May 2014 - Newsletter

All are excited about the upcoming 13th Annual NYSORA Symposium in September at the Marriott Marquis Hotel located in the heart of Times Square in New York City. The NYSORA Think Tank sessions (TNT) introduced at last year's NYSORA Annual Symposium, which consist of 20-minute presentations, and 10-minute rapid-fire question and answer sessions, proved to be a huge hit and garnered lots of positive feedback. A unique aspect of the TNT structure is that the delegates are allowed to ask questions, limited to 15 seconds whereas the speaker has 60 seconds to reply. The NYSORA signature TNT lectures allows a larger number of delegates to ask questions and receive answers without the delegates and/or speaker getting entangled in overly lengthy considerations and rebuttals. Additional Symposium highlights will be featured in future newsletters leading up to the symposium.

TNT discussions from the 12th NYSORA Symposium

Liposomic Bupivacaine – EXPAREL: What is new and what it means to your practice:

It is no secret that the liposome-encapsulated bupivacaine, EXPAREL, has become the “talk of the town”. An increasing number of surgeons are using EXPAREL in their practice, where applicable. Infiltration after total knee replacement with large doses of EXPAREL and local anesthetic mixed together has also become commonplace across United States. Therefore, for this year's NYSORA September Symposium, we invited an orthopedic surgeon who utilizes EXPAREL in his daily practice for total knee replacement to discuss any advantages or disadvantages. The delegates will have a chance to challenge the orthopedic surgeon on this practice as well as discuss their own observations. While EXPAREL has not been approved for use in peripheral nerve blocks, it is not a secret that some experts in local and regional anesthesia are starting to use EXPAREL for studies and indications where continuous catheters may be contraindicated. At the 13th Annual NYSORA Symposium there will be several experts sharing their expert opinions on this topic.

EXPAREL

Pec 1, Pec 2, Pec 3, Pec 4, Pec 5 and Serratus blocks

The widespread use of ultrasound knowledge and sonographic anatomy has resulted in an ever-increasing number of ultrasound guided nerve blocks and various tissue plane blocks for postoperative analgesia. Among the new techniques, PEC1 and PEC2 blocks and serratus anterior blocks promoted by Dr. Rafael Blanco are perhaps the most intriguing and most talked about. In September, Dr. Rafael Blanco will share his experiences on these techniques, and will discuss techniques and pharmacology ingredients necessary for their successful use. A discussion on their analgesic potency will take place in the NYSORA TNT format.

Artist rendition of Rafael Blanco on the road from Abu Dhabi to NYC

Interscalene blocks and phrenic paralysis

A recent article on anesthesiology by Dr. Kaufman and colleagues featured 19 patients who sustained severe injury to their phrenic nerve requiring surgical intervention for treatment. The etiology of this complication remains only speculative although etiologies ranging from direct injury to the phrenic nerve to inflammatory changes to the anterior scalene muscle, have all been postulated. Editorials have gone as far as to suggest abandoning interscalene blocks because of this risk. To demystify the nature of the lesions and the severity of the injury we have invited Dr. Matthew Kaufman, the first author of the article, to share his experiences in the TNT track of the 13th Annual NYSORA September Symposium.

Click for case report

Scientific abstracts

At last year's 12th Annual NYSORA Symposium a number of scientific abstracts were presented by delegates from throughout the world. Moving forward however, NYSORA plans to expand sharing the scientific information with the ever-growing number of NYSORA delegates. The NYSORA symposium in September will feature an abstract competition with monetary awards of $750, $550 and $250 for the winners of the first, second, and third-best scientific abstract.

Abstract presentations from last year's symposium

New to this process of scientific abstract presentation NYSORA will print all posters to avoid the hassles of poster printing and transporting. All that is required is one PowerPoint slide following the NYSORA template that will be sent to the authors. Once the authors input their basic information, the NYSORA staff will format and print all posters. The posters will be displayed throughout the meeting without the need for presenters put them up or take them down. Moreover, all accepted abstracts scoring >5 (on a 0-10 scale) will be printed in a Journal supplement to Minerva Anaesthesiologica, an indexed peer reviewed Journal.

63% of 12th NYSORA Symposium attendees were from the United States. The pie chart illustrates the breakdown of last year's international delegates.

The pie chart illustrates the breakdown of last year's United States attendance

Best practice protocols

Total knee replacement and hip arthroplasty are common orthopedic procedures that present significant challenges in regards to postoperative analgesia. Various institutions use a number of different protocols and there does not seem to be a universal agreement on the best protocol or standard of care. At the 13th Annual NYSORA September Symposium we will feature several prominent leaders in this area who will share their secrets on how they tackle postoperative pain in patients with major orthopedic surgery.

Dr. Malikah Latmore supervising a resident performing a popliteal sciatic block in a patient after total knee replacement

Adductor canal blocks

At last year's September annual symposium, we had the pleasure of hosting our colleague from Denmark (Pia Jaeger, MD) who spearheaded the development and usage of adductor canal blocks as a replacement for femoral blocks. Clearly, the task at hand is to provide additional analgesia to the knee while avoiding the weakness of the quadriceps muscle which could interfere with early mobilization and rehabilitation. However, based on multiple discussion blogs/sessions on Anesthesiology Network, some clinicians doubt the analgesic value of the adductor canal block. It is for this reason that at the upcoming 13th Annual NYSORA September Symposium we have decided to dissect this issue further and discuss the pluses and minuses of adductor canal blocks.

NYSORA's new range of illustrations from its new reverse-Ultrasound Anatomy Project. Shown is subsartorius space of relevance to "adductor canal" block

Networking at NYSORA September

Saying that NYSORA invented "CME Networking" would not be an exaggeration. Indeed, a number of our delegates are coming for the opportunity to interact with top opinion leaders, get to know the who's who in regional anesthesia and integrate into the greater regional anesthesia community. This year would not be an exception. The networking event - NYSORA's fabled Saturday evening cruise around Manhattan is back by popular demand. Featuring dancing, socializing and the gorgeous skyline of New York City, the evening cruise is an event not to be missed. Be sure to sign up as limited space is available.

NYSORA's fabled Manhattan Hudson River Cruise on Saturday Night

Also, if you are a Speaker or Exhibitor, do not miss the fabled NYSORA Bowling competition on Friday night taking place at the NYC renowned Lucky Strike Lanes. This event is for Speakers and Exhibitors only.

Bowling for Exhibitors and Speakers. Be ready to compete.

NYSORA reporter Matt Becker had a chance to interview Harold Minkowitz, MD about the use of EXPAREL in his institution. Dr. Minkowitz was one of the primary Investigators on the recently completed multi-institutional trial on EXPAREL for femoral nerve blocks in patients having total knee arthroplasty.

The liposome encapsulated bupivacaine (EXPAREL) has been recently FDA approved for soft tissue infiltration and it looks like the surgeons are competing against each other for who is going to use it first in their practice. They also seem to be coming up with all kinds of cocktails, dosages and their own injecting techniques. We have even heard of surgeons who have developed their own secret cocktails. What do you see out there in private practice in Houston?

The environment in which I work is conservative. People are using EXPAREL on label. The usage is really spreading by word of mouth as physicians are seeing the effect of the drug on their patients. However, in terms of cocktails and special uses they are limiting administration to the on label usage at this time.

What are the most common usages by surgeons that you see in your practice?

Initially the usage was confined to hemorrhoid and bunion surgery. It's use has now been adopted for abdominal surgeries, such as bariatric surgery and abdominoplasties, and also breast reconstruction and orthopedics for total-joint infiltrations. In our institution EXPAREL has been used in almost every surgery that results in significant postoperative pain.

Do these surgeons mix EXPAREL with other local anesthetics, or do they use it alone?

Some surgeons administer it following the use of local anesthetics. Others use it as a sole agent. It depends on the surgeon and their personal preference.

Can you share some dosages or volumes that are used for a few common procedures that you see being used often?

In small cases such as bunions we are using volumes as low as 10 cc but for the abdominal and plastic cases 100 to 200 cc are being infiltrated. Obviously the bigger the surgical area, the more the dilution. For total knee replacement, the surgeon is infiltrating about 100/120 cc of total volume.

What are the actual maximum doses that are being used?

We don't go above 266mg.

Ok so they pretty much stick to what the packaging says?

Correct. We administer the drug per package insert recommendations.

Have you seen any complications yet?

No. I have not seen any as yet.

In how many patients is EXPAREL used say in a month, or how many have you done so far in your practice?

We do hundreds of cases a month and I am not sure of the exact number, but we have a very busy practice.

OK, do you see EXPAREL being used, or experimented with, in peripheral nerve blocks?

No, we are a totally "by the label" group. My only experience would be from the multi-institutional femoral nerve block study, which was recently concluded.

Can you tell us a little about that nerve block study? What were you expecting to find, what did you actually find, and were you either positively or negatively surprised by the results obtained?

It was a blinded femoral nerve block study in patients undergoing total knee replacement surgery. Patients either received Exparel or placebo. For rescue pain control, both groups had access to narcotics. For additional analgesia, a bupivacaine infusion to the femoral nerve via a femoral catheter was available. (this had been placed at the time of initial nerve block). Injection was easily performed and the patients did well. However I was unaware into which group the patients fell until the results were revealed to me. Despite the sciatic nerve not being blocked, the patients from the EXPAREL group still did better than the patients in the placebo group. The study demonstrated that femoral nerve block with Exparal was safe and efficacious.

Are you itching to use EXPAREL in your own practice after, hopefully, the FDA approval comes in sometime next year?

There is no question that I am ready to start using it for peripheral nerve blocks in patients for post-op pain control.

Memorial Hermann Memorial City Medical Center, Houston, TX