Regional Anesthesiaanalgesia in trauma patients Mansour Yousef Nadhari

Regional Anesthesia/analgesia in trauma patients? Mansour Yousef Nadhari Head of department - Consultant Anesthesiology and Pain Management Rashid Hospital – Trauma centre Dubai Health Authority - DUBAI – UAE

450 emergencies / day 39 => OR < 24 h C Max 100/1 h 8 ORs – 24/7

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

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

Anaesthesiology Dpt Vision - Clinical excellence - Education - Research Missions >>>>>> Value Evidence Based Medicine Quality 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

“Poly Traumas” in RHTC q 202 in 2011 under estimated (400) q Age 31 [0 -66] Males 87% ASA 2 -4 = 7% q ISS >16 = 154 / 202 patients Ortho-trauma surgeries in 2012 4040 patients

“Traumas” in the world q 16 000 deaths/ trauma daily under estimated ( over 5 M/an). q Trauma = 9% of the total deaths q 3 rd mortality and 1 st for 1 -40 YO q Prevalence of chronic pain related to injury in trauma patients o Up to 80% after 4 months* o Up to 62% after 1 year** * Trevino CM J trauma 2012 ** Rivara FP Arch Surg 2008

RA : The evidence • Meta analysis ‣ inclusion critera : - PNB vs opioids - Post op analgesia ‣ 19 articles ‣EBM = Grade A 1 Richman J et al Anesth Analg 2006 All papers shows RA > Opioids

RA : The evidence Max. Mean VAS Scores Side effects RA Nausea Vomiting 38/182 (20, 9%) Sedation 12/45 (26, 7%) Pruritus 11/113 (9, 7%) Sens/mot Block 22/70 (31, 4%) Odds ratio Opioids 95/195 (48, 7%) 23/44 (52, 3%) 29/109 (26, 6%) 9/60 (15%) < 0, 001 0, 278 < 0, 012 0, 332 < 0, 001 0, 297 < 0, 023 0, 386

RA in trauma patients • 30 patients • Morphine Used over 24 hours • VAS pain scores Cooper J Journal of ortho Trauma. 2004

RA in trauma patients VAS and morphin consumption Cooper J Journal of Ortho Trauma. 2004

RA in trauma patients Hip Fracture: Fascia iliaca block vs Opioid analgesia P<0, 05 Foss N anesthesiology 2007

RA in trauma patients Hip Fracture: Fascia iliaca block vs Opioid analgesia Fascia iliaca block group: Lower VAS scores Higher patients's satisfaction Less side effects Foss N anesthesiology 2007

RA = rehabilitation concept 535 patients (94% > 60 yo) • Analgesia: Femoral catheter • Anesthesiologist at the door • Nutrition program • Fluid and Oxygen • urinary only if needed Pedersen SJ et al J Am Geriatr Soc. 2008 • Analgesia: opioids • Anesthesiologist pre op • Nutrition • urinary cath systematic

RA = rehabilitation concept 535 patients (94% > 60 yo) Intensive Conventional P Complications 20% 33% =. 002 Hospitalisation 9. 7 days 15. 8 days <. 001 12 months mortality 12% 23% =. 02 Pedersen SJ et al J Am Geriatr Soc. 2008

RA = rehabilitation concept 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 Lower risk if GA + RA Post op rehabilitation Rosencher N. , Journal of thrombosis and haemostasis 2006

RA = rehabilitation concept Severity of thorax trauma Efficient Reg. analgesia: Survival from 64% to 98% for 8+ Benjamin T. Flagel et al surgery 2005

RA = rehabilitation concept Unilateral thoracic trauma : VEMS Peak flow Significant benefits of the paravertebral block VAS rest VAS cough Freq Respi Pa. CO 2 Pa. O 2/Fi. O 2 Sa. O 2 Karmakar MK Chest 2003

RA = rehabilitation concept For hip fracture RA improves the post op mental status on elderly patient Parker MJ Cochrane data base 2004

RA = rehabilitation concept For hip fracture RA improves the post op mental status on elderly patient Mini Mental Status Exam 65 patients > 65 YO Femoral catheter No Femoral catheter Perrier V Ann. Francaise Anesth Rea 2010 D 1 D 2

Is "Trauma" a CI for RA ? • • 18% nerve injuries by the trauma in upper limb* RA not CI** Documention of neurological status prior to RA * Bounes V AFAR 2003 ** Horlocker TT Anesth analg 1999 ** Hebl J Anesth Analg 2001

RA in trauma patients Regional anesthesia /analgesia : ‣Better analgesia ‣improves the outcome ‣Part of rehabilitation concept

When to perform Author Year Location Cooper 2004 OT Foss 2007 ED Pedersen 2008 ED ASAP

Block on accident site Hip Fracture 62 patients : Femoral nerve block vs Metamizol analgesia » Schiferer A. , AA 2007

Block on accident site Hip Fracture: Femoral nerve block vs Metamizol analgesia » Schiferer A. , AA 2007

Block on accident site Femoral block by emergency doctors* Axillary or interscalen performed by anesthesiologists** 187 blocks+ caths on the battle field*** In Europe *Lopez RAPM 2003 *Goslan AFAR 2005 **Lopez AFAR 2002 **Lagrabette AFAR 2008 ***Buckenmair ASRA 2007 Docs in ambulance

RA in trauma patients Regional anesthesia /analgesia performance : ‣ASAP ! ‣Done not only by anesthesiologists

RA in trauma patients Guidelines of Performance of Regional anesthesia by non anesthesiologist physicians in ED Edited by French society of anesthesiology and critical care

RA 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

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