regional anesthesia in the prevention of persistent postsurgical pain

To Block or Not to Block:Prevention of Persistent

Postoperative Pain

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

MedicineStanford University School of Medicine

Chief, Anesthesiology and Perioperative CareVeterans Affairs Palo Alto Health Care System

@EMARIANOMD

Persistent Postsurgical Pain

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.


Chronic Pain after Surgery


Kehlet H, et al. Lancet 2006;367:1618


Overview Risk Factors for Persistent

Postsurgical Pain (PPSP) Potential Role of Regional Anesthesia

and Analgesia Pharmacologic Interventions for PPSP


Risk Factors for PPSP Patient phenotypic factors

– Preexisting pain before surgery– High consumption of analgesic

medications preoperatively– Catastrophizing– Severe acute postoperative pain

Patient genetic factors (~45%) Nerve injury during surgery,

inflammation, and neuronal plasticityRichebe P, et al. CJA

2015;62:1329Clarke H, et al. CJA

2015;62:294


Bayman EO, et al. Anesth 2017 epub


Catastrophizing as a Risk Factor157 Knee

Replacement Patients

PainCatastrophizingScale≥16 considered high score

Riddle DL, et al. CORR 2010;468:798


Catastrophizing as a Risk Factor

Riddle DL, et al. CORR 2010;468:798


Opioid-Induced Hyperalgesia

Angst MS, et al. Pain 2003;106:49


Kehlet H, et al. Lancet 2006;367:1618

How Can Regional Anesthesia Help?


What Regional Anesthesia Does

Mitigates maximal pain intensity after surgery1

Decreases opioid consumption2 (maybe less opioid-induced hyperalgesia)

Facilitates early mobility3

Avoids immobility which can produce hyperalgesia and persistent pain4,5

1. Ilfeld BM. A&A 2011;113(4):9042. Richman JM, et al. A&A 2006;102:2483. Ilfeld & Mariano, et al. Pain 2010;150:477

4. Ohmichi Y, et al. Eur J Pain 2012;16:3385. Guo TZ, et al. J Pain 2014;15:1033


Preventing PPSP

Primary prevention: avoid injury/surgery

Secondary prevention: early intervention to prevent transition from acute to chronic Gilron & Kehlet. CJA 2014;61:101


Chronic Pain after Thoracotomy

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

Heterogeneity in study designs Many contributing factors: patients,

surgical technique, pre- and postop pain

To date, no convincing evidence that PVB decreases chronic pain after thoracotomy

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


Chronic Pain after Breast Surgery

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

59% response rate Prevalence of pain after >1 year

postop:– Mastectomy/reconstruction = 49%– Mastectomy alone = 31%– Augmentation = 38%– Reduction = 22% Wallace MS, et al. Pain 1996;66:195



Secondary outcome of previously-published RCT– Immediate postop pain less in PVB group

(p<0.01) Less pain in PVB group at 6 (p=0.029; n=60)

and 12 mos (p=0.003; n=59)Kairaluoma P, et al. A&A 2004;99:1837



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

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

1.13)–No difference (crosses 1)

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

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


3 day infusion of ropivacaine vs. saline

At 12 months:– 13% pain-induced dysfunction for

ropivacaine vs. 47% for saline (p=0.011)– Mean BPI 1.6 ± 4.6 for ropivacaine vs.

5.9 ± 11.3 for saline (p=0.007)

Ilfeld BM, et al. Ann Surg Onc 2015;22:2017


Is the Infusion Long Enough?

Lavand’homme, et al. CORR 2014;472:1409

TKA Patients

Normal

Persistent Pain

Neuropathic Pain


Think Multimodal

Anesthesiology 2012;116:248


Ketamine


Where Ketamine Works

Himmelseher & Durieux. Anesth 2005;102:211


When to Administer Ketamine

Himmelseher & Durieux. Anesth 2005;102:211


Ketamine and OIH

Angst MS, et al. Pain 2003;106:49


Pregabalin

1. Lavand’homme, et al. CORR 2014;472:14092. Buvanendran A, et al. A&A 2010;110:199

For TKA, incidence of PPSP may be as high as 58% with 11% reporting neuropathic symptoms1

Pregabalin may decrease neuropathic PPSP after TKA2

– 0% vs. 9% (placebo) at 3 months (p=0.001)

– 0% vs. 5% (placebo) at 6 months (p=0.014)


Gabapentin

Clarke H, et al. A&A 2012;115:428


Framework for Approaching PPSP

Gilron & Kehlet. CJA 2014;61:101


Overview We discussed:

–Risk Factors for Persistent Postsurgical Pain (PPSP)

–Potential Role of Regional Anesthesia and Analgesia

–Pharmacologic Interventions for PPSP

regional anesthesia in the prevention of persistent postsurgical pain

Health & Medicine