Clinical and Health Affairs
Multimodal Clinical Pathways, Perineural Catheters, and Ultrasound-Guided Regional Anesthesia: The Anesthesiologist’s Repertoire for the 21st Century
By Adam D. Niesen, M.D., and James R. Hebl, M.D.
■ Regional anesthesia is making a comeback because of improved technology and research that shows that its use results in less discomfort for patients and shorter hospital stays. This article provides a brief history of regional anesthesia, describes current techniques for administering it, and discusses potential benefits associated with it. It also describes Mayo Clinic’s Total Joint Regional Anesthesia Clinical Pathway, a comprehensive care plan for patients undergoing joint replacement surgery that uses peripheral nerve blockade and multimodal analgesia.
Total hip and total knee arthroplasty are two of the most commonly performed surgeries in the United States. Medicare pays for more of these procedures than any others.1,2 Patients undergoing total joint arthroplasty experience significant postoperative pain. Failure to provide adequate analgesia impedes the start of physical therapy, which is important for maintaining joint range-of-motion, prolongs hospital stays, and increases hospital expenditures. Traditionally, analgesia following total joint replacement surgery has been provided by patient-controlled intravenous analgesia. However, the new standard for managing pain in these patients is through multimodal clinical pathways with an emphasis on regional anesthesia and the use of perineural catheters.
Spinal blocks and epidurals are probably the first techniques that come to mind when reading the words “regional anesthesia.” Although these techniques are still essential tools, anesthesiologists now have at their disposal an array of options. As technology and techniques have improved and as both clinical use and indications have expanded, regional anesthesia has undergone a renaissance of sorts. The most significant advancements have occurred in the use of continuous peripheral nerve catheters (for both inpatients and outpatients) and ultrasound-guided regional anesthesia techniques.
Historical Perspective
Regional anesthesia and the use of peripheral nerve blockade have evolved greatly since the discovery of cocaine as an effective local anesthetic by Austrian ophthalmologist Carl Koller, M.D., in 1884. In 1920, Charles Mayo, M.D., traveled to Paris to visit his surgical colleague Victor Pauchet, M.D., and to learn new surgical techniques.3 Pauchet had mastered the German technique of transcutaneous regional anesthetic blockade. Pauchet’s pupil, Gaston Labat, M.D., was finishing his training and provided anesthesia while Mayo and Pauchet operated. Mayo was so impressed with these regional techniques that he recruited Labat to Mayo Clinic. In October 1920, Labat began his work in Rochester, where he taught regional anesthesia to physicians at Mayo Clinic and wrote the book Regional Anesthesia: Its Technic and Clinical Application. The popular book helped propagate interest in regional anesthesia across the United States.
Use of regional anesthesia waxed and waned during the ensuing decades; but during the 21st century it has again become popular as both the technology and the reliability of the equipment used for its administration have improved. With this resurgence has come an awareness on the part of clinicians and patients of the benefits of regional anesthesia, many of which are now being described in the literature.
Regional Anesthesia Techniques
Regional anesthesia is categorized as central (ie, neuraxial) and peripheral based on the anatomic location of the nerve block. Neuraxial techniques include spinal, epidural, and caudal blockade, and peripheral techniques encompass blockade in all other regions. Most peripheral techniques were initially used as a form of intraoperative anesthesia for a particular part of the body (eg, the arm or lower leg). However, with the development of longer-acting local anesthetics and peripheral nerve catheter techniques, many of these techniques are now being used for providing postoperative analgesia for days following surgery, especially for patients undergoing orthopedic procedures.
In an attempt to maximize the benefits of regional anesthesia, the Mayo Clinic department of anesthesiology in collaboration with the department of orthopedic surgery developed the Mayo Clinic Total Joint Regional Anesthesia (TJRA) Clinical Pathway. The TJRA Clinical Pathway is a comprehensive care plan for patients undergoing major joint replacement surgery that emphasizes the use of multimodal analgesia and peripheral nerve blockade and perineural catheters. Multimodal analgesia involves the use of several analgesic agents in limited doses that act through different physiologic mechanisms. The advantage of a multimodal regimen is that it capitalizes on the synergistic effects of these medications (ie, enhanced analgesia) while minimizing or eliminating adverse side effects because of the limited doses administered.
Patients undergoing total knee arthroplasty receive a preoperative femoral nerve catheter with an initial bolus of local anesthetic (Figure 1). Select patients also receive a single-injection sciatic nerve block. Total hip arthroplasty patients receive a posterior lumbar plexus (psoas compartment) perineural catheter with an initial bolus of local anesthetic (Figure 2). Preoperative oral adjuvants include extended release oxycodone (age-dependent dosing), celecoxib, and gabapentin. Preoperative medications are modified or omitted at the discretion of the anesthesiologist based on the patient’s comorbidities. Intraoperative management includes either spinal or general anesthesia, once again based on patient comorbidities and patient preference. Intraoperative opioid administration is limited and done at the discretion of the attending anesthesiologist. No intravenous opioids are administered during the postoperative period. Rather, a postoperative multimodal analgesic regimen is initiated. Options used during the postoperative period are listed in the table. All perineural catheters remain in situ so that local anesthetic can be infused a minimum of 36 hours postoperatively. Most perineural catheters are discontinued on the morning of the second postoperative day.
Patients receiving the Mayo Clinic TJRA Clinical Pathway experience superior analgesia with fewer opioid-related side effects when compared with control patients.4 Visual analog pain scores are significantly lower among TJRA patients both at rest and during physical therapy sessions throughout their hospital stay. Opioid requirements are also significantly less among TJRA patients. Opioid-related side effects such as nausea, vomiting, and urinary retention are also significantly reduced throughout most of the perioperative period.4
Postoperative milestones such as the ability to transfer from bed-to-chair and eligibility for discharge are achieved significantly sooner in patients receiving the multimodal TJRA Clinical Pathway when compared with those who are not given the pathway. Discharge eligibility is achieved a mean of 1.7±1.9 days sooner among TJRA patients when compared with matched controls. At the time of hospital discharge, TJRA patients have better joint range of motion than others; these gains in range of motion persist to the six-week to eight-week surgical follow-up visit.4
Severe postoperative complications (eg, neurologic injury, myocardial infarction, renal dysfunction, localized bleeding, deep venous thrombosis/pulmonary embolism, joint dislocation, and wound infection) are similar between TJRA patients and patients receiving patient-controlled analgesia. However, postoperative ileus occurs significantly more often among control patients receiving intravenous opioids, resulting in delayed postoperative feedings.4 In addition, significantly fewer TJRA patients experience postoperative urinary retention and postoperative cognitive dysfunction when compared with matched controls. Approximately 15% of control patients and 1% of TJRA patients experience postoperative cognitive dysfunction (defined as disorientation to person, place, or time, hallucinations, or any other cognitive condition requiring further assessment by a physician) during their hospitalization.5
The Financial Impact of Clinical Pathways
Changes in patient management and improved perioperative outcomes may decrease costs associated with joint replacement surgery by reducing hospital stays and services needed during hospitalization (ie, resources needed to manage side effects or complications). The cost of treating patients using the TJRA Clinical Pathway at Mayo Clinic is $1,999 less per surgical episode when compared with the cost of treating patients who do not use it.6 Analysis of the components of cost (hospital and physician charges) found that hospital-related costs were significantly less within the TJRA cohort and accounted for the majority of the total savings. The difference in hospital costs was attributed primarily to significant reductions in medical and surgical supply costs, operating room costs, and anesthesia supply costs. Although room and board and pharmacy costs were also lower among the TJRA cohort, these costs were not found to be statistically significant. Overall, physician costs were not found to be significantly different between groups. In addition, the cost savings associated with the TJRA Clinical Pathway were found to be greatest among patients with a higher number of associated comorbidities (ie, older, sicker patients).6
The use of regional anesthesia techniques and perineural catheters is not limited to inpatients undergoing surgery. In fact, outpatients having procedures (eg, rotator cuff repair, anterior cruciate ligament repair) with regional anesthesia also have improved pain scores, decreased need for opioids, less postoperative nausea and vomiting, and fewer hospital readmissions than those who receive other forms of anesthesia. In addition, many are discharged to home hours sooner and report a higher degree of satisfaction.7 Continuous peripheral nerve blockade also may be used in the outpatient setting for more painful procedures such as anterior cruciate ligament reconstruction or uni-compartmental knee arthroplasty. Disposable local anesthetic infusion devices allow patients to go home after ambulatory surgery with superior analgesia lasting a prolonged period of time. The small diameter and flexible nature of perineural catheters allows them to be easily removed by the patient at the end of their local anesthetic infusion.
Potential Benefits of Regional Anesthesia
During the perioperative period, opioids and the stress associated with surgery can suppress the immune system. This is of particular concern in patients undergoing cancer surgery, as changes in the immune system may increase their risk of cancer recurrence. Regional anesthesia is known to reduce the need for opioids. In addition, it attenuates the stress response by blocking afferent neural transmission.8 Preliminary investigations have suggested that these benefits of regional anesthesia may have a significant clinical impact. For example, patients receiving thoracic paravertebral blockade prior to breast cancer surgery have been found to have a longer cancer-free survival interval and a lower incidence of cancer recurrence when compared with patients not receiving a regional technique.9 Similar evidence exists for patients undergoing epidural anesthesia for prostate cancer and colon cancer surgery.10,11 Although these are preliminary studies, they suggest one more way that anesthetic technique may affect patient outcomes.
Further study is needed to more clearly define the association between regional anesthesia and cancer recurrence.
Conclusion
Today, there is renewed interest in the use of regional anesthesia for a number of reasons. Advances in perineural catheter techniques, nerve localization, block success, and overall safety have dramatically improved patients’ perioperative outcomes, satisfaction, and quality of life. Despite recent progress, additional research is needed to better define the impact of regional anesthesia techniques on major clinical (eg, cancer recurrence) and financial (eg, direct medical costs) outcomes. Thus far, however, evidence suggests a bright and promising future for regional anesthesia.3
In 1922, William J. Mayo, M.D., wrote “Regional anesthesia is here to stay.” Clearly, this prediction is as true today as it was nearly a century ago. MM
Adam Niesen is an instructor in anesthesi-ology and James Hebl is an associate professor of anesthesiology at the Mayo Clinic College of Medicine.
References
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