis rates:– 19/79 (24%) in IV PCA group19/79 (24%) in IV PCA group– 3/50 (6%) in PVB group3/50 (6%) in PVB group– p=0.013p=0.013



Long-Term OutcomesLong-Term Outcomes 129 patients met inclusion criteria129 patients met inclusion criteria

– 50 patients received PVB (2 failures)50 patients received PVB (2 failures)– 79 patients received IV PCA79 patients received IV PCA

No demographic, tumor quality, or No demographic, tumor quality, or therapeutic differences between groupstherapeutic differences between groups

Recurrence/metastasis rates:Recurrence/metastasis rates:– 19/79 (24%) in IV PCA group19/79 (24%) in IV PCA group– 3/50 (6%) in PVB group3/50 (6%) in PVB group– p=0.013p=0.013


Mechanism?Preserving immune

competence?Direct effect?

Indirect effect? Both?


Long-Term OutcomesLong-Term Outcomes

14 studies met criteria EA±GA vs. GA 14 studies met criteria EA±GA vs. GA (including Cummings study, n=42,151)(including Cummings study, n=42,151)

Improved overall survival with EAImproved overall survival with EA No difference in cancer recurrenceNo difference in cancer recurrence

Chen & Miao. PLOS ONE Chen & Miao. PLOS ONE 2013;8:e565402013;8:e56540

Cummings KC, et al. Anesth Cummings KC, et al. Anesth 2012;116:797 2012;116:797


Chronic Pain after Breast Chronic Pain after Breast SurgerySurgery

Survey of 479 women who underwent Survey of 479 women who underwent breast surgery over a 4-year periodbreast surgery over a 4-year period

59% response rate59% response rate Prevalence of pain after >1 year postop:Prevalence of pain after >1 year postop:

– Mastectomy/reconstruction = Mastectomy/reconstruction = 49%49%– Mastectomy alone = Mastectomy alone = 31%31%– Augmentation = Augmentation = 38%38%– Reduction = Reduction = 22%22%

Wallace MS, et al. Pain 1996;66:195Wallace MS, et al. Pain 1996;66:195


Chronic Pain after Breast Chronic Pain after Breast SurgerySurgery

Meta-analysis: 3 studies assessed this Meta-analysis: 3 studies assessed this outcome (n=167)outcome (n=167)

All PVB-GA vs. GAAll PVB-GA vs. GA At 6 mos, RR=0.16, 95%CI (0.02-1.13)At 6 mos, RR=0.16, 95%CI (0.02-1.13)

– No difference (crosses 1)No difference (crosses 1) At 12 mos, RR=0.61, 95%CI (0.08-4.90)At 12 mos, RR=0.61, 95%CI (0.08-4.90)

– No difference (crosses 1)No difference (crosses 1)

Schnabel A, et al. BJA 2010;105:842Schnabel A, et al. BJA 2010;105:842


Chronic Pain after Chronic Pain after ThoracotomyThoracotomy

Incidence is approximately Incidence is approximately 50%50%– 3-16% report pain as moderate-severe3-16% report pain as moderate-severe

Heterogeneity in study designsHeterogeneity in study designs Many contributing factors: patients, Many contributing factors: patients,

surgical technique, pre- and postop painsurgical technique, pre- and postop pain To date, To date, no convincing evidenceno convincing evidence that that

PVB decreases chronic pain after PVB decreases chronic pain after thoracotomythoracotomy

Wildgaard & Kehlet. Eur J CTS Wildgaard & Kehlet. Eur J CTS 2009;36:1702009;36:170


One Size Does Not Fit AllOne Size Does Not Fit All

REGIONAL ANESTHESIOLOGIST


What Is Multimodal What Is Multimodal Analgesia?Analgesia?

Anesthesiology 2012;116:248Anesthesiology 2012;116:248


Potential Limitations of Big Potential Limitations of Big DataData

Lack of randomizationLack of randomization Bias Bias Missing or wrong dataMissing or wrong data Inability to determine causalityInability to determine causality Restrictions to data accessRestrictions to data access Cost to access dataCost to access data Lack of skills necessary to use dataLack of skills necessary to use data


SummarySummary We discussed the benefits of regional We discussed the benefits of regional

anesthesia on pain and rehabilitative anesthesia on pain and rehabilitative outcomesoutcomes

We identified applications of “big We identified applications of “big data” in outcomes assessmentdata” in outcomes assessment

We critically evaluated the evidence We critically evaluated the evidence related to regional anesthesia and related to regional anesthesia and long-term outcomeslong-term outcomes

regional anesthesia and perioperative outcomes

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