Intensive care specialists play increasingly greater role in the prevention and treatment of physiologic and psychological stress in critically ill patients in order to prevent detrimental consequences ranging from systemic inflammatory response syndrome, to cardiac complications, to posttraumatic stress disorder. Studies have addressed the questions of an optimal sedation regimen, and several evidence-based guidelines and strategies have been published but are frequently not followed. The analgesic component for sufficient stress relief, however, has not been addressed extensively, and few recommendations, primarily based on individual clinical practices, are currently available.
In view of the side effects of opioids, especially respiratory depression, altered mental status, and reduced bowel function, regional analgesia utilizing neuraxial and peripheral nerve blocks offer significant advantages. The lack of a universally reliable pain assessment tool (“analgesiometer”) in the critically ill contributes to the dilemma of adequate analgesia. Many patients in the critical care unit are not able to communicate or use a conventional visual or numeric analog scale to quantify pain. Alternative assessment tools derived from pediatric or geriatric practice that rely on grimacing and other physiologic responses to painful stimuli might be useful but have been inadequately studied in the intensive care unit (ICU). Changes in heart rate and blood pressure in response to nursing activities, dressing changes, or wound care can also serve as indirect measurements of pain, and sedation measures like the Ramsay Sedation Scale or the Riker Sedation-Agitation Scale scale might be helpful although not specifically designed for pain assessment.
The objective of this chapter is to describe the indications, limitations, and practical aspects of continuous regional analgesic techniques in the critically ill based on the available evidence, which at the moment is limited to case reports, cohort studies, expert opinion, and extrapolation from studies looking primarily at the intraoperative use of regional anesthesia extending into the postoperative ICU stay as summarized in a 2012 systematic review in Regional Anesthesia Pain Medicine by Stundner and Memtsoudis who conclude, “Regional anesthesia can be useful in the management of a large variety of conditions and procedures in critically ill patients. Although the attributes of regional anesthetic techniques could feasibly affect outcomes, no conclusive evidence supporting this assumption exists to date, and further research is needed to elucidate this entity.”
Epidural analgesia is probably the most commonly used regional analgesic technique in the ICU setting. Some indications in which epidural analgesia may not improve mortality rates but may facilitate management and improve patient comfort in the ICU include chest trauma, thoracic and abdominal surgery, major vascular surgery, major orthopedic surgery, acute pancreatits, paralytic ileus, cardiac surgery, and intractable angina pain. Although high-risk patients seem to profit most from epidural analgesia, the current literature does not address the specific circumstances of the critically ill patient with multiple comorbidities and organ failure. For that reason, an individual approach is necessary when considering the application of epidural analgesia in this population.
In a survey of 216 general ICUs in England, Low found that 89% of the responding units used epidural analgesia, but only 32% had a written policy governing its use. Although 68% of the responding units would not place an epidural catheter in a patient with positive blood cultures, only 52% considered culture-negative sepsis or systemic inflammatory response syndrome (SIRS) to be a contraindication. The majority of respondents did not list lack of consent or the need for anticoagulation after catheter placement as contraindications to the insertion of an epidural catheter. Although the issues of consent, possible coagulopathy, and infection can be addressed rather easily in elective procedures, they become major problems in newly admitted patients; for example, those with multiple trauma or painful intraabdominal processes, especially acute pancreatitis. There is also controversy regarding the safety of placing epidural catheters in sedated patients, and confirmation of a good catheter position can be difficult in the critically ill patient if sensory level testing is not reliable.
Positioning the patient for the procedure may be difficult depending on the underlying injury, the number and position of drains and catheters, and the presence of external fixation devices. Table 1 summarizes the indications, contraindications, and practical problems involved with the placement of epidural catheters.
The help of trained nursing staff is essential for good positioning and safe handling of tubes and catheters during the procedure. Maximum barrier precautions, similar to those used in the placement of central lines, should also be considered when placing epidural catheters in the critically ill. Tunneling the catheter should be considered to prevent dislocation and reduce the risk of catheter site infection. To confirm the correct position of the epidural catheter, electrical stimulation during placement or a postplacement radiograph with a small amount of non-neurotoxic contrast medium may be beneficial. Learn more about Infection Control in Regional Anesthesia.
Bolus injections of long-acting local anesthetics, such as bupivacaine, ropivacaine, or levobupivacaine, or the discontinuation of continuous infusion as needed will allow neurologic assessment when necessary. Monitoring of motor-evoked potentials (MEPs) to the lower extremities and somatosensory-evoked potentials (SSEPs) of the tibial nerve may serve as indicators when the neurologic examination is doubtful due to the patient’s altered mental status. Although routinely used in the operating room for monitoring spinal cord integrity and for the diagnosis and prognosis of spinal cord injury, the use of this technology in the ICU in the context of epidural analgesia has not been adequately assessed.
The most common side effects of epidural blocks are bradycardia and hypotension related to sympathetic block. Hemodynamic changes can be more pronounced with intermittent bolus dosing, in patients with hypovolemia, and in those with reduced venous return secondary to high positive end-expiratory pressure (PEEP) ventilation.
TABLE 1. Epidural analgesia in the Critically Ill.
|Indications||Contraindications||Practical Problems||Dose Suggestions|
|Chest trauma||Coagulopathy or current use of anticoagulants during catheter placement and removal61,62||Positioning of patient||Bolus regimen:|
|Thoracic surgery||Monitoring of neurologic function (consider MEP/SSEP)||5–10 mL 0.125–0.25%
bupivacaine or 0.1–0.2%
ropivacaine q 8–12 h
|Paralytic ileus||Consider addition of 1–2 meg
clonidine in hemodynamically
|Intractable angina||Local infection at puncture site|
or trauma of lower
|Severe hypovolemia||Continuous infusion:|
|Acute hemodynamic instability||0.0625% bupivacaine or 0.1%
ropivacaine at 5 mL/h
disease of lower
|Obstructive ileus||Consider addition of opioids (eg,
or clonidine if high systemic
opioid demands persist
Based on data from lumbar punctures and meningitis from the beginning of the twentieth century, current sepsis and bacteremia are considered contraindications for intrathecal opioid applications and, by analogy, for the placement of an epidural catheter. However, many ICU patients, especially after trauma or major surgery, present with a clinical picture of SIRS. Fever and increased white blood cell count alone, that is, in the absence of positive blood cultures, do not provide a reliable diagnosis of bacteremia.
The combination of the serum markers C-reactive protein (CRP), procalcitonin, and interleukin-6, on the other hand, have been shown to indicate bacterial sepsis with a high degree of sensitivity and specificity and can guide the decision to place an epidural catheter. Regarding the patient’s coagulation status, the current recommendations of the American Society of Regional Anesthesia and Pain Medicine (ASRA) should be followed. Adequate safety intervals during the administration of anticoagulant drugs are equally important for the placement and removal of epidural catheters. Although there is no compelling evidence of an increased risk of epidural bleeding with developing coagulopathy or therapeutic anticoagulation while an epidural catheter is in place, the benefits of epidural analgesia should be weighed against this potential, highly detrimental complication. This risk might lead to increased utilization of paravertebral blocks, as described in a U.K. survey of elective thoracic surgery. However, Luvet and colleagues have described a high misplacement rate of paravertebral catheters using the landmark technique and a discrepancy between contrast medium spread and loss of sensation, which makes an assessment of the effectiveness of this technique in the sedated critically ill patient very difficult.
In a small cohort study of 153 thoracic and 4 lumbar epidurals in critically ill patients, we could not identify an increased complication risk compared to the reference databank. However, the duration of catheter use was significantly longer (mean 5 days, range 1–21 days) in the critically ill group.
- The most common side effects of epidural blocks are bradycardia and hypotension related to sympathetic block.
- Hemodynamic changes can be more pronounced with intermittent bolus dosing, in patients with hypovolemia, or in patients with reduced venous return secondary to high positive end-expiratory pressure ventilation.
- Discontinuation of continuous infusion allows neurologic assessment when necessary.
- There is no hard evidence that there is increased risks of epidural bleeding with developing coagulopathy or therapeutic anticoagulation while an epidural catheter is in place. Nevertheless, the benefits of epidural analgesia should be weighed against the risk of this serious complication.
PERIPHERAL NERVE BLOCKS FOR THE UPPER EXTREMITIES
There are currently no randomized, controlled trials or large prospective trials evaluating the use of peripheral nerve blocks for the upper extremity in critically ill patients. Nevertheless, severe trauma to the shoulder or arm is often part of multiple injuries due to traffic or workplace accidents, often in combination with blunt chest trauma requiring mechanical ventilation. These injuries can contribute to severe pain, especially during positioning of the patient. If the orthopedic injury is part of complex trauma including brain injury in which the mental status of the patient is altered and opioid-based analgesic regimens might mask the neurologic situation, sufficient analgesia can be achieved for the shoulder or upper limb with either continuous interscalene, continuous cervical paravertebral, or infraclavicular approaches to the brachial plexus.
Particular concerns arise concerning the placement of regional blocks in ICU patients with impaired mental status due to neurologic injury or therapeutic sedation. Benumof reported a small series of serious complications, including spinal cord injury related to the interscalene approach, which may have been associated with sedation or general anesthesia. His case descriptions relate to spinal cord injury in heavily sedated or anesthetized patients and not to the injury of the peripheral nerves. Despite this, the performance of blocks anatomically close to the neuraxis can indeed carry a higher risk of spinal cord needle or injection injury. In sedated critically ill patients, a combination of ultrasound and nerve stimulation for the placement of interscalene catheters and a technique with a less medial needle direction should help to minimize the risk of complications.
Perhaps most importantly, such blocks should be performed only by clinicians with adequate experience. The unavoidable blocking of the phrenic nerve and the loss of hemi-diaphragmatic function should be considered while planning the intervention. Although phrenic nerve block has negligible effects in mechanically ventilated patients, it may impair weaning from mechanical ventilation in high-risk patients. Furthermore, the proximity of the insertion site of the interscalene catheter to a tracheostomy tube might increase the risk of infection, and careful, standardized monitoring of the puncture site is therefore needed. Positioning problems might limit the use of the cervical paravertebral approach, which provides good analgesia for the shoulder, arm, and hand.
The continuous infraclavicular and axillary approaches provide good analgesia for most of the arm, elbow, and hand. A bolus injection of local anesthetic through the catheter should be considered especially in patients who need surgical anesthesia for procedures such as painful dressing changes or debridements for burns or large soft tissue wounds in the affected area. A lateral infraclavicular approach avoids the pneumothorax and allows better securing of the catheter, compared to more proximal approaches to brachial plexus block where the catheter is placed more superficially and the soft tissue is more movable.
- In patients with altered mental status in whom opioid-based analgesic regimens might make neurologic evaluation difficult, excellent analgesia can be achieved for the shoulder or upper limb with continuous interscalene, cervical paravertebral, or infraclavicular approaches to the brachial plexus.
- Performance of blocks anatomically close to the centroneuraxis can carry a higher risk of spinal cord needle or injection injury. In heavily sedated critically ill patients, such blocks should be performed only by clinicians with adequate experience.
- An interscalene brachial plexus block results in the loss of hemi-diaphragmatic function. Although phrenic nerve block has negligible effects in mechanically ventilated patients, it may impair weaning from mechanical ventilation in high-risk patients.
- Real-time ultrasound guidance for peripheral catheter placement
PERIPHERAL NERVE BLOCKS FOR THE LOWER EXTREMITIES
Femoral nerve catheters are helpful in the management of acute pain from femoral neck fractures in the period between injury to shortly after surgical stabilization of the fracture. Skilled use of ultrasound might limit the unavoidable pain associated with nerve stimulation in this situation, which otherwise can be treated with small doses of intravenous remifentanil (0.3–0.5 mcg/kg) or ketamine (0.2–0.4 mg/kg). A fascia iliaca compartment block might be a technical alternative.
A continuous femoral catheter in combination with a sciatic block provides excellent pain relief for the whole leg and even surgical anesthesia for procedures like external fixation. Whether an anterior or posterior approach (midgluteal or subgluteal classical Labat approach with one or two injections) to the sciatic nerve is chosen depends largely on the skills of the operator and the ability to adequately position the patient for the procedure.
If a combination of catheter techniques is used, as is often needed for the lower extremity, the total daily dose of local anesthetic should be adjusted based on catheter location, admixtures like epinephrine, drug interactions, and disease states as summarized in a recent review by Rosenberg and coworkers. A bolus injection of long-lasting local anesthetics in combination with clonidine or buprenorphine may help to reduce the overall amount of local anesthetic needed and minimize the effects of local anesthetic toxicity, although research results on these adjuvants are equivocal at present.
OTHER REGIONAL ANALGESIC TECHNIQUES
Celiac plexus blocks may provide excellent analgesia for pancreatitis and cancer-related upper abdominal pain, but technical difficulties in the critically ill (computed tomography [CT] guidance, fluoroscopy, or transgastric ultrasound) and the need for repeated injections limit their value for acutely critically ill patients.
Intrapleural catheters for pain control after chest trauma are of limited value secondary to concurrent drainage from chest tubes. The risk of pneumothorax limits their benefits for the management of pain after conventional cholecystectomy compared with the epidural or paravertebral technique in ventilated patients. Thoracic paravertebral catheters can be a valuable alternative to epidural catheters for the management of unilateral pain restricted to a few dermatomes (eg, rib fractures or zoster neuralgia). Table 2 provides a summary of the most utilized continuous peripheral catheters.
Single-injection nerve blocks (eg, intercostal blocks for the placement of chest tubes), scalp blocks for the placement of halo fixation, and sufficient local infiltration anesthesia for typical ICU procedures (eg, placement of arterial and central venous catheters, lumbar punctures, and ventriculostomies) are often forgotten, although they are easy and safe to perform. If EMLA cream is used for topical anesthesia, it needs to be applied 30–45 minutes before the procedure to achieve optimal effect. Intrathecal morphine injections as a single shot or via spinal catheter (microcatheters are currently not approved in the United States but are available in Europe) can be an alternative to epidural catheters, especially if only short-term use after surgery is anticipated.
SYSTEMIC EFFECTS & COMPLICATIONS OF LOCAL ANESTHETICS IN THE CRITICALLY ILL PATIENT
Local anesthetics have been shown to have several positive systemic effects (including analgesic, bronchodilatory, neuroprotective, anti-inflammatory, antiarrhythmic, and antithrombotic properties) when given or absorbed in adequate quantities (the exact dose-response relationships are widely unknown).
They also have negative effects, such as neurotoxicity (dose-dependent), myotoxicity, inhibition of wound healing, cardiotoxicity (dose-dependent), and central nervous excitation or depression (dose dependent). To prevent local anesthetic systemic toxicity from accidental intravascular injection, a test dose of local anesthetic or saline with 1:200,000 epinephrine can be used with catheter placement, but the sensitivity of heart rate, blood pressure increase, and T-wave changes might be altered in ICU patients, especially those treated with beta-block and α2-agonists or catecholamines.
Careful aspiration to check for blood return should be performed before each bolus injection. Most studies examining plasma levels of local anesthetics were not performed in critically ill patients. Scott and colleagues described the safe use of epidural ropivacaine 0.2% for 72 hours wi žth plasma levels far below the toxic threshold, and Gottschalk and associates observed safe plasma levels after 96 hours in patients treated with thoracic epidural ropivacaine 0.375%, indicating no significant accumulation over time. A lipid resuscitation protocol should be in place and part of the regular resuscitation drills in the ICU, where practitioners are often not as familiar with this topic as are operating room (OR) anesthesiologists but have easy access to the required quantities of lipid emulsion.
TABLE 2. Continuous peripheral nerve blocks in the critically Ill.
|Block||Indications||Contraindications||Practical Problems||Dose Suggestions|
|Interscalene||Shoulder/arm pain||Untreated contralateral pneumothorax||Horner syndrome may obscure neurologic assessment||Bolus regimen:a|
|10 mL 0.25% bupivacaine or 0.2% ropivacaine q 8–12 h and on demand|
|Dependence on diaphragmatic breathing||Block of ipsilateral phrenic nerve|
|Contralateral vocal cord palsy||Close proximity to tracheostomy and jugular vein line sites||Continuous infusion:|
|0.125% bupivacaine or 0.1–0.2% ropivacaine at 5 mL/h|
|Local infection at puncture site|
|Cervical paravertebral||Shoulder/elbow/wrist pain||Severe coagulopathy||Horner syndrome may obscure neurologic assessment||Bolus regimen:a|
|Dependence on diaphragmatic breathing||10 mL 0.25% bupivacaine or 0.2% ropivacaine q 8–12 h and on demand|
|Contralateral vocal cord palsy||Block of ipsilateral phrenic nerve||Continuous infusion:|
|Local infection at puncture site||Patient positioning||0.125% bupivacaine or 0.1–0.2% ropivacaine at 5 mL/h|
|Infraclavicular||Arm/hand pain||Severe coagulopathy||Pneumothorax risk||Bolus regimen:a|
|Untreated contralateral pneumothorax||Steep angle for catheter placement||10–20 mL 0.25% bupivacaine or 0.2% ropivacaine q 8–12 h and on demand|
|Local infection at puncture site||Interference with subclavian lines||Continuous infusion:|
|0.125% bupivacaine or 0.1–0.2% ropivacaine at 5–10 mL/h|
|Axillary||Arm/hand pain||Local infection at puncture site||Arm positioning||Bolus regimen:a|
|Catheter maintenance||10–20 mL 0.25% bupivacaine or 0.2% ropivacaine q 8–12 h and on demand|
|0.125% bupivacaine or 0.1–0.2% ropivacaine at 5–10 mL/h|
|Unilateral chest or abdominal pain restricted|
to few dermatomes
|Severe coagulopathy||Patient positioning||Bolus regimen:a|
sometimes hard to
|10–20 mL 0.25% bupivacaine
or 0.2% ropivacaine q 8–12 h
and on demand
|Local infection at|
|0.125% bupivacaine or 0.1–0.2%
ropivacaine at 5–10 mL/h
|Femoral or sciatic||Unilateral leg pain||Severe coagulopathy||Patient positioning||Bolus regimen:a|
|Local infection at|
|Interference of femoral|
nerve catheters with
|10 mL 0.25% bupivacaine or
0.2% ropivacaine q 8–12 h
and on demand
|0.125% bupivacaine or 0.1–0.2%
ropivacaine at 5 mL/h
GENERAL MANAGEMENT ASPECTS OF CONTINUOUS REGIONAL ANALGESIA CATHETERS IN CRITICALLY ILL PATIENTS
In general, given the lack of cooperation and communication in many ICU patients, regional analgesia techniques using continuous catheters in the ICU require a higher level of vigilance than needed for regular ward patients. Close cooperation between the ICU team and the acute pain or anesthesia service of the hospital is required.
Critical care nursing personnel should be specifically trained in handling regional analgesia catheters and must be aware of the potential complications and their early warning signs. Because of the frequently large and confusing numbers of various infusion catheters in critically ill patients, the risk of drug errors and incorrect administration of drugs through continuous regional analgesia catheters may be higher in these patients. Well-trained and highly qualified personnel are the best safeguard against these complications aside from eye-catching labels, standardized care protocols, and perhaps specially designed connectors for those catheters.
Comprehensive diagnostic approaches, including magnetic resonance imaging (MRI) or CT, should be undertaken when there are clinical signs of possible bleeding complications (eg, suspected epidural or retroperitoneal hematoma). Structured observations of catheters for infectious complications and careful adherence to aseptic technique during catheter placement and tunneling, as well as the possible use of antibiotic-coated catheters in the future, may reduce possible infectious complications.
Catheters should not be removed routinely after certain time intervals but only when clinical signs of infection appear. A study by Langevin suggests that if catheters become disconnected when the fluid in the catheter is static, the proximal 25 centimeters of the catheter may be immersed in a disinfectant, cut, and reconnected to a sterile connector. This technique is feasible only for catheters in which the fluid column can be observed. Stimulating catheters should never be cut because of the danger of unwinding the internal metal spiral wire, which conducts electrical current. No study has examined the risk of reconnecting these catheters after thorough disinfection of the outer surface, which is likely a common practice in many institutions. Cuvillon and colleagues reported a high overall incidence of colonization (57%) of femoral catheters without septic complications. Therefore, the decision to reconnect or remove the catheter must be made on a case-by-case basis and based on the specific clinical circumstances. The overall risk of permanent neurologic damage (from direct trauma, bleeding, or serious infection) or death from regional anesthesia and analgesia seems to be low in the perioperative setting, as shown by large surveys by Auroy and coworkers and Moen and associates. Although both studies certainly include critically ill patients, there are no specific subgroup data available.
If the patient is cooperative enough, patient-controlled regional anesthesia (PCRA) regimen is preferable, and such systems can also be used in a nurse-controlled fashion for intermittent bolus application without the need for additional manipulation of the infusion system.
While the evidence for the overall improvement of patient safety using ultrasound-guided regional anesthesia (UGRA) placement techniques is limited and a certain level of training necessary, the use of ultrasound seems to be especially beneficial in the critically ill patient. In a semiquantitative review, Morin and coworkers demonstrated better analgesia with the use of stimulating catheters, which seem to be another instrument to improve the effectiveness of regional analgesia in the critically ill. Read more about Continuous Peripheral Nerve Blocks: Local Anesthetic Solutions and Infusion Strategies.
The complexity of individual clinical situations can be demonstrated by the following case example: A 55-year-old male patient with polycythemia vera, treated with periodic phlebotomy and a history of lower extremity DVTs [deep venous thromboses], was admitted to the hospital with acute ischemia of all 5 fingers of his right hand. His INR [international normalized ratio] on admission was 2.5. His fingers were cold and painful and showed bluish discoloration. The patient was evaluated by vascular surgeons and an angiogram showed arterial thrombosis of the right hand and rtPA [recombinant tissue plasminogen activator] thrombolysis was started by an indwelling catheter from the right femoral artery to the right subclavian artery. The patient was admitted to the Surgical Intensive Care Unit for monitoring during TPA [tissue plasminogen activator]-thrombolysis.
Overnight, no significant improvement in limb perfusion could be seen and the patient underwent re-angiography on postoperative day 1. Given the amount of residual thrombosis, rtPA-treatment was continued. Overnight, on postoperative day 1, the patient became disoriented after receiving a single dose of meperidine in addition to his morphine PCA [patient-controlled analgesia] for worsening pain in his arm. A CT scan performed at that time to exclude an acute bleeding complication was read as normal and his neurologic status returned to baseline. rtPA treatment was discontinued after 48 hours on postoperative day 2, and the catheter was removed. A heparin infusion was titrated to a PTT [partial thromboplastin time] around 70 seconds. Around midnight the patient became agitated and disoriented.
Another head CT was performed which showed left cerebellum hypodensity and the patient became more and more unresponsive. Brain MRI revealed multiple infarcts involving the left cerebellum, the right cerebellum, the bilateral thalami and the left medial temporal occipital region. MRA [magnetic resonance angiogram] showed left vertebral artery thrombosis. The patient was treated symptomatically with small doses of haloperidol and the heparin infusion was discontinued by the neurologist’s recommendation to prevent hemorrhagic transformation of the cerebellar infarcts. In the morning, the patient was still somnolent but complained about severe pain in his right arm when aroused. Also, the discoloration of his fingers was slowly progressing proximally and the distal parts were cold and numb. The patient also described a burning sensation in addition to the sharp and shooting pain. Morphine PCA and systemic narcotics had been discontinued secondary to his worsened neurostatus. 18 hours after discontinuation of rtPA and 9 hours after discontinuation of the heparin infusion his fibrinogen levels were still markedly elevated but his INR and PTT had returned to high normal values.
An axillary brachial plexus catheter was placed using the stimulating catheter (Stimucath®, Arrow International, Reading, USA) and a good motor response with hand extension and thumb adduction at 0.44 mA was elicited via the indwelling catheter after ultrasound guided advancement of the catheter. A bolus of 20 mL of mepivacaine 1.5 percent and 20 mL of ropivacaine 0.75 percent were injected through the catheter and resulted in pain relief after 10 minutes. The skin temperature in the affected hand rose from 34.5 degrees Celsius to 36 degrees Celsius 30 minutes after injection of the local anesthetic. Ultrasound guidance was used for the placement of the axillary catheter to avoid accidental puncture of the axillary artery or vein 4. The catheter was tunneled to prevent dislocation and there was mild oozing at the tunnel site but no hematoma formation. A cerebral angiogram was performed and showed left vertebral artery thrombosis and a patent right vertebral artery.
Lower extremity duplex sonography showed extensive subacute deep venous thrombosis bilaterally and an inferior vena cava filter was placed. Transthoracic echo and transesophageal echo showed a small PFO [patent foramen ovale] with minimal right to left shunt with Valsalva maneuver. The axillary catheter was bolused with 10 mL of 0.5 percent ropivacaine every 8 hours. This regimen allowed consistent pain relief and sympathetic block. Finger cyanosis was improving rapidly. With improved neurostatus, the patient was also started on gabapentin 900 mg every 8 hours, 325 mg of aspirin and codeine tablets PRN. The hematologist recommended enoxaparin 100 mg sc q 12 hours for the treatment of his hypercoagulable state. The axillary catheter was removed after 5 days immediately before his evening dose of enoxaparin. No bleeding complications were observed. His neurological status as well as the finger ischemia continued to improve.
Regional analgesia, whether utilizing single-injection regional blocks or continuous neuraxial or peripheral catheters, can play a valuable role in a multimodal approach to pain management in the critically ill patient to achieve optimum patient comfort and to reduce physiologic and psychological stress. By avoiding high systemic doses of opioids, several complications, such as withdrawal syndrome, delirium, mental status changes, and gastrointestinal dysfunction, can be reduced or minimized. Because of the limited patient cooperation that is common during the placement and monitoring of continuous regional analgesia in the critically ill, indications for its use must be carefully based on anatomy, clinical features of pain, coagulation status, and logistic circumstances.
Highly trained nursing personnel and well-trained physicians are essential prerequisites for the safe use of these techniques in the critical care environment. These recommendations are based on small series, uncontrolled trials, and extrapolations from controlled trials in the perioperative setting; further research on the use of regional analgesia techniques in the critically ill is needed before definitive guidelines can be established.
- Brodner G, Pogatzki E, Van Aken H, et al: A multimodal approach to control postoperative pathophysiology and rehabilitation in patients undergoing abdominothoracic esophagectomy. Anesth Analg 1998;86: 228–234.
- Brodner G, Mertes N, Buerkle H, et al: Acute pain management: Analysis, implications and consequences after prospective experience with 6349 surgical patients. Eur J Anaesthesiol 2000;17:566–575.
- Herridge MS: Long-term outcomes after critical illness. Curr Opin Crit Care 2002;8:331–336.
- Afessa B, Green B, Delke I, et al: Systemic inflammatory response syndrome, organ failure, and outcome in critically ill obstetric patients treated in an ICU. Chest 2001;120:1271–1277.
- Peyton PJ, Myles PS, Silbert BS, et al: Perioperative epidural analgesia and outcome after major abdominal surgery in high-risk patients. Anesth Analg 2003;96:548.
- De Leon-Casasola OA, Lema MJ, Karabella D, et al: Postoperative myocardial ischemia: Epidural versus intravenous patient-controlled analgesia. A pilot project. Reg Anesth 1995;20:105–112.
- Jones C, Skirrow P, Griffiths RD, et al: Rehabilitation after critical illness: A randomized, controlled trial. Crit Care Med 2003;31:2456–2461.
- Cuthbertson BH, Hull A, Strachan M, et al: Post-traumatic stress disorder after critical illness requiring general intensive care. Intensive Care Med 2004;30:450–455.
- Campbell AS: Recognising post-traumatic stress in intensive care patients. Intensive Crit Care Nurs 1995;11:60–65.
- Dellinger RP, Levy MM, Rhodes A, et al: Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock, 2012. Crit Care Med 2013;39:165–228.
- Mehta S, McCullagh I, Burry L: Current sedation practices: lessons learned from international surveys. Anesthesiol Clin 2011;29:607–624.
- Barr J, Fraser GL, Puntillo K et al: Clinical practice guidelines for the management of pain, agitation and delirium in adult patients in the intensive care unit. Crit Care Med 2013;41:263–306.
- Lütz A, Goldmann A, Weber-Carstens S et al: Weaning from mechanical ventilation and sedation. Curr Opinion Anaesthesiol 2012;25:164–169.
- Degrado JR, Anger KE, Szumita PM, et al: Evaluation of a local ICU sedation guideline on goal directed administration of sedatives and analgesics. J Pain Res 2011;4:127–134.
- Pasero C, McCaffery M: Multimodal balanced analgesia in the critically ill. Crit Care Nurs Clin North Am 2001;13:195–206.
- Schulz-Stübner S, Boezaart A, Hata S: Regional Analgesia in the Critically Ill. Crit Care Med 2005;33:1400–1407.
- Schulz-Stübner S: The critically ill patient and regional anesthesia. Curr Opin Anaesthesiol 2006;19:538–544.
- Dilworth NM, MacKellar A: Pain relief for the pediatric surgical patient. J Pediatr Surg 1987;22:264–266.
- Manworren RC, Hynan LS: Clinical validation of FLACC: preverbal patient pain scale. Pediatr Nurs 2003;29:140–146.
- Breau LM, Finley GA, McGrath PJ, et al: Validation of the Noncommunicating Children’s Pain Checklist-Postoperative Version. Anesthesiology 2002;96:528–535.
- Feldt KS: The checklist of nonverbal pain indicators (CNPI). Pain Manag Nurs 2000;1:13–21.
- Blenkharn A, Faughnan S, Morgan A: Developing a pain assessment tool for use by nurses in an adult intensive care unit. Intensive Crit Care Nurs 2002;18:332–341.
- Riker RR, Picard JT, Fraser GL: Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. Crit Care Med 1999;27:1325–1329.
- Riker RR, Fraser GL: Sedation in the intensive care unit: refining the models and defining the questions. Crit Care Med 2002;30: 1661–1663.
- Stundner O, Memtsoudis SG: Regional anesthesia in critically ill patients. Reg Anesth Pain Med 2012;37:537–544.
- Naber L, Jones G, Halm M: Epidural analgesia for effective pain control. Crit Care Nurse 1994;14:69–72, 77–83; quiz 84–85.
- Holcomb JB, McMullin NR, Kozar RA, et al: Morbidity from rib fractures increases after age 45. J Am Coll Surg 2003;196:549–555.
- Karmakar MK, Ho AM: Acute pain management of patients with multiple fractured ribs. J Trauma 2003;54:615–625.
- Luchette FA, Radafshar SM, Kaiser R, et al: Prospective evaluation of epidural versus intrapleural catheters for analgesia in chest wall trauma. J Trauma 1994;36:865–9; discussion 869–870.
- Catoire P, Bonnet F: [Locoregional analgesia in thoracic injuries]. Can Anesthesiol 1994;42:809–814.
- Asantila R, Rosenberg PH, Scheinin B: Comparison of different methods of postoperative analgesia after thoracotomy. Acta Anaesthesiol Scand 1986;30:421–425.
- Licker M, Spiliopoulos A, Frey JG, et al: Risk factors for early mortality and major complications following pneumonectomy for non-small cell carcinoma of the lung. Chest 2002;121:1890–1897.
- Carli F, Trudel JL, Belliveau P: The effect of intraoperative thoracic epidural anesthesia and postoperative analgesia on bowel function after colorectal surgery: a prospective, randomized trial. Dis Colon Rectum 2001;44:1083–1089.
- Jorgensen H, Wetterslev J, Moiniche S, et al: Epidural local anaesthetics versus opioid-based analgesic regimens on postoperative gastrointestinal paralysis, PONV and pain after abdominal surgery. Cochrane Database Syst Rev 2000:CD001893.
- Albani A, Renghi A, Gramaglia L, et al: Regional anaesthesia in vascular surgery: a multidisciplinary approach to accelerate recovery and postoperative discharge. Minerva Anestesiol 2001;67:151–154.
- Bush RL, Lin PH, Reddy PP, et al: Epidural analgesia in patients with chronic obstructive pulmonary disease undergoing transperitoneal abdominal aortic aneurysmorraphy—a multi-institutional analysis. Cardiovasc Surg 2003;11:179–184.
- Wu CL, Anderson GF, Herbert R, et al: Effect of postoperative epidural analgesia on morbidity and mortality after total hip replacement surgery in Medicare patients. Reg Anesth Pain Med 2003;28:271–278.
- Niesel HC, Klimpel L, Kaiser H, et al: [Epidural block for analgesia and treatment of acute pancreatitis]. Reg Anaesth 1991;14:97–100.
- Baig MK, Wexner SD: Postoperative ileus: a review. Dis Colon Rectum 2004;47:516–526. 40. Kreis ME, Kasparek MS, Becker HD, et al: [Postoperative ileus: part II (Clinical therapy)]. Zentralbl Chir 2003;128:320–328.
- Holte K, Kehlet H: Postoperative ileus: progress towards effective management. Drugs 2002;62:2603–2615.
- Kehlet H, Holte K: Review of postoperative ileus. Am J Surg 2001;182:3S–10S.
- Peterson KL, DeCampli WM, Pike NA, et al: A report of two hundred twenty cases of regional anesthesia in pediatric cardiac surgery. Anesth Analg 2000;90:1014–1019.
- Aybek T, Kessler P, Dogan S, et al: Awake coronary artery bypass grafting: utopia or reality? Ann Thorac Surg 2003;75:1165–1170.
- Svorkdal N: Pro: anesthesiologists’ role in treating refractory angina: spinal cord stimulators, thoracic epidurals, therapeutic angiogenesis, and other emerging options. J Cardiothorac Vasc Anesth 2003;17:536–545.
- Marchertiene I: [Regional anesthesia for patients with cardiac diseases]. Medicina (Kaunas) 2003;39:721–729.
- Thompson JS: The role of epidural analgesia and anesthesia in surgical outcomes. Adv Surg 2002;36:297–307.
- Rodgers A, Walker N, Schug S, et al: Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 2000;321:1493.
- Burton AW, Eappen S: Regional anesthesia techniques for pain control in the intensive care unit. Crit Care Clin 1999;15:77–88, vi.
- Low JH: Survey of epidural analgesia management in general intensive care units in England. Acta Anaesthesiol Scand 2002;46:799–805.
- Bromage PR, Benumof JL: Paraplegia following intracord injection during attempted epidural anesthesia under general anesthesia. Reg Anesth Pain Med 1998;23:104–107.
- Krane EJ, Dalens BJ, Murat I, et al: The safety of epidurals placed during general anesthesia. Reg Anesth Pain Med 1998;23:433–438.
- Herwaldt LA PJ, Coffin SA, Schulz-Stübner S: Nosocomial infections associated with anesthesia. In Mayhall CG (ed): Hospital Epidemiology and Infection Control, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2004, pp 1073–1117.
- Tsui BC, Gupta S, Finucane B: Confirmation of epidural catheter placement using nerve stimulation. Can J Anaesth 1998;45:640–644.
- Tsui BC, Guenther C, Emery D, et al: Determining epidural catheter location using nerve stimulation with radiological confirmation. Reg Anesth Pain Med 2000;25:306–309.
- Wegeforth PLJ: Lumbar puncture as a factor in the pathogenesis of meningitis. Am J Med Sci 1919;158:183–202.
- Bell K, Wattie M, Byth K, et al: Procalcitonin: a marker of bacteraemia in SIRS. Anaesth Intensive Care 2003;31:629–636.
- Du B, Pan J, Chen D, et al: Serum procalcitonin and interleukin-6 levels may help to differentiate systemic inflammatory response of infectious and non-infectious origin. Chin Med J (Engl) 2003;116:538–542.
- Luzzani A, Polati E, Dorizzi R, et al: Comparison of procalcitonin and C-reactive protein as markers of sepsis. Crit Care Med 2003;31: 1737–1741.
- Delevaux I, Andre M, Colombier M, et al: Can procalcitonin measurement help in differentiating between bacterial infection and other kinds of inflammatory processes? Ann Rheum Dis 2003;62: 337–340.
- Horlocker TT, Wedel DJ, Rowlingson JC, 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;35:64–101.
- Gogarten W, Van Aken H, Büttner J, et al: Regional anesthesia and thromboembolism prophylaxis/anticoagulation. Revised guidelines of the German Society of Anesthesiology and Intensive Care Medicine. Anaesth Intesivmed 2003;44:218–230.
- Vandermeulen E, Gogarten W, Van Aken H: [Risks and complications following peridural anesthesia]. Anaesthesist 1997;46(Suppl 3): S179–S186.
- Kotemane C, Gopinath N, Vaja R: Analgesic techniques following thoracic surgery: a survey of United Kingdom practice. Eur J Anesthesiol 2010;27:897–899.
- Luvet C, Siegenthaler A, Szucs-Farkas Z et al: The location of paravertebral catheters placed using the landmark technique. Anesthesia 2012;67:1321–1326.
- Schulz-Stübner S, Czaplik M: Quality management in regional anesthesia using the example of the Regional Anesthesia Surveillance System (RASS). Schmerz 2013;27:56–66.
- Boezaart AP, de Beer JF, du Toit C, et al: A new technique of continuous interscalene nerve block. Can J Anaesth 1999;46:275–281.
- Brown DL: Brachial plexus anesthesia: An analysis of options. Yale J Biol Med 1993;66:415–431.
- Schulz-Stübner S: [Brachial plexus. Anesthesia and analgesia]. Anaesthesist 2003;52:643–657.
- Boezaart AP, De Beer JF, Nell ML: Early experience with continuous cervical paravertebral block using a stimulating catheter. Reg Anesth Pain Med 2003;28:406–413.
- Boezaart AP, Koorn R, Borene S, et al: Continuous brachial plexus block using the posterior approach. Reg Anesth Pain Med 2003;28:70–71.
- Boezaart AP, Koorn R, Rosenquist RW: Paravertebral approach to the brachial plexus: an anatomic improvement in technique. Reg Anesth Pain Med 2003;28:241–244.
- Ilfeld BM, Enneking FK: Brachial plexus infraclavicular block success rate and appropriate endpoints. Anesth Analg 2002;95:784.
- Benumof JL: Permanent loss of cervical spinal cord function associated with interscalene block performed under general anesthesia. Anesthesiology 2000;93:1541–1544.
- Meier G, Bauereis C, Maurer H, et al: [Interscalene plexus block. Anatomic requirements—Anesthesiologic and operative aspects]. Anaesthesist 2001;50:333–341.
- Meier G, Bauereis C, Heinrich C: [Interscalene brachial plexus catheter for anesthesia and postoperative pain therapy. Experience with a modified technique]. Anaesthesist 1997;46:715–719.
- Sala-Blanch X, Lazaro JR, Correa J, et al: Phrenic nerve block caused by interscalene brachial plexus block: Effects of digital pressure and a low volume of local anesthetic. Reg Anesth Pain Med 1999;24:231–235.
- Neuburger M, Kaiser H, Rembold-Schuster I, et al: [Vertical infraclavicular brachial-plexus block. A clinical study of reliability of a new method for plexus anesthesia of the upper extremity]. Anaesthesist 1998;47:595–599.
- Borene SC, Edwards JN, Boezaart AP: At the cords, the pinkie towards: Interpreting infraclavicular motor responses to neurostimulation. Reg Anesth Pain Med 2004;29:125–129.
- Sandhu NS, Capan LM: Ultrasound-guided infraclavicular brachial plexus block. Br J Anaesth 2002;89:254–259.
- Ang ET, Lassale B, Goldfarb G: Continuous axillary brachial plexus block—a clinical and anatomical study. Anesth Analg 1984;63: 680–684.
- Sia S, Lepri A, Campolo MC, et al: Four-injection brachial plexus block using peripheral nerve stimulator: a comparison between axillary and humeral approaches. Anesth Analg 2002;95:1075–1079, table of contents.
- Retzl G, Kapral S, Greher M, et al: Ultrasonographic findings of the axillary part of the brachial plexus. Anesth Analg 2001;92:1271–1275.
- Kapral S, Jandrasits O, Schabernig C, et al: Lateral infraclavicular plexus block vs. axillary block for hand and forearm surgery. Acta Anaesthesiol Scand 1999;43:1047–1052.
- Greher M, Retzl G, Niel P, et al: Ultrasonographic assessment of topographic anatomy in volunteers suggests a modification of the infraclavicular vertical brachial plexus block. Br J Anaesth 2002;88: 632–636.
- Jandard C, Gentili ME, Girard F, et al: Infraclavicular block with lateral approach and nerve stimulation: extent of anesthesia and adverse effects. Reg Anesth Pain Med 2002;27:37–42.
- Finlayson BJ, Underhill TJ: Femoral nerve block for analgesia in fractures of the femoral neck. Arch Emerg Med 1988;5:173–176.
- Tan TT, Coleman MM: Femoral block for fractured neck of femur in the emergency department. Ann Emerg Med 2003;42:596–597; author reply 597.
- Marhofer P, Schrogendorfer K, Koinig H, et al: Ultrasonographic guidance improves sensory block and onset time of three-in-one blocks. Anesth Analg 1997;85:854–857.
- Lopez S, Gros T, Bernard N, et al: Fascia iliaca compartment block for femoral bone fractures in prehospital care. Reg Anesth Pain Med 2003;28:203–207.
- Cuignet O, Pirson J, Boughrouph J, et al: The efficacy of continuous fascia iliaca compartment block for pain management in burn patients undergoing skin grafting procedures. Anesth Analg 2004;98:1077–1081, table of contents.
- Kaden V, Wolfel H, Kirsch W: [Experiences with a combined sciatic and femoral block in surgery of injuries of the lower leg]. Anaesthesiol Reanim 1989;14:299–303.
- Barbero C, Fuzier R, Samii K: Anterior approach to the sciatic nerve block: Adaptation to the patient’s height. Anesth Analg 2004;98:1785–1788, table of contents.
- Franco CD: Posterior approach to the sciatic nerve in adults: is euclidean geometry still necessary? Anesthesiology 2003;98:723–728.
- Di Benedetto P, Casati A, Bertini L, et al: Posterior subgluteal approach to block the sciatic nerve: Description of the technique and initial clinical experiences. Eur J Anaesthesiol 2002;19:682–686.
- Bailey SL, Parkinson SK, Little WL, et al: Sciatic nerve block. A comparison of single versus double injection technique. Reg Anesth 1994;19:9–13.
- Rosenberg PH, Veering BT, Urmey WF: Maximum recommended doses of local anesthetics: A multifactorial concept. Reg Anesth Pain Med 2004;29:564–575.
- Casati A, Magistris L, Fanelli G, et al: Small-dose clonidine prolongs postoperative analgesia after sciatic-femoral nerve block with 0.75% ropivacaine for foot surgery. Anesth Analg 2000;91:388–392.
- Gao F, Waters B, Seager J, et al: Comparison of bupivacaine plus buprenorphine with bupivacaine alone by caudal block for postoperative pain relief after hip and knee arthroplasty. Eur J Anaesthesiol 1995;12:471–476.
- Culebras X, Van Gessel E, Hoffmeyer P, et al: Clonidine combined with a long acting local anesthetic does not prolong postoperative analgesia after brachial plexus block but does induce hemodynamic changes. Anesth Analg 2001;92:199–204
- Picard PR, Tramer MR, McQuay HJ, et al: Analgesic efficacy of peripheral opioids (all except intra-articular): a qualitative systematic review of randomised controlled trials. Pain 1997;72:309–318.
- Wehling MJ, Koorn R, Leddell C, et al: Electrical nerve stimulation using a stimulating catheter: What is the lower limit? Reg Anesth Pain Med 2004;29:230–233.
- Costello TG, Cormack JR, Hoy C, et al: Plasma ropivacaine levels following scalp block for awake craniotomy. J Neurosurg Anesthesiol 2004;16:147–150.
- Rawal N, Tandon B: Epidural and intrathecal morphine in intensive care units. Intensive Care Med 1985;11:129–133.
- Shroff A, Rooke GA, Bishop MJ: Effects of intrathecal opioid on extubation time, analgesia, and intensive care unit stay following coronary artery bypass grafting. J Clin Anesth 1997;9:415–419.
- Hall R, Adderley N, MacLaren C, et al: Does intrathecal morphine alter the stress response following coronary artery bypass grafting surgery? Can J Anaesth 2000;47:463–466.
- Bowler I, Djaiani G, Abel R, et al: A combination of intrathecal morphine and remifentanil anesthesia for fast-track cardiac anesthesia and surgery. J Cardiothorac Vasc Anesth 2002;16:709–714.
- Schulz-Stübner S: Regionalanästhesie und -analgesie: Techniken und Therapieschemata für die Praxis. Stuttgart: Schattauer, 2003.
- Zink W, Seif C, Bohl JR, et al: The acute myotoxic effects of bupivacaine and ropivacaine after continuous peripheral nerve blocks. Anesth Analg 2003;97:1173–1179, table of contents.
- Zink W, Graf BM: Local anesthetic myotoxicity. Reg Anesth Pain Med 2004;29:333–340.
- Zink W, Graf BM: [Toxicology of local anesthetics. Clinical, therapeutic and pathological mechanisms]. Anaesthesist 2003;52:1102–1123.
- Scott DA, Emanuelsson BM, Mooney PH, et al: Pharmacokinetics and efficacy of long-term epidural ropivacaine infusion for postoperative analgesia. Anesth Analg 1997;85:1322–1330.
- Gottschalk A, Burmeister MA, Freitag M, et al: [Plasma levels of ropivacaine and bupivacaine during postoperative patient controlled thoracic epidural analgesia]. Anasthesiol Intensivmed Notfallmed Schmerzther 2003;38:705–709.
- Weinberg GL: Lipid emulsion infusion: resuscitation for local anesthetic and other drug overdose. Anesthesiology 2012;117:180–187.
- Langevin PB, Gravenstein N, Langevin SO, et al: Epidural catheter reconnection. Safe and unsafe practice. Anesthesiology 1996;85: 883–888.
- Cuvillon P, Ripart J, Lalourcey L, et al: The continuous femoral nerve block catheter for postoperative analgesia: bacterial colonization, infectious rate and adverse effects. Anesth Analg 2001;93:1045–1049.
- Auroy Y, Benhamou D, Bargues L, et al: Major complications of regional anesthesia in France: the SOS Regional Anesthesia Hotline Service. Anesthesiology 2002;97:1274–1280.
- Auroy Y, Narchi P, Messiah A, et al: Serious complications related to regional anesthesia: Results of a prospective survey in France. Anesthesiology 1997;87:479–486.
- Moen V, Dahlgren N, Irestedt L: Severe neurological complications after central neuraxial blocks in Sweden 1990–1999. Anesthesiology 2004;101:950–959.
- Savoia G, Alampi D, Amantea B, et al: Postoperative pain treatment SIAARTI recommendations 2010. Short version. Minerva Anestesiol 2010;76:657–667.
- Neal JM, Brull R, Chan VW, et al: The ASRA evidence-based assessment of ultrasound guided regional anesthesia and pain medicine: executive summary. Reg Anesth Pain Med 2010;35;S1–S9.
- Sites BD, Chan VW, Neal JM, et al: The American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anesthesia and Pain Therapy and joint committee recommendations for education and training in ultrasound-guided regional anesthesia. Reg Anesth Pain Med 2010;35:S74–S80.
- Morin AM, Kranke P, Wulf H: The effect of stimulating versus nonstimulating catheter techniques for continuous regional anesthesia: a semiquantitative systematic review. Reg Anesth Pain Med 2010;35:194–199.
- Schulz-Stübner S, Martin C: Axillary catheter with intermittent boluses of local anesthetic for ischemic upper limb pain 18 hours after failed rtPA thrombolysis. Eur J Anaesthesiol 2007;24:722–724.
- Candido KD, Franco CD, Khan MA, et al: Buprenorphine added to the local anesthetic for brachial plexus block to provide postoperative analgesia in outpatients. Reg Anesth Pain Med 2001; 26:352–356.