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Regional Anesthesia in the Prevention of Persistent Postsurgical Pain

Persistent postsurgical pain (PPSP), or chronic pain that develops after surgery, occurs more frequently than one may expect: up to 50% after relatively common operations. For anesthesiologists, surgeons, and pain physicians, there is an urgent need to discover methods to prevent the development of PPSP which is considered one of the more dreaded adverse outcomes following elective surgery.

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Regional Anesthesia in the Prevention of Persistent Postsurgical Pain

  1. 1. To Block or Not to Block: Prevention of Persistent Postoperative Pain Edward R. Mariano, M.D., M.A.S. Professor of Anesthesiology, Perioperative & Pain Medicine Stanford University School of Medicine Chief, Anesthesiology and Perioperative Care Veterans Affairs Palo Alto Health Care System @EMARIANOMD
  2. 2. 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.
  3. 3. Persistent Postsurgical Pain Chronic Pain after Surgery
  4. 4. Persistent Postsurgical Pain Kehlet H, et al. Lancet 2006;367:1618
  5. 5. Persistent Postsurgical Pain Overview  Risk Factors for Persistent Postsurgical Pain (PPSP)  Potential Role of Regional Anesthesia and Analgesia  Pharmacologic Interventions for PPSP
  6. 6. Persistent Postsurgical Pain Overview  Risk Factors for Persistent Postsurgical Pain (PPSP)  Potential Role of Regional Anesthesia and Analgesia  Pharmacologic Interventions for PPSP
  7. 7. Persistent Postsurgical Pain 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 plasticity Richebe P, et al. CJA 2015;62:1329 Clarke H, et al. CJA 2015;62:294
  8. 8. Persistent Postsurgical Pain Bayman EO, et al. Anesth 2017 epub
  9. 9. Persistent Postsurgical Pain Catastrophizing as a Risk Factor 157 Knee Replacement Patients Pain Catastrophizing Scale ≥16 considered high score Riddle DL, et al. CORR 2010;468:798
  10. 10. Persistent Postsurgical Pain Catastrophizing as a Risk Factor Riddle DL, et al. CORR 2010;468:798
  11. 11. Persistent Postsurgical Pain Opioid-Induced Hyperalgesia Angst MS, et al. Pain 2003;106:49
  12. 12. Persistent Postsurgical Pain Overview  Risk Factors for Persistent Postsurgical Pain (PPSP)  Potential Role of Regional Anesthesia and Analgesia  Pharmacologic Interventions for PPSP
  13. 13. Persistent Postsurgical Pain Kehlet H, et al. Lancet 2006;367:1618 How Can Regional Anesthesia Help?
  14. 14. Persistent Postsurgical Pain 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):904 2. Richman JM, et al. A&A 2006;102:248 3. Ilfeld & Mariano, et al. Pain 2010;150:477 4. Ohmichi Y, et al. Eur J Pain 2012;16:338 5. Guo TZ, et al. J Pain 2014;15:1033
  15. 15. Persistent Postsurgical Pain Preventing PPSP  Primary prevention: avoid injury/surgery  Secondary prevention: early intervention to prevent transition from acute to chronic Gilron & Kehlet. CJA 2014;61:101
  16. 16. Persistent Postsurgical Pain 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
  17. 17. Persistent Postsurgical Pain 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
  18. 18. Persistent Postsurgical Pain Chronic Pain after Breast Surgery  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
  19. 19. Persistent Postsurgical Pain Chronic Pain after Breast Surgery  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
  20. 20. Persistent Postsurgical Pain  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
  21. 21. Persistent Postsurgical Pain Is the Infusion Long Enough? Lavand’homme, et al. CORR 2014;472:1409 TKA Patients Normal Persistent Pain Neuropathic Pain
  22. 22. Persistent Postsurgical Pain Overview  Risk Factors for Persistent Postsurgical Pain (PPSP)  Potential Role of Regional Anesthesia and Analgesia  Pharmacologic Interventions for PPSP
  23. 23. Persistent Postsurgical Pain Think Multimodal Anesthesiology 2012;116:248
  24. 24. Persistent Postsurgical Pain Ketamine
  25. 25. Persistent Postsurgical Pain Where Ketamine Works Himmelseher & Durieux. Anesth 2005;102:211
  26. 26. Persistent Postsurgical Pain When to Administer Ketamine Himmelseher & Durieux. Anesth 2005;102:211
  27. 27. Persistent Postsurgical Pain Ketamine and OIH Angst MS, et al. Pain 2003;106:49
  28. 28. Persistent Postsurgical Pain Pregabalin 1. Lavand’homme, et al. CORR 2014;472:1409 2. 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)
  29. 29. Persistent Postsurgical Pain Gabapentin Clarke H, et al. A&A 2012;115:428
  30. 30. Persistent Postsurgical Pain Framework for Approaching PPSP Gilron & Kehlet. CJA 2014;61:101
  31. 31. Persistent Postsurgical Pain Overview  We discussed: – Risk Factors for Persistent Postsurgical Pain (PPSP) – Potential Role of Regional Anesthesia and Analgesia – Pharmacologic Interventions for PPSP

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