Regional Anesthesia Offers Alternative to Opioids for TJR

Although anesthesiologists have been performing regional blocks with nerve stimulation for years, the introduction of ultrasound guidance has improved efficiency dramatically, leading to faster block placement and onset in skilled hands.

These advancements have come at an opportune time, said Sonia Szlyk, MD, as opioid-related adverse events have become an increasing burden on the health care system (J Pain Palliat Care Pharmacother 2013;27:62-70).

“One of the reasons that regional anesthesia is so impactful is that it offers an alternative to opioids,” said Dr. Szlyk, who is director of regional anesthesia, North American Partners in Anesthesia, Mid-Atlantic Division and INOVA Fair Oaks Hospital, in Virginia. “If you can reduce the risk of opioid-related adverse events, patients will have better outcomes, and a regional anesthesia program will be more successful in a bundled payment scenario.”

Besides those advantages, regional anesthesia is more than just an opioid-sparing technique. As Dr. Szlyk reported at the 2017 Interdisciplinary Conference on Orthopedic Value-Based Care, neuraxial and peripheral nerve blocks can improve outcomes, reduce rates of readmission and increase patient satisfaction—all at a lower cost.

“It’s important to communicate to all members of the interdisciplinary care team that regional anesthesia has significantly evolved,” Dr. Szlyk said. “This is not your father’s nerve block.”

Adductor Canal Catheter

In the setting of multimodal analgesia, adductor canal catheters can produce improved outcomes and cost savings, Dr. Szlyk noted, especially for total or partial knee replacements.

A study of 252 primary total knee arthroplasties between January 2012 and July 2013 showed that updates to an existing orthopedic enhanced recovery after surgery (ERAS) pathway shortened hospital stays (J Arthroplasty 2015;30:1705-1709). The researchers substituted a standard long-acting, bupivacaine-based spinal with mepivacaine and replaced femoral nerve block catheters with adductor canal catheters for 48 hours. As part of the updated pathway, patients also were required to attend a preoperative education class with a care companion or “coach,” even if they’d undergone previous joint replacement surgery, and attend a physical therapy session on the day of surgery.

It was found that mean length of stay decreased by nearly a day (76.6 down to 56.1 hours) along with the 30-day readmission rate (7% vs. 3%), and more patients were discharged to home (from 27% to 52%). Secondary functional outcomes improved too, including increased ambulation distance (postoperative day 1 and 2), fewer falls, decreased transfusion and less nausea.

“Lower-extremity nerve blocks can be a delicate balancing act,” Dr. Szlyk explained. “We’re concerned about providing analgesia while minimizing quadriceps weakness. With an ultrasound-guided adductor canal block, the local anesthetic is injected distal to the perforators to vastus medialis, preserving quadriceps function and enabling early participation in physical therapy.”

Indeed, as Dr. Szlyk reported, a randomized double-blind study showed that quadriceps strength was significantly higher in patients receiving an adductor canal block catheter than a femoral nerve block catheter (52% vs. 15%, respectively) after total knee arthroplasty (Reg Anesth Pain Med 2013;38:526-532).

“The patient should be able to comfortably perform a straight-leg raise in the PACU as soon as the spinal has worn off,” she said. “That is our team’s criterion for an optimal block.”

Although the adductor canal catheter is not a panacea, she added, in the setting of multimodal analgesia, it can help anesthesiologists meet and exceed increased expectations for pain management and physical therapy. Multimodal premedication includes nonsteroidal anti-inflammatory agents and acetaminophen, which decreases both 24-hour usage of morphine and pain scores in patients (Pain Manag 2015;5:185-196). Gabapentin and pregabalin also reduce opioid requirements in the first 24 to 48 hours, but use beyond postoperative day 4 is not as well supported.

Fascia Iliaca Block

ERAS pathways for total hip replacement, hip fracture and hip arthroscopy may incorporate ultrasound-guided fascia iliaca blocks.

“The vast majority of our surgeons are using an anterior, muscle-sparing approach in the setting of multimodal analgesia, and these patients actually do very well with just a non-narcotic, short-acting spinal,” Dr. Szlyk said, “but there are scenarios where fascia iliac blocks and catheters are beneficial.”

For hip fracture patients at risk for delirium, a randomized placebo-controlled study (J Orthop Traumatol 2009;10:127-133) found that the incidence of delirium decreased with a preoperative fascia iliaca block versus placebo (10.78% vs. 23.8%, respectively). Moreover, for patients who experienced delirium, duration also was shorter with the fascia iliaca block than placebo (5.22 vs. 10.97 days, respectively).

“Delirium is a common and costly complication for elderly hip fracture patients,” Dr. Szlyk said. “Opioid-sparing techniques such as spinal anesthesia and fascia iliaca block have demonstrated better overall outcomes.”

In addition, a separate study of continuous fascia iliaca catheters in hip fracture patients showed reduced pain scores and a greater than one-day decrease in length of stay, Dr. Szlyk reported (J Clin Med Res 2012;4:45-48).

“The health care system is increasingly focused on value-based care, and patient satisfaction and pain management are at the heart of that,” she concluded. “Regional anesthesia makes it easy to do the right thing for our patients.”

Zeev N. Kain, MD, MBA, FAAP, president of the American College of Perioperative Medicine; and Chancellor’s Professor of Anesthesiology & Pediatrics & Psychiatry; and chair of the Department of Anesthesiology & Perioperative Care at University of California Irvine Health, commented that “as joint replacement moves to outpatient centers, the chosen anesthetic technique becomes paramount for successful discharge home.

“Within this context, regional techniques for joint replacement are becoming an alternative to opioids, which in addition to having multiple adverse effects, may hinder the discharge home,” Dr. Kain concluded.