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Regional Anaesthesia Techniques for Pain Control in Critically Ill Patients

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Critical Care Sedation

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Abstract

The pathophysiologic origins of pain in critically ill patients can be explained by several mechanisms. Invasive procedures, surgeries, trauma, inflammation, pre-existing chronic pain condition and immobility represent possible sources of pain in this clinical setting. Pain affects all body systems through neurohormonal mechanisms, catecholamine and inflammatory mediators release and the resulting general stress response. Sympathetic activation together with inflammatory response may have negative effects on the cardiovascular and renal systems. Pain can also lead to immune system dysfunction, hypercoagulable states and disrupted sleep quality. Accordingly, pain control is essential for reducing the aforementioned complications. A satisfactory analgesia is also critical to alleviate pain associated with breathing in patients with thoracic trauma, improving patient ventilator synchrony and facilitating ventilator weaning. A multidisciplinary approach to pain management should include both pharmacological and non-pharmacological interventions. Regional anaesthesia has become valuable for the treatment of pain during and after a wide range of surgical and invasive painful procedures at the bedside. The benefits provided by the implementation of regional anaesthesia are several: anti-inflammatory and antithrombotic effects, improvement of gastrointestinal/hepatic microcirculation and enhancement in respiratory function. Furthermore, the use of regional analgesic techniques allows the maintenance of analgesia without the need of systemic agents, thus reducing opioid use and its side effects. However, regional anaesthesia encounters special challenges when performed in critically ill patients (e.g. coagulopathies, infections, sedation). Ultrasound guidance during nerve blockade has brought important changes in this field.

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References

  1. Clark F, Gilbert HC. Regional analgesia in the intensive care unit. Principles and practice. Crit Care Clin. 2001;17(4):943–66.

    Article  CAS  PubMed  Google Scholar 

  2. Hannibal KE, Bishop MD. Chronic stress, cortisol dysfunction, and pain: a psychoneuroendocrine rationale for stress management in pain rehabilitation. Phys Ther. 2014;94(12):1816–25. https://doi.org/10.2522/ptj.20130597.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Richardson J, Sabanathan S, Shah R. Post-thoracotomy spirometric lung function: the effect of analgesia. A review. J Cardiovasc Surg (Torino). 1999;40(3):445–56.

    CAS  Google Scholar 

  4. Lindenbaum L, Milia DJ. Pain management in the ICU. Surg Clin North Am. 2012;92(6):1621–36. https://doi.org/10.1016/j.suc.2012.08.013.

    Article  PubMed  Google Scholar 

  5. Carrier FM, Turgeon AF, Nicole PC, Trepanier CA, Fergusson DA, Thauvette D, et al. Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials. Can J Anaesth. 2009;56(3):230–42. https://doi.org/10.1007/s12630-009-9052-7.

    Article  PubMed  Google Scholar 

  6. Freise H, Lauer S, Konietzny E, Hinkelmann J, Minin E, Van Aken HK, et al. Hepatic effects of thoracic epidural analgesia in experimental severe acute pancreatitis. Anesthesiology. 2009;111(6):1249–56. https://doi.org/10.1097/ALN.0b013e3181c1494e.

    Article  CAS  PubMed  Google Scholar 

  7. Petrini F, Accorsi A, Adrario E, Agro F, Amicucci G, Antonelli M, et al. Recommendations for airway control and difficult airway management. Minerva Anestesiol. 2005;71(11):617–57.

    CAS  PubMed  Google Scholar 

  8. Law JA, Broemling N, Cooper RM, Drolet P, Duggan LV, Griesdale DE, et al. The difficult airway with recommendations for management-part 2-the anticipated difficult airway. Can J Anaesth. 2013;60(11):1119–38. https://doi.org/10.1007/s12630-013-0020-x.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Enterlein G, Byhahn C, American Society of Anesthesiologists Task F. Practice guidelines for management of the difficult airway: update by the American society of anesthesiologists task force. Anaesthesist. 2013;62(10):832–5. https://doi.org/10.1007/s00101-013-2222-6.

    Article  CAS  PubMed  Google Scholar 

  10. Joshi GP, Bonnet F, Shah R, Wilkinson RC, Camu F, Fischer B, et al. A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia. Anesth Analg. 2008;107(3):1026–40. https://doi.org/10.1213/01.ane.0000333274.63501.ff.

    Article  CAS  PubMed  Google Scholar 

  11. Bulger EM, Edwards T, Klotz P, Jurkovich GJ. Epidural analgesia improves outcome after multiple rib fractures. Surgery. 2004;136(2):426–30. https://doi.org/10.1016/j.surg.2004.05.019.

    Article  PubMed  Google Scholar 

  12. Gauss A, Jahn SK, Eberhart LH, Stahl W, Rockemann M, Georgieff M, et al. Cardioprotection by thoracic epidural anesthesia? : meta-analysis. Anaesthesist. 2011;60(10):950–62. https://doi.org/10.1007/s00101-011-1941-9.

    Article  CAS  PubMed  Google Scholar 

  13. Nygard E, Kofoed KF, Freiberg J, Holm S, Aldershvile J, Eliasen K, et al. Effects of high thoracic epidural analgesia on myocardial blood flow in patients with ischemic heart disease. Circulation. 2005;111(17):2165–70. https://doi.org/10.1161/01.CIR.0000163551.33812.1A.

    Article  CAS  PubMed  Google Scholar 

  14. Beattie WS, Badner NH, Choi PT. Meta-analysis demonstrates statistically significant reduction in postoperative myocardial infarction with the use of thoracic epidural analgesia. Anesth Analg. 2003;97(3):919–20.

    Article  PubMed  Google Scholar 

  15. Lu CH, Chen JL, Wu CT, Liaw WJ, Yeh CC, Cherng CH, et al. Effect of epidural neuraxial blockade-dependent sedation on the Ramsay sedation scale and the composite auditory evoked potentials index in surgical intensive care patients. J Formos Med Assoc. 2010;109(8):589–95. https://doi.org/10.1016/S0929-6646(10)60096-4.

    Article  PubMed  Google Scholar 

  16. Hollmann MW, Durieux ME. Local anesthetics and the inflammatory response: a new therapeutic indication? Anesthesiology. 2000;93(3):858–75.

    Article  CAS  PubMed  Google Scholar 

  17. Freise H, Daudel F, Grosserichter C, Lauer S, Hinkelmann J, Van Aken HK, et al. Thoracic epidural anesthesia reverses sepsis-induced hepatic hyperperfusion and reduces leukocyte adhesion in septic rats. Crit Care. 2009;13(4):R116. https://doi.org/10.1186/cc7965.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Schaper J, Ahmed R, Perschel FH, Schafer M, Habazettl H, Welte M. Thoracic epidural anesthesia attenuates endotoxin-induced impairment of gastrointestinal organ perfusion. Anesthesiology. 2010;113(1):126–33. https://doi.org/10.1097/ALN.0b013e3181de0fdd.

    Article  PubMed  Google Scholar 

  19. Nishimori M, Ballantyne JC, Low JH. Epidural pain relief versus systemic opioid-based pain relief for abdominal aortic surgery. Cochrane Database Syst Rev. 2006;3:CD005059. https://doi.org/10.1002/14651858.CD005059.pub2.

    Google Scholar 

  20. Werawatganon T, Charuluxanun S. Patient controlled intravenous opioid analgesia versus continuous epidural analgesia for pain after intra-abdominal surgery. Cochrane Database Syst Rev. 2005;1:CD004088. https://doi.org/10.1002/14651858.CD004088.pub2.

    Google Scholar 

  21. Guay J, Kopp S. Epidural pain relief versus systemic opioid-based pain relief for abdominal aortic surgery. Cochrane Database Syst Rev. 2016;1:CD005059. https://doi.org/10.1002/14651858.CD005059.pub4.

    Google Scholar 

  22. Choi PT, Bhandari M, Scott J, Douketis J. Epidural analgesia for pain relief following hip or knee replacement. Cochrane Database Syst Rev. 2003;3:CD003071. https://doi.org/10.1002/14651858.CD003071.

    Google Scholar 

  23. Nishimori M, Low JH, Zheng H, Ballantyne JC. Epidural pain relief versus systemic opioid-based pain relief for abdominal aortic surgery. Cochrane Database Syst Rev. 2012;7:CD005059. https://doi.org/10.1002/14651858.CD005059.pub3.

    Google Scholar 

  24. Horlocker TT, Wedel DJ, Rowlingson JC, Enneking FK, Kopp SL, Benzon HT, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American society of regional anesthesia and pain medicine evidence-based guidelines (third edition). Reg Anesth Pain Med. 2010;35(1):64–101.

    Article  CAS  PubMed  Google Scholar 

  25. Gogarten W. The influence of new antithrombotic drugs on regional anesthesia. Curr Opin Anaesthesiol. 2006;19(5):545–50. https://doi.org/10.1097/01.aco.0000245282.45529.b0.

    Article  PubMed  Google Scholar 

  26. Harrop-Griffiths W, Cook T, Gill H, Hill D. Regional anaesthesia and patients with abnormalities of coagulation: the association of anaesthetists of Great Britain & Ireland the obstetric anaesthetists’ association regional anaesthesia UK. Anaesthesia. 2013;68(9):966–72. https://doi.org/10.1111/anae.12359.

    Article  Google Scholar 

  27. Batra RK, Krishnan K, Agarwal A. Paravertebral block. J Anaesthesiol Clin Pharmacol. 2011;27(1):5–11.

    PubMed  PubMed Central  Google Scholar 

  28. Truitt MS, Murry J, Amos J, Lorenzo M, Mangram A, Dunn E, et al. Continuous intercostal nerve blockade for rib fractures: ready for primetime? J Trauma. 2011;71(6):1548–1552.; discussion 52. https://doi.org/10.1097/TA.0b013e31823c96e0.

    PubMed  Google Scholar 

  29. Rafi AN. Abdominal field block: a new approach via the lumbar triangle. Anaesthesia. 2001;56(10):1024–6.

    Article  CAS  PubMed  Google Scholar 

  30. Milan Z, Tabor D, McConnell P, Pickering J, Kocarev M, du Feu F, et al. Three different approaches to Transversus abdominis plane block: a cadaveric study. Med Glas. 2011;8(2):181–4.

    Google Scholar 

  31. Abdallah FW, Laffey JG, Halpern SH, Brull R. Duration of analgesic effectiveness after the posterior and lateral transversus abdominis plane block techniques for transverse lower abdominal incisions: a meta-analysis. Br J Anaesth. 2013;111(5):721–35. https://doi.org/10.1093/bja/aet214.

    Article  CAS  PubMed  Google Scholar 

  32. Brogi E, Kazan R, Cyr S, Giunta F, Hemmerling TM. Transversus abdominal plane block for postoperative analgesia: a systematic review and meta-analysis of randomized-controlled trials. Can J Anaesth. 2016;63(10):1184–96. https://doi.org/10.1007/s12630-016-0679-x.

    Article  PubMed  Google Scholar 

  33. Johns N, O'Neill S, Ventham NT, Barron F, Brady RR, Daniel T. Clinical effectiveness of transversus abdominis plane (TAP) block in abdominal surgery: a systematic review and meta-analysis. Colorectal Dis. 2012;14(10):e635–42. https://doi.org/10.1111/j.1463-1318.2012.03104.x.

    Article  CAS  PubMed  Google Scholar 

  34. Mishriky BM, George RB, Habib AS. Transversus abdominis plane block for analgesia after Cesarean delivery: a systematic review and meta-analysis. Can J Anaesth. 2012;59(8):766–78. https://doi.org/10.1007/s12630-012-9729-1.

    Article  PubMed  Google Scholar 

  35. Fredrickson MJ, Paine C, Hamill J. Improved analgesia with the ilioinguinal block compared to the transversus abdominis plane block after pediatric inguinal surgery: a prospective randomized trial. Paediatr Anaesth. 2010;20(11):1022–7. https://doi.org/10.1111/j.1460-9592.2010.03432.x.

    Article  PubMed  Google Scholar 

  36. Bingham AE, Fu R, Horn JL, Abrahams MS. Continuous peripheral nerve block compared with single-injection peripheral nerve block: a systematic review and meta-analysis of randomized controlled trials. Reg Anesth Pain Med. 2012;37(6):583–94. https://doi.org/10.1097/AAP.0b013e31826c351b.

    Article  CAS  PubMed  Google Scholar 

  37. Wu JJ, Lollo L, Grabinsky A. Regional anesthesia in trauma medicine. Anesthesiol Res Pract. 2011;2011:713281. https://doi.org/10.1155/2011/713281.

    PubMed  PubMed Central  Google Scholar 

  38. Mar GJ, Barrington MJ, McGuirk BR. Acute compartment syndrome of the lower limb and the effect of postoperative analgesia on diagnosis. Br J Anaesth. 2009;102(1):3–11. https://doi.org/10.1093/bja/aen330.

    Article  CAS  PubMed  Google Scholar 

  39. Neal JM, Barrington MJ, Brull R, Hadzic A, Hebl JR, Horlocker TT, et al. The second ASRA practice advisory on neurologic complications associated with regional anesthesia and pain medicine: executive summary 2015. Reg Anesth Pain Med. 2015;40(5):401–30. https://doi.org/10.1097/AAP.0000000000000286.

    Article  CAS  PubMed  Google Scholar 

  40. Ihnatsenka B, Boezaart AP. Ultrasound: basic understanding and learning the language. Int J Shoulder Surg. 2010;4(3):55–62. https://doi.org/10.4103/0973-6042.76960.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Geng J, Chen XL, Wang XD, Guo XY, Li M. Ultrasound imaging increases first-attempt success rate of neuraxial block in elderly patients. Zhonghua Yi Xue Za Zhi. 2016;96(43):3459–63. https://doi.org/10.3760/cma.j.issn.0376-2491.2016.43.004.

    CAS  PubMed  Google Scholar 

  42. Perlas A, Chaparro LE, Chin KJ. Lumbar neuraxial ultrasound for spinal and epidural anesthesia: a systematic review and meta-analysis. Reg Anesth Pain Med. 2016;41(2):251–60. https://doi.org/10.1097/AAP.0000000000000184.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Anaesthesia and Intensive Care, University of Pisa, Pisa, Italy

    Francesco Forfori & Etrusca Brogi

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  1. Francesco Forfori
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  2. Etrusca Brogi
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Correspondence to Francesco Forfori .

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  1. Department of Anesthesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy

    Angelo Raffaele De Gaudio

  2. Department of Anesthesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy

    Stefano Romagnoli

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Forfori, F., Brogi, E. (2018). Regional Anaesthesia Techniques for Pain Control in Critically Ill Patients. In: De Gaudio, A., Romagnoli, S. (eds) Critical Care Sedation. Springer, Cham. https://doi.org/10.1007/978-3-319-59312-8_8

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  • DOI: https://doi.org/10.1007/978-3-319-59312-8_8

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