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Is regional analgesia being used to its full potential? For postsurgical pain control P E R S P E C T I V E S I N A N E S T H E S I O L O G Y Broadening the value of regional analgesia So what's preventing greater use of regional block? Current regional analgesia options continue to have limitations when it comes to postsurgical pain management. As a result, physicians are forced to weigh the pros and cons of single-shot and continuous infusion blocks for each patient. 3,4 Single-shot blocks meet the anesthesiologists' goals of being simple, quick, and reliable, providing assurance that the right dose was administered to the right site and that it will last for the intended amount of time. 5 However, even when single-shot blocks are chosen, it is often necessary to supplement with opioids or continuous infusion catheters and pumps to compensate for the limited duration of current short-acting, local analgesics. As a result, associated side effects of these additional agents and modalities may undermine patient recovery. 4,6-8 Continuous infusion blocks: longer duration, bigger challenges? While continuous infusion blocks can extend the duration of blocks well into the postsurgical period, they can be burdensome on several fronts. For patients: continuous infusion blocks require the use of catheters, which can impede patient mobility due to cumbersome bags and tubing, and can increase the risk of myotoxicity, infection, and overdosing/underdosing due to device malfunction. Catheters can also migrate, dislodge, or clog, further complicating patient care. 3,6-9 For treating physicians: the use of catheters may introduce unintended variability by requiring dose adjustments while necessitating management of transient adverse events, which can contribute to insufficient pain control and interfere with postsurgical recovery. 8,10 Significant financial consideration: an associated financial burden exists for the equipment required for administration of continuous infusion blocks and postadministration monitoring, which can amount to more than $600 per patient. One must consider these costs compared with those for single-shot blocks. 7,11 What is the next level of postsurgical patient care? Despite numerous advancements in postsurgical pain management, patients have seen little or no improvement in postsurgical pain control over the past 20 years. 12 Moving forward, an ideal solution would effectively incorporate the strengths of both single-shot and continuous block options in a single therapy while minimizing their inherent risks and shortcomings: • Maintaining the simplicity of single-shot technique without opioid supplementation • Avoiding use of devices and their inherent limitations • Achieving longer-lasting effects to rival those provided by catheters and infusion devices Regional analgesia allows for pain to be targeted at its source while significantly reducing pharmacologic load, including the use of opioids. It's also been shown to offer an advantage in reducing postsurgical pain compared with general anesthesia. 1,2 As part of the commitment to improving postsurgical patient care, we must remain focused on what can be done to help ensure that regional analgesia is being used to its full potential to manage postsurgical pain. References: 1. Liu SS, Strodtbeck WM, Richman JM, Wu CL. A comparison of regional versus general anesthesia for ambulatory anesthesia: a meta-analysis of randomized controlled trials. Anesth Analg. 2005;101(6):1634-1642. 2. What is regional anesthesia? Hospital for Special Surgery. http://www.hss.edu/anesthesiology-anesthetic-techniques. asp#.VNk3GC42dVc. Accessed February 9, 2015. 3. Chelly JE, Ghisi D, Fanelli A. Continuous peripheral nerve blocks in acute pain management. Br J Anaesth. 2010;105(suppl 1):i86-i96. 4. Brummett CM, Williams BA. Additives to local anesthetics for peripheral nerve blockade. Int Anesthesiol Clin. 2011;49(4):104-116. 5. Buckenmaier III C, Bleckner L. Military Advanced Regional Anesthesia and Analgesia Handbook. Washington, DC: Broden Institute; 2008. 6. Golf M, Daniels SE, Onel E. A phase 3, randomized, placebo- controlled trial of DepoFoam ® bupivacaine (extended-release bupivacaine local analgesic) in bunionectomy. Adv Ther. 2011;28(9):776-788. 7. Bingham AE, Fu R, Horn J-L, Abrahams MS. Continuous peripheral nerve block compared with single-injection peripheral nerve block: a systemic review and meta-analysis of randomized controlled trials. Reg Anesth Pain Med. 2012;37(6):583-594. 8. Medtronic. Important safety information for drug delivery systems. http://www.medtronic.com/patients/cancer/important-safety- information/. Updated June 4, 2014. Accessed February 11, 2015. 9. Marhofer D, Marhofer P, Triffterer L, Leonhardt M, Weber M, Zeitlinger M. Dislocation rates of perineural catheters: a volunteer study. Br J Anaesth. 2013;111(5):800-806. 10. Subramaniam R, Sathappan SS. The effects of single shot versus continuous femoral nerve block on postoperative pain and rehabilitation following total knee arthroplasty. Malays Orthop J. 2010;4(1):19-25. 11. Knight KH, Brand FM, Mchaourab AS, Veneziano G. Implantable intrathecal pumps for chronic pain: highlights and updates. Croat Med J. 2007;48:22-34. 12. Gan TJ, Habib AS, Miller TE, White W, Apfelbaum JL. Incidence, patient satisfaction, and perceptions of post-surgical pain: results from a US national survey [published online November 15, 2013]. Curr Med Res Opin. 2014;30(1):149-160. doi:10.1185/03007995.2013.860019. Dragan Gastevski, MD Anesthesiology, Pain Medicine Chicago, IL ©2015 Pacira Pharmaceuticals, Inc. Parsippany, NJ 07054 PP-EX-US-0631 02/15 A D V E R T O R I A L