American Society of Regional Anesthesia and Pain Medicine August 2018 - 12
The Crisis of Drug Shortages in Regional Anesthesia and Analgesia
T
he crisis of prescription opioid overuse and abuse has affected
countries around the world, and anesthesiologists are wellpositioned to make positive changes.1 Even minor outpatient
surgical procedures and their associated anesthesia and analgesia
techniques can lead to long-term opioid use.2,3 Patients who
present for surgery with an active opioid prescription are very likely
to still be on opioids after a year.4
Anesthesiologists have been working to establish regional
anesthesiology and acute pain medicine programs with careful
coordination of inpatient and outpatient pain management to
improve patient outcomes. Regional anesthesia, especially with
continuous peripheral nerve block (CPNB) techniques, has been
shown repeatedly to reduce patients' need for opioid analgesia.5
Today, the new crisis of drug shortages threatens to reverse our
many advancements in perioperative pain control. Local anesthetics
or numbing medications represent a class of drugs that is our
strongest weapon against opioids. These drugs (eg, bupivacaine,
lidocaine, ropivacaine) are currently in shortage.6 Regional
anesthesia with targeted injections of local anesthetic eliminates
sensation at the site of surgery and can obviate the need for
injectable opioids (eg, fentanyl, hydromorphone, morphine), which
also happen to be in short supply.6
The following are potential
ramifications of the current drug
shortages affecting anesthesia and
pain management on patient care.
A shortage of local anesthetic
medications makes it impossible
for anesthesiologists to provide this
potent form of opioid-sparing pain
control for all surgical patients. This
also means that local anesthetics
cannot be administered by surgeons
as wound infiltration to help patients
with incisional pain, and epidural
analgesia for laboring women may
not be universally available.
Edward R. Mariano, MD, MAS
Stanford University School
of Medicine
Stanford, California
and
Veterans Affairs Palo Alto
Health Care System
Palo Alto, CA
INCREASED INCIDENCE OF
POSTOPERATIVE COMPLICATIONS
Based on a study by Memtsoudis
and colleagues, 18 overall 30day mortality for total knee
arthroplasty patients is lower for
patients who receive regional
anesthesia, either neuraxial and
combined neuraxial-general
anesthesia, compared to general
anesthesia alone. In most categories, the rates of occurrence of
in-hospital complications (eg, all-cause infections, pulmonary,
cardiovascular, acute renal failure) were also lower for the
neuraxial and combined neuraxial-general anesthesia groups
combined with the general anesthesia-only group, and transfusion
requirements were lowest for neuraxial anesthesia patients
compared to all other groups.18 That said, the inability to offer
regional anesthesia (ie, spinal or epidural) to all patients because
of lack of local anesthetics represents a threat to patient safety.
"The new crisis of drug
shortages threatens to reverse
the many advancements in
perioperative pain control."
DECREASED QUALITY OF
PERIOPERATIVE PAIN MANAGEMENT
Peripheral nerve blocks (also
referred to as "regional anesthesia techniques") offer patients
many potential advantages in the immediate postoperative
period, including decreased pain, nausea and vomiting, and time
spent in the recovery room.7,8 Long-acting local anesthetics (eg,
bupivacaine, levobupivacaine, and ropivacaine) generally provide
analgesia of similar duration for 24 hours or less.9-12 The clinical
effects of nerve blocks typically last long enough for patients to
meet discharge eligibility from recovery and prevent unnecessary
hospitalization for pain control.13 A continuous peripheral nerve
block (CPNB, also known as "perineural catheters") permits delivery
of local anesthetic solutions to the site of a peripheral nerve on an
ongoing basis.14 Portable infusion devices can deliver a solution of
plain local anesthetic for days after surgery, often with the ability
to titrate the dose up and down or even stop infusion temporarily
when patients feel too numb.15,16
In a meta-analysis comparing CPNB to single-injection peripheral
nerve blocks in humans, CPNB resulted in lower patient-reported
worst pain scores and pain scores at rest on postoperative day
12
(POD) 0, 1, and 2.17 Patients who
receive CPNB also experience less
nausea, consume less opioids, sleep
better, and are more satisfied with
pain management.17 By using local
anesthetic medication to interrupt
nerve transmission along peripheral
nerves, patients continue to
experience decreased sensation as
long as the infusion is running.
INCREASED RISK FOR PERSISTENT POSTSURGICAL PAIN
Chronic pain may develop after many common operations, including
breast surgery, hernia repair, thoracic surgery, and amputation, and
is associated with severe acute pain in the postoperative period.18
Researchers conducting a Cochrane systematic review and metaanalysis reviewed published studies on the subject, and the results
favored epidural analgesia for prevention of persistent postsurgical
pain (PPSP) after thoracotomy and favored paravertebral block
for prevention of PPSP after breast cancer surgery at 6 months.20
American Society of Regional Anesthesia and Pain Medicine
2018
Table of Contents for the Digital Edition of American Society of Regional Anesthesia and Pain Medicine August 2018
American Society of Regional Anesthesia and Pain Medicine August 2018 - 1
American Society of Regional Anesthesia and Pain Medicine August 2018 - 2
American Society of Regional Anesthesia and Pain Medicine August 2018 - 3
American Society of Regional Anesthesia and Pain Medicine August 2018 - 4
American Society of Regional Anesthesia and Pain Medicine August 2018 - 5
American Society of Regional Anesthesia and Pain Medicine August 2018 - 6
American Society of Regional Anesthesia and Pain Medicine August 2018 - 7
American Society of Regional Anesthesia and Pain Medicine August 2018 - 8
American Society of Regional Anesthesia and Pain Medicine August 2018 - 9
American Society of Regional Anesthesia and Pain Medicine August 2018 - 10
American Society of Regional Anesthesia and Pain Medicine August 2018 - 11
American Society of Regional Anesthesia and Pain Medicine August 2018 - 12
American Society of Regional Anesthesia and Pain Medicine August 2018 - 13
American Society of Regional Anesthesia and Pain Medicine August 2018 - 14
American Society of Regional Anesthesia and Pain Medicine August 2018 - 15
American Society of Regional Anesthesia and Pain Medicine August 2018 - 16
American Society of Regional Anesthesia and Pain Medicine August 2018 - 17
American Society of Regional Anesthesia and Pain Medicine August 2018 - 18
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American Society of Regional Anesthesia and Pain Medicine August 2018 - 20
American Society of Regional Anesthesia and Pain Medicine August 2018 - 21
American Society of Regional Anesthesia and Pain Medicine August 2018 - 22
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http://www.brightcopy.net/allen/asra/18-04
http://www.brightcopy.net/allen/asra/18-3
http://www.brightcopy.net/allen/asra/18-2
http://www.brightcopy.net/allen/asra/18-1
http://www.brightcopy.net/allen/asra/17-4
http://www.brightcopy.net/allen/asra/17-3
http://www.brightcopy.net/allen/asra/17-2
http://www.brightcopy.net/allen/asra/17-1
http://www.brightcopy.net/allen/asra/16-4
http://www.brightcopy.net/allen/asra/16-3
http://www.brightcopy.net/allen/asra/16-2
http://www.brightcopy.net/allen/asra/16-1
http://www.brightcopy.net/allen/asra/15-4
http://www.brightcopy.net/allen/asra/15-3
https://www.nxtbook.com/allen/asra/15-2
https://www.nxtbook.com/allen/asra/15-1
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