5 Key Advances in Anesthesia

Anesthesia

By: Jim Burger

Published: 4/3/2019

Share:

The latest tools and techniques that enable safe and pain-free same-day discharge.


Surgeons grab headlines for performing innovative procedures and nurses will always be the heart of health care, but it’s the anesthesia providers who ultimately green light the complex cases that are pushing outpatient surgery forward. Without their mastery of airway management and deft touch in controlling post-op pain, patients who undergo surgeries that used to require several overnight stays wouldn’t be ready or willing to walk out of your facility hours after they walked in. Look closely and you’ll notice there are plenty of exciting things happening at the head of the OR table, beginning with efforts to address a national crisis.

1. Opioid-sparing pain management
PUSHING FORWARD New IV NSAIDs in the pipeline promise to give providers even more opioid-sparing options to manage post-op pain.   |  Pamela Bevelhymer, RN, BSN, CNOR

That opioids are a major concern isn’t big news. That in many ways they’re an even bigger problem than previously realized may be the more important recent revelation.

“We now know that the intraoperative use of opioids — particularly potent lipophilic ones like fentanyl, sufentanil and especially remifentanil — produce hyperalgesia intolerance,” says Eugene Viscusi, MD, a professor of anesthesiology and the chief of pain medicine at Thomas Jefferson University Hospital in Philadelphia, Pa. “In other words, they literally cause more pain and higher opioid requirements. It’s pretty alarming to realize that you’re giving what you think are pain drugs only to find out they actually increase pain and opioid use.”

By now you know that the opioid crisis has led to a spike in ongoing efforts to find analgesic combinations that serve as opioid alternatives (as well as a spike in the use of the word multimodal).

“We have a lot more tools available if we want to avoid opioids,” says Dr. Viscusi. “In fact, the data now strongly show that opioids are not the most powerful analgesic agent. There are a lot of drugs that are on par in terms of efficacy.”

The quest for perfect pain management, or something as close as possible to perfection, continues, fueled by the overlap of art and science.

“We’re still learning a lot about opioid-sparing techniques, because as a society we spent many decades using opioids as a crutch,” says Mohammad Piracha, MD, an anesthesiologist and pain management specialist at Weill Cornell and the Center for Comprehensive Spine Care in New York City. “We’ve forgotten about some other medications that are supremely effective. There are so many classes of medications that have gone by the wayside, because there was such a surge of opioid use. I think some people are starting to look back and say, you know what, this medication used to work great.”

Medications like these:

  • Ketamine, which was recently FDA-approved as a nasal spray to treat depression, is also showing considerable promise as an anesthetic agent.

“There’s a host of emerging data supporting ketamine as not only reducing tolerance and hyperalgesia, but also providing a lot of other benefits,” says Dr. Viscusi, “including cognitive preservation and ancillary anti-inflammatory effects. I think you’re going to see ketamine coming back as a background infusion drug in a lot of anesthesia.”

  • Intravenous lidocaine infusion is also promising. “There are a lot of data to support it,” adds Dr. Viscusi. “It’s a potent anti-inflammatory, and it appears to reduce the inflammatory response to surgery. It also seems to improve functional outcomes longer-term, even months after surgery.”

An intravenous version of the common NSAID meloxicam may also be FDA-approved by the time you read this (March 24 is the targeted approval date). It could provide a much faster onset of action and the potential for sustained analgesia.

SCREEN SHOT Video laryngoscopes continues to evolve and could someday replace direct laryngoscopy as the go-to approach for airway management.   |  Pamela Bevelhymer, RN, BSN, CNOR

“Its once-daily IV dosing will appeal to many and will likely become a useful tool in our pain armamentarium,” says anesthesiologist D. John Doyle, MD, of the Cleveland (Ohio) Clinic, before adding a cautionary note about its use with elderly patients and those at risk for renal injury.

A combination of bupivacaine and meloxicam (HTX-011) is also in the pipeline and is designed to reduce inflammation and reverse the acidic environment caused by surgery, “allowing enhanced penetration of bupivacaine into the nerves and thereby potentiating its effect.”

“The data is very good,” says Dr. Viscusi, who expects it to be approved this spring. “It looks as if it could last up to 72 hours.”

  • Exparel (liposomal bupivacaine suspension) gained FDA approval in April 2017 for use as an interscalene brachial plexus regional block during shoulder arthroscopies and rotator cuff repairs. The local anesthetic, delivered as a single-dose injection at the surgical site, continues to be a popular choice among some orthopedic surgeons for limiting post-op pain in total hip and knee patients.

Its promised efficacy, proponents acknowledge, relies on the knowledge and refined skills of the practitioner. “With liposome, if you’re not a good infiltrator and you don’t do very, very fastidious multiple injections all over the place, you don’t distribute the drug and you’re not going to like the results,” says Dr. Viscusi, adding that more data is needed to support Exparel’s use.

The final verdict may still be out on the drug’s efficacy, but if it can consistently deliver on its promise of 48 to 72 hours of post-operative relief, it will be another valuable addition to post-op pain protocols. “Instead of having a catheter, which always carries a risk of infection, you can do a one-time nerve block that lasts for 2 or 3 days,” says Dr. Piracha. “Obviously, that has a lot of value.”

  • Clorotekal (chloroprocaine hydrochloride), a spinal anesthetic that wears off in 40 to 45 minutes, instead of the usual hour-plus you’d typically get with bupivacaine, is potentially invaluable in the get-’em-up and get-’em-out world of same-day surgery.

“Its metabolism by ester hydrolysis may ultimately make it a favorite for short-duration spinals and other blocks in the outpatient arena,” says Dr. Doyle, adding that, like bupivacaine, its cardiotoxic effects are minimal, and, like lidocaine, it has minimal neurotoxic impact.

That should translate to a shorter time in the PACU and a shorter recovery time. In fact, one study found that patients given Clorotekal were ready to be discharged about 80 minutes sooner (150 vs. 230 minutes) than the bupivacaine group. Clorotekal also has a quicker onset time and has been associated with a lower urinary retention rate than other anesthetics.

We're still learning a lot about opioid-sparing techniques, because as a society we spent many decades using opioids as a crutch.

— Mohammad Piracha, MD

2. Video laryngoscopy

By now every provider knows about video laryngoscopes, but the day may be coming when intubating with direct laryngoscopy feels like typing a term paper on a manual Smith-Corona.

“The really big change [in video laryngoscope design] that has happened over the last 5 or 10 years is the advent of portable high-level batteries and high-resolution screens that are like what we have on phones,” says Dr. Piracha. “Before, what we had was pseudo-portable — you had to wheel the device into the room. Now, with newer technologies, it’s literally in your pocket.”

So, it’s time to toss out the old handle and blade? Probably not — at least not until video scopes become as ubiquitous as mobile phones.

“There are those who make the case that direct laryngoscopy is now obsolete,” says Dr. Doyle, “but I think that anesthesia providers should still be trained in direct laryngoscopy, in addition to video laryngoscopy and fiberoptic bronchoscopy, at least for the time being.”

In fact, the training advantage is one of the most important features that video scopes offer, says Dr. Piracha. “It’s an extremely good teaching tool, and very useful to understand the basic airway anatomy,” he says. “In fact, whenever I have a super-new trainee in my operating room who has never done a laryngoscopy, I have them do it first on a video laryngoscope, so they get an idea of what the anatomy looks like.”

But then it’s back to basics, says Dr. Piracha, who agrees that the time to ditch direct hasn’t yet arrived. “You have to remember that, as with all technology, there’s always a chance of failure or unavailability,” he explains. “What if something happens and your screen breaks and you can’t see anything? I foresee video scopes becoming more and more prominent, but I think it’s still extremely important to be very proficient with just the traditional handle, light and blade.”

3. Point-of-care ultrasound

Pont-of-care ultrasound — PoCUS is what practitioners call it — is transforming how some providers practice. “It will revolutionize the way we assess patients,” says Dr. Viscusi. “I can put a probe on a patient and get a pretty good assessment of their cardiac function. I can scan the stomach of an obese patient or a patient with reflux to decide whether or not they have a full stomach, and whether I need to do a rapid sequence [intubation].”

PoCUS is a hot topic in the field, says Eric Schwenk, MD, FASA, an associate professor of anesthesiology and the director of orthopedic anesthesia at Jefferson.

“What a lot of us like about it is that it helps to answer a very focused and simple yes-or-no question — does this patient have a pneumothorax?” he says. “It’s quick and dirty. You put a probe on the belly or chest, you do the exam, and there are a couple of different signs you’re looking for. The accuracy is quite good.”

4. “Smart” pain pumps

The better and smarter the pain pump, the more confidence patients and providers will have in the use of continuous peripheral nerve blocks.

“Block techniques are very valuable, because the source of the pain is very definitive and you can pinpoint where the nerve is damaged,” says Dr. Piracha. “If you can block that nerve signal, you’ve solved a big chunk of the pain that the patient might be experiencing.”

With improving technology, expect pumps to have more features and less that can go wrong. “I do think that pumps are going to continue to evolve and become more efficient,” says Dr. Piracha. “For example, with features like intermittent blousing, if a patient can’t hit the [bolus] button because they’re asleep, they may wake up in a disturbing amount of pain. But pumps can be programmed to release a small bolus, say, every 3 hours. Those kinds of built-in technologies are bound to come about, because the technology is becoming readily available and a lot cheaper.”

5. Truncal blocks

As an alternative to epidurals, truncal regional blocks are also compatible with the desire to enhance throughput and minimize opioid use. The TAP (transversus abdominis plane) block is the best-known of the group, but several others are also increasingly being used, including the erector spinae block and the quadratus lumborum block. The blocks are effectuated by injecting local anesthesia into particular muscle planes, where it spreads and reaches target nerves.

“It’s an area of interest that’s expanding,” says Dr. Schwenk. “As the population gets older, we’re dealing with patients with cardiac disease or pulmonary disease, for whom general anesthesia isn’t preferable — either from their perspective or from ours. Some of these procedures can be done with truncal blocks and a little bit of light sedation.”

Published guidelines are scarce, because most of the techniques are so new, says Dr. Schwenk, adding that it remains less than fully clear exactly how the mechanism of action works. “Some of the blocks are promising, although they need additional study,” he adds. “But we know they seem to work surprisingly well for some people.”

Dr. Schwenk believes epidural analgesia is still the gold standard when it comes to thoracic and abdominal surgery, but surgeries are becoming less invasive with the push to get patients moving and out faster.

“And if a patient or surgeon doesn’t want an epidural, it’s nice to have an option other than just giving the patient a lot of morphine,” he adds. “It’s good to have that tool in your toolbox.” OSM

Related Articles

Lessons Learned From a Renowned Team Physician

Jared Bilski | Editor-in-Chief 12/18/2024

As a well-known team physician for not one but two professional Chicago franchises — the Bulls and the White Sox — Adam Yanke, MD, PhD, sees his fair share of non-athlete...