Regional Anesthesia/analgesia in trauma patients?

Mansour Yousef NadhariMansour Yousef NadhariHead of department - Consultant Head of department - Consultant Anesthesiology and Pain ManagementAnesthesiology and Pain ManagementRashid Hospital – Trauma centreRashid Hospital – Trauma centreDubai Health Authority - DUBAI – UAEDubai Health Authority - DUBAI – UAE

450 emergencies / day39 => OR < 24hC Max 100/1h8 ORs – 24/7

165 846 In to the EDSurgery = 10 434 Patients• 9630 IN • 804 OUT)Beds 620Consultations 119 574

Anaesthesiology DptConsultants = 3Seniors = 7Specialists = 28Fellows = 2Anaesth nurses = 40

Anaesthesiology DptVision - Clinical excellence- Education- Research

Missions >>>>>>>>>>>

ValueEvidence Based MedicineQuality evaluation : JCI

Anaesthesiology- OR-- ED--- Intensive cares---- Post op----- Pain Clinic

Training Center in Anesthesiology Dec 2009- RA-- Interventional Pain--- Ventilation---- TCI modes----- Airway Management

Diploma of RA 2010/2011

R & D in Anesthesiology- Clinical / Telemedicine pain management-- Animal Lab nov 2009

202 in 2011 under estimated (400)

Age 31 [0-66] Males 87% ASA 2-4 = 7%

ISS >16 = 154 / 202 patients

202 in 2011 under estimated (400)

Age 31 [0-66] Males 87% ASA 2-4 = 7%

ISS >16 = 154 / 202 patients

““Poly TraumasPoly Traumas”” in RHTC in RHTC

Ortho-trauma surgeries in 2012

4040 patients

Ortho-trauma surgeries in 2012

4040 patients

16 000 deaths/ trauma daily under estimated ( over 5 M/an).

Trauma = 9% of the total deaths

3rd mortality and 1st for 1-40 YO

Prevalence of chronic pain related to injury in trauma patients

o Up to 80% after 4 months*

o Up to 62% after 1 year**

16 000 deaths/ trauma daily under estimated ( over 5 M/an).

Trauma = 9% of the total deaths

3rd mortality and 1st for 1-40 YO

Prevalence of chronic pain related to injury in trauma patients

o Up to 80% after 4 months*

o Up to 62% after 1 year**

““TraumasTraumas”” in the world in the world

* Trevino CM J trauma 2012** Rivara FP Arch Surg 2008

RA : The evidenceRA : The evidence

• Meta analysis‣ inclusion critera :

- PNB vs opioids- Post op analgesia

‣19 articles

‣EBM = Grade A1

All papersshows

RA >Opioids

Richman J et al Anesth Analg 2006

RA : The evidenceRA : The evidence

VASScores

Max. Mean

Side effects RA Opioids Odds ratio

Nausea Vomiting 38/182 (20,9%)

95/195(48,7%)

< 0,001 0,278

Sedation 12/45(26,7%)

23/44(52,3%)

< 0,012 0,332

Pruritus 11/113(9,7%)

29/109(26,6%)

< 0,001 0,297

Sens/mot Block 22/70(31,4%)

9/60(15%)

< 0,023 0,386

RA in trauma patientsRA in trauma patients

• 30 patients• Morphine Used over 24 hours• VAS pain scores

Cooper J Journal of ortho Trauma. 2004

Cooper J Journal of Ortho Trauma. 2004

VAS and morphin consumption

RA in trauma patientsRA in trauma patients

Hip Fracture: Fascia iliaca block vs Opioid analgesia

P<0,05

Foss N anesthesiology 2007

RA in trauma patientsRA in trauma patients

Hip Fracture: Fascia iliaca block vs Opioid analgesia

Foss N anesthesiology 2007

Fascia iliaca block group:

Lower VAS scoresHigher patients's satisfactionLess side effects

Fascia iliaca block group:

Lower VAS scoresHigher patients's satisfactionLess side effects

RA in trauma patientsRA in trauma patients

• Analgesia: Femoral catheter• Anesthesiologist at the door• Nutrition program• Fluid and Oxygen • urinary only if needed

• Analgesia: opioids• Anesthesiologist pre op• Nutrition • urinary cath systematic

Pedersen SJ et al J Am Geriatr Soc. 2008

RA = rehabilitation conceptRA = rehabilitation concept

535 patients (94% > 60 yo)

Pedersen SJ et al J Am Geriatr Soc. 2008

Intensive Conventional P

Complications 20% 33% =.002

Hospitalisation 9.7 days 15.8 days <.001

12 months mortality 12% 23% =.02

RA = rehabilitation conceptRA = rehabilitation concept

535 patients (94% > 60 yo)

French Escorte study: observational study of a cohort of patients with hip fracture in 531 hospitals ( 6860 patients) during 2 months with a 6 months follow up

Rosencher N., Journal of thrombosis and haemostasis 2006

RA = rehabilitation conceptRA = rehabilitation concept

Lower risk if

GA + RA Post op rehabilitation

Lower risk if

GA + RA Post op rehabilitation

Benjamin T. Flagel et al surgery 2005 Benjamin T. Flagel et al surgery 2005

Severity of thorax trauma

RA = rehabilitation conceptRA = rehabilitation concept

Efficient Reg. analgesia:

Survival from 64% to 98% for 8+

Efficient Reg. analgesia:

Survival from 64% to 98% for 8+

VAS rest VAS cough

VEMS

PaCO2Freq Respi

Peak flow

PaO2/FiO2

SaO2

Unilateral thoracic trauma :

Significant benefits of the paravertebral block

Karmakar MK Chest 2003

RA = rehabilitation conceptRA = rehabilitation concept

Parker MJ Cochrane data base 2004

For hip fracture RA improves the post op mental status on elderly patient

RA = rehabilitation conceptRA = rehabilitation concept

Perrier V Ann. Francaise Anesth Rea 2010

For hip fracture RA improves the post op mental status on elderly patient

RA = rehabilitation conceptRA = rehabilitation concept

Mini Mental Status Exam 65 patients > 65 YO

Femoral catheter

No Femoral catheter D0 D2D1

Is "Trauma" a CI for RA ?Is "Trauma" a CI for RA ?

• 18% nerve injuries by the trauma in upper limb*

• RA not CI**

* Bounes V AFAR 2003** Horlocker TT Anesth analg 1999** Hebl J Anesth Analg 2001

Documention of neurological status prior to RA

Documention of neurological status prior to RA

RA in trauma patientsRA in trauma patients

Regional anesthesia /analgesia :

‣Better analgesia‣improves the outcome‣Part of rehabilitation concept

Regional anesthesia /analgesia :

‣Better analgesia‣improves the outcome‣Part of rehabilitation concept

When to performWhen to perform

Author Year Location

Cooper 2004 OT

Foss 2007 ED

Pedersen 2008 ED ASAP

Block on accident siteBlock on accident site

Hip Fracture 62 patients : Femoral nerve block vs Metamizol analgesia

» Schiferer A., AA 2007

Block on accident siteBlock on accident site

Hip Fracture: Femoral nerve block vs Metamizol analgesia

» Schiferer A., AA 2007

Block on accident siteBlock on accident site

In EuropeDocs in

ambulance

Femoral block by emergency doctors*

Axillary or interscalen performed by anesthesiologists**

187 blocks+ caths on the battle field***

*Lopez RAPM 2003*Goslan AFAR 2005**Lopez AFAR 2002**Lagrabette AFAR 2008***Buckenmair ASRA 2007

RA in trauma patientsRA in trauma patients

Regional anesthesia /analgesiaperformance :

‣ASAP !‣Done not only by anesthesiologists

Regional anesthesia /analgesiaperformance :

‣ASAP !‣Done not only by anesthesiologists

RA in trauma patientsRA in trauma patients

Guidelines of Performance of Regional anesthesia by non anesthesiologist physicians in ED

Edited by French society of anesthesiology and critical careSAMU France = Medical mobile unitsFrench society of emergency medicine

RA in trauma patientsRA in trauma patients

Requirements:• Equipped units for RA

• Trolley of RA, US machine, Intra lipid...

• Trained physicians for defined blocks• Superficial face blocks• Femoral • Distal blocks of Upper limb

• Trained nurses• Specific protocols and guidelines

Requirements:• Equipped units for RA

• Trolley of RA, US machine, Intra lipid...

• Trained physicians for defined blocks• Superficial face blocks• Femoral • Distal blocks of Upper limb

• Trained nurses• Specific protocols and guidelines

ConclusionConclusion

Regional anesthesia/analgesia is a part of the peri-operative medicine which starts at least in the ED for

trauma patients