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Regional Anesthesia/analgesia in trauma patients?

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 < 24h C Max 100/1h 8 ORs – 24/7.

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Regional Anesthesia/analgesia in trauma patients?

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  1. 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

  2. 450 emergencies / day 39 => OR < 24h C Max 100/1h 8 ORs – 24/7

  3. 165 846 In to the ED • Surgery = 10 434 Patients • 9630 IN • 804 OUT) • Beds 620 • Consultations 119 574

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

  5. Anaesthesiology • OR • - ED • -- Intensive cares • --- Post op • ---- Pain Clinic • Anaesthesiology Dpt • Vision • Clinical excellence • Education • Research • Missions >>>>>>>>>>> • Value • Evidence Based Medicine • Quality evaluation : JCI • 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

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

  7. “Traumas” in the world • 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 • Up to 80% after 4 months* • Up to 62% after 1 year** * Trevino CM J trauma 2012 ** Rivara FP Arch Surg 2008

  8. RA : The evidence • Meta analysis • inclusion critera : • PNB vs opioids • Post op analgesia • 19 articles • EBM = Grade A1 RA > Opioids All papers shows Richman J et al Anesth Analg 2006

  9. RA : The evidence Max. Mean VAS Scores

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

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

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

  13. 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

  14. RA = rehabilitation concept 535 patients (94% > 60 yo) • 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

  15. RA = rehabilitation concept 535 patients (94% > 60 yo) Pedersen SJ et al J Am Geriatr Soc. 2008

  16. 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

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

  18. VEMS PaCO2 Freq Respi Peak flow PaO2/FiO2 SaO2 RA = rehabilitation concept Unilateral thoracic trauma : Significant benefits of the paravertebral block VAS rest VAS cough Karmakar MK Chest 2003

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

  20. 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 D0 D1 D2 Perrier V Ann. Francaise Anesth Rea 2010

  21. 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

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

  23. When to perform

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

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

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

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

  28. 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 SAMU France = Medical mobile units French society of emergency medicine

  29. 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

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

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