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April 1, 2013 Volume 77, Number 4
Regional Anesthesia and Analgesia for Trauma Patients Stavros G. Memtsoudis, M.D., Ph.D.

Ottokar Stundner, M.D.



Regional anesthetic and analgesic techniques are increasingly recognized as valuable interventions outside of the traditional perioperative arena and elective surgical settings, including in critically ill and acute trauma patients.1,2 Despite a paucity of literature on the subject, this expansion of use makes intuitive sense, as the potential benefits of regional anesthesia and pain management may prove especially beneficial in the trauma population. In this context – the relative lack of central nervous system effects – regional techniques may have a positive impact on respiratory function, avoid cardiovascular derangements, facilitate the evaluation of a patient’s cognitive status, and perhaps even improve the ability of patients to tolerate bedside procedures and rehabilitative measures in this often tenuous patient population. Moreover, traditional, systemic analgesic management is often not sufficient to control often intense levels of pain associated with severe trauma.3

Barring contraindications and given availability of adequately trained personnel, regional techniques could not only be applied during the preparation for surgery but also as early as in the emergency room or in a pre-clinical setting.

Many reports of successful utilization of regional anesthesia in trauma patients originate from military medicine, where nerve blocks with or without insertion of a catheter were successfully utilized to facilitate evacuation of victims from war zones.4,5 Indications in civilian medicine studies thus far include, but are not limited to, hip fractures,6,7 femur fractures,8,9 knee injuries,10 leg, ankle and foot injuries,11 upper-limb fractures12,13 and shoulder dislocations.14,15 After thoracic trauma and multiple rib fractures, adequate analgesia is critical to alleviate pain associated with breathing, subsequently improving the patient’s ventilatory mechanics and possibly averting the need for intubation or shortening the period of mechanical respirator support. Thoracic epidural analgesia,16 thoracic paravertebral analgesia,17,18 continuous intercostal nerve block,19-21 and other methods have proven safe and effective for this purpose. Further, regional analgesic techniques may reduce the need for excessive sedation of patients on ventilators and facilitate modern practices of frequent periods of wakefulness and neurologic assessments.

Despite the enthusiasm regarding advantages of regional analgesic techniques in trauma, one has to keep in mind that outcome studies remain rare and the questions of whether regional techniques can decrease complications has not yet been answered conclusively. However, given the fact that trauma patients may represent a population at high risk for adverse events, it may also be a prime target population to evaluate and show benefit in clinical studies.

A number of factors should be considered before deliberating regional analgesic and anesthetic techniques in trauma patients. First, not all injury patterns can be readily treated with neuraxial techniques or nerve blocks, and not all nerve blocks lend themselves to utilization in this group of patients.2 For instance, complex peripheral nerve blocks might not be feasible in situations where time is critical. Moreover, regional techniques are not void of side effects and complications, including hypotension in the case of neuraxial techniques and near-cord nerve blocks, potential for spinal cord or peripheral nerve injury, hemorrhage and local anesthetic systemic toxicity.22 Coagulopathies, which are not uncommon in trauma victims requiring extensive resuscitation, carry the risk of prolonged bleeding, hematoma formation and related nerve damage. Guidelines addressing the safety of performance of regional anesthesia in this group of patients are available23 but largely limited to expert opinion and small-scale studies, and thus the final decision remains subject to critical weighing of benefits and risks on a case-by-case basis. Other comorbidities warranting a conservative approach toward regional anesthesia include infection and immune-compromise. Dreaded complications of these conditions include spread and colonization of microorganisms leading to meningitis, epidural abscess or localized infections at the puncture site.24,25 Furthermore, some regional techniques have traditionally been considered contraindicated for fear of the potential to disguise motor deficits and pain as a warning sign of compartment syndrome. However, the same issue has also been raised in patients receiving controlled intravenous analgesia. In a recent systematic review, regional analgesia was not associated with delays in treatment of compartment syndrome. A high level of clinical suspicion as well as utilization of tissue pressure monitoring was recommended.26 Finally, experienced and trained staff is required in order to adequately select patients and safely and efficiently perform regional blocks in an acute trauma setting.

Despite recent findings that promote the safe use of numerous regional and neuraxial techniques in many acutely traumatized patients, experience is largely limited to single case reports and small observational studies. Thus, more research is necessary in order to convince (especially non-anesthesiology) physicians of the important role that the use of regional anesthetic techniques can play in the treatment of trauma patients. While the focus should be on clinical outcomes primarily, the economic impact of these interventions should be critically examined and extended beyond the traditional perioperative scope, as long-term outcomes such as reduction of phantom limb pain in cases of traumatic amputation and its associated costs may be affected. Such evaluation may require the design of multicenter studies in order to achieve adequate sample sizes in the setting of large heterogeneity among the trauma population and in order to allow for the drawing of adequate conclusions. Nevertheless, such extensive efforts may represent a rare and important opportunity to further establish the anesthesiologist’s role outside the operating room and potentially provide evidence of the impact of regional anesthetic and analgesic interventions on patient outcome in trauma patients.

In conclusion, given adequate patient selection and availability of resources, regional analgesia and anesthesia may prove to be a major factor in an attempt to improve the care of trauma patients. Further, systematic research is warranted to clarify its role and impact.



Stavros G. Memtsoudis, M.D., Ph.D. is Clinical Professor of Anesthesiology and Public Health Director, Critical Care Services, Hospital for Special Surgery-Weill Cornell Medical College, New York, New York.

Ottokar Stundner, M.D. is a resident and Research Fellow, Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria, and Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York.


References
1.  Stundner O, Memtsoudis SG. Regional anesthesia and analgesia in critically ill patients: a systematic review. Reg Anesth Pain Med. 2012;37(5):537-544.
2. Wu JJ, Lollo L, Grabinsky A. Regional anesthesia in trauma medicine. Anesthesiol Res Pract. 2011;2011:713281.
3.  Abou-Setta AM, Beaupre LA, Rashiq S, et al. Comparative effectiveness of pain management interventions for hip fracture: a systematic review. Ann Intern Med. 2011;155(4):234-245.
4. Malchow RJ, Black IH. The evolution of pain management in the critically ill trauma patient: Emerging concepts from the global war on terrorism. Crit Care Med. 2008;36(7 suppl):S346-S357.
5. Buckenmaier CC,3rd, Rupprecht C, McKnight G, et al. Pain following battlefield injury and evacuation: a survey of 110 casualties from the wars in Iraq and Afghanistan. Pain Med. 2009;10(8):1487-1496.
6. Foss NB, Kristensen BB, Bundgaard M, et al. Fascia iliaca compartment blockade for acute pain control in hip fracture patients: a randomized, placebo-controlled trial. Anesthesiology. 2007;106(4):773-778.
7. Beaudoin FL, Nagdev A, Merchant RC, Becker BM. Ultrasound-guided femoral nerve blocks in elderly patients with hip fractures. Am J Emerg Med. 2010;28(1):76-81.
8. Mutty CE, Jensen EJ, Manka MA,Jr, Anders MJ, Bone LB. Femoral nerve block for diaphyseal and distal femoral fractures in the emergency department. J Bone Joint Surg Am. 2007;89(12):2599-2603.
9. Elkhodair S, Mortazavi J, Chester A, Pereira M. Single fascia iliaca compartment block for pain relief in patients with fractured neck of femur in the emergency department: a pilot study. Eur J Emerg Med. 2011;18(6):340-343.
10. Barker R, Schiferer A, Gore C, et al. Femoral nerve blockade administered preclinically for pain relief in severe knee trauma is more feasible and effective than intravenous metamizole: a randomized controlled trial. J Trauma. 2008;64(6):1535-1538.
For a complete list of references, please refer to the back of the online version of the ASA NEWSLETTER at asahq.org or email communications@asahq.org.