Nerve Blocks for Trauma Patients: Stop Worrying, Theyre Safe - - PowerPoint PPT Presentation

Nerve Blocks for Trauma Patients: Stop Worrying, They’re Safe - Patients Will Do Well Sonia Szlyk, MD Director of Regional Anesthesia North American Partners in Anesthesia, Mid-Atlantic Division INOVA Fair Oaks Hospital, VA

Disclosure • National Speakers’ Bureau - Halyard Health

My Perspective Large academic hospital Freestanding Orthopaedic ASC NAPA Private practice hospital Mid-Atlantic 14 Hospitals 6 ASCs >350 MDs, CRNAs

“There is a FRACTURE!” “There is PAIN!” “There is a BLOCK!” Edvard Munch

Opioid-based Pain Management • Undesirable side effects - Respiratory depression - Vasodilation and hypotension when hypovolemic - Delirium - Nausea, vomiting - Immunosuppression - Increased monitoring requirements - Increased LOS - Opioid epidemic Gadsden, J. Regional Anesthesia for the Trauma Patient. Local and Regional Anesthesia 2015:8 45 - 55.

Chronic Pain Syndrome • Pain lasting > 3 months after injury • Up to 77% of patients with severe MSK trauma • Increased risk with intense acute pain at time of injury • Association with post-traumatic stress disorder Gadsden, J. Regional Anesthesia for the Trauma Patient. Local and Regional Anesthesia 2015:8 45 - 55.

Peripheral Nerve Block Benefits • Excellent site-specific analgesia • Avoid or reduce opioid requirements and related side effects • Decreased morbidity and mortality • Femur, hip fracture, digital replantation • Avoid general anesthesia or sedation • Reduced LOS in ER, OR, and CCU • Decreased cost Gadsden, J. Regional Anesthesia for the Trauma Patient. Local and Regional Anesthesia 2015:8 45 - 55.

Role of Nerve Block Catheters • Initial surgical procedure • Serial procedures • Debridements • Fracture fixation • Skin grafting • Postoperative pain management Gadsden, J. Regional Anesthesia for the Trauma Patient. Local and Regional Anesthesia 2015:8 45 - 55.

Nerve Blocks for Hip & Femur Fracture • Fascia iliaca block • Femoral nerve block • Lumbar plexus block - Not commonly used due to anticoagulation Mayo Foundation for Medical Education. Gadsden, J. Regional Anesthesia for the Trauma Patient. Local and Regional Anesthesia 2015:8 45 - 55.

Nerve Blocks for Hip & Femur Fracture • Best modality for reducing acute pain associated with hip fracture - versus… opioids, traction, multimodal, neurostimulation Gadsden, J. Regional Anesthesia for the Trauma Patient. Local and Regional Anesthesia 2015:8 45 - 55.

Fascia Iliaca Block • Lateral femoral cutaneous • Femoral • Obturator • “Anterior approach lumbar plexus” • Allows anticoagulation

Bow-Tie Approach FIB SUPERIOR INFERIOR • Compartment block = High volume Sartorius • 50 - 60 cc local anesthetic Internal Oblique Fascia Iliaca Iliacus 50 cc Compartment Block 20 cc 0.2% Ropivacaine 30 cc 0.5% Ropivacaine

Fascia Iliaca Block No Block FIB cath POD 0 Pain 4.1 1.7 POD 1 Pain 2.9 1.4 Ave LOS 5.9 days 4.8 days

Placebo FIB Incidence of Delirium 23.8% 10.78% Mean Duration of Delirium 10.97 days 5.22 days

Ultrasound-guided Femoral Nerve Block In - plane Nerve LATERAL Decreased number of needle passes Decreased vascular injury Liu, S. Ultrasound-Guided Regional Anesthesia and Analgesia. A Qualitative Systematic Review. Reg Anesth Pain Med 2009;34: 47 - 59.

Ultrasound-guided Femoral Nerve Block Single Shot Block 0.5% Ropivacaine 30 cc Nerve Block Catheter 0.5% Ropivacaine 30 cc bolus 0.2% Ropivacaine @ 8cc/hr LATERAL Liu, S. Ultrasound-Guided Regional Anesthesia and Analgesia. A Qualitative Systematic Review. Reg Anesth Pain Med 2009;34: 47 - 59.

Popliteal Sciatic Catheter • Tibia/Fibula Fracture • Ankle fracture • Achilles rupture

LATERAL Start in fossa, then scan up leg

Interscalene Catheter • Clavicle fracture • Shoulder reduction • Benefits - Reduced sedation - Reduced monitoring - Decreased LOS Gadsden, J. Regional Anesthesia for the Trauma Patient. Local and Regional Anesthesia 2015:8 45 - 55.

MSM ASM LATERAL !

LATERAL Local anesthetic spread !

Supraclavicular Catheter • ORIF humerus • ORIF distal radius • ORIF elbow • Digital replantation Neal, J. RAPM, vol. 32. n. 2. March-April 2009.

LATERAL 0.5% Ropivacaine 30 mL

Nerve Block for Digital Replantation • Sympathetic blockade • Maximal vasodilation • Decreased vasospasm • Reduced stress response • Decreased hypercoagulability and thrombotic events Gadsden, J. Regional Anesthesia for the Trauma Patient. Local and Regional Anesthesia 2015:8 45 - 55.

Acute Compartment Syndrome • High-energy injury to soft tissue - 1/3 of cases are tibial fracture (prox. diaphysis) - Forearm fracture • Crush injury • Burns • Arterial puncture • Circumferential dressing • Snake bites Gadsden, J. Regional Anesthesia for the Trauma Patient. Local and Regional Anesthesia 2015:8 45 - 55.

Acute Compartment Syndrome Diagnosis • Diagnosis reliant on vigilance - Pain out of proportion to injury (passive stretch) - Paresthesia - Compartment pressure • No evidence that peripheral nerve blocks delay diagnosis of ACS • May facilitate the recognition of pathologic breakthrough pain Gadsden, J. Regional Anesthesia for the Trauma Patient. Local and Regional Anesthesia 2015:8 45 - 55.

Nerve Block Considerations for Acute Compartment Syndrome • Lower concentration and rate of local anesthetic - 0.1% Ropivacaine • Catheter enables flexibility - Adjust rate for surgical vs post pain use - Can stop infusion, restart, or bolus prn • Increased concern if patient develops new onset breakthrough pain Gadsden, J. Regional Anesthesia for the Trauma Patient. Local and Regional Anesthesia 2015:8 45 - 55.

Risk of… Low • Infection (0 - 3%) - Risk inherent to trauma population, increased if ICU - Most commonly superficial infection • Nerve Injury - Reduced risk with ultrasound guidance & experience • Anticoagulation-related bleeding - Benefit of peripheral nerve blocks vs. spinal or epidural - Avoid lumbar plexus block if anticoagulated Gadsden, J. Regional Anesthesia for the Trauma Patient. Local and Regional Anesthesia 2015:8 45 - 55. Choi, J. Regional Anesthesia for Trauma Outside the Operating Theater. Current Opinion Anesthesiology 2013, 26:495 - 500.

Strategy for • Vigilance • Communication • Experienced orthopedic and anesthesia team BETTER PAIN CONTROL IMPROVED OUTCOMES Gadsden, J. Regional Anesthesia for the Trauma Patient. Local and Regional Anesthesia 2015:8 45 - 55.