ALR CONTINUE A DOMICILE Cadre réglementaire et prise en ... · Peri op er at ive pa in ma na ge men t st rat egi es for this ope rat ion ha ve ... ultras ou nd -g ui de d regi ona

ALR CONTINUE A DOMICILE Cadre réglementaire et prise en charge

infirmière spécifique

Dr GRILLO Philippe,

Anesthésiste-réanimateur, Marseille

ALR CONTINUE A DOMICILE

• Pourquoi un cathéter péri-nerveux ?

Pourquoi un cathéter péri-nerveux ?



Capdevila 2005



Capdevila 2005



Capdevila 2005



Capdevila 2005

Pourquoi un cathéter péri-nerveux ? Pourquoi un cathéter péri-nerveux ?

Richman 2006



Richman 2006



Richman 2006

Particularités Françaises

Critères d’éligibilité à l’ambulatoire

BNP continus à domicile : indications

INDICATIONS : LA BALANCE DES REALITES INDICATIONS : LA BALANCE DES REALITES

Problèmes potentielsBénéfices potentiels

Vigilance et expertise Pression de production

Correl 2014

INDICATIONS : LA BALANCE DES REALITES


Vigilance et expertise Pression de production

Correl 2014

LA BALANCE DES REALITES LA BALANCE DES REALITES


• Contrôle efficace de la douleur

• Réhabilitation précoce

• Amélioration du vécu du patient

• Engourdissement ++

• Bloc moteur

• Effets secondaires

Quel est notre objectif ? Pain Management and thePerioperative

Surgical HomeGetting theDesiredOutcomeRight

JamesCyriac, MD, MaximeCannesson, MD, PhD, andZeevKain, MD, MBA

Inthisissueof Regional AnesthesiaandPainMedicine, Grevstadet al1 present theresultsof astudycomparingquadricepsstrengthafter total kneearthroplasty (TKA) after either asingle-injectionfem-

oral nerveblock or asingle-injection adductor canal block (ACB). Weapplaud theauthorson theirimportantworkandstudydesignandexecution.Thisarticleisparticularlyrelevantbecausethemanage-mentof acutepainafterTKAcontinuestobeasubjectof intenseinterestbecauseof thesignificantpainburdenassociatedwiththissurgical procedureandthegrowingnumberof TKAsperformedworldwide.IntheUnitedStatesalone,in2010,morethan700,000primaryTKAswereperformed,2anumber that isexpectedtoreachastaggering3.4millionannuallyby2030.3Theneedisclear toestablishaneffectiveand reliableanalgesic protocol that can effectively managethesepatientswith maximal efficacy andminimal sideeffects, andthisstudy isanother stepforwardinthiseffort.

Goldstandardanalgesic techniquesarenotoriously difficult todefine, and theoptimal analgesicprotocol for TKA isno exception. Perioperativepain management strategies for thisoperation haveevolvedconsiderablyfromheavyrelianceonintravenousopioidstomultimodal analgesiaincorporatingepidural analgesia4 and/or peripheral nerveblocks.5 Inrecent years, concernshaveemergedregardingtheuseof femoral nerveblocksforpost-TKAanalgesia.Themotorinnervationof thequadricepsmuscleisinvariablycompromisedwithfemoral nerveblock,potentiallycausingdelaysinphysical therapypar-ticipationaswell ascasereportsof falls.6 Twodiscretemotor-sparingalternativestothefemoral nerveblock weredevelopedasameanstoprovideanalgesiawhilelimitingquadricepsweakness. A local in-filtration techniquedevelopedby Kerr et al7 involvestheintraoperativeperiarticular injectionof localanesthetic around theknee joint. The ACB was also defined around the same time by pioneers inultrasound-guidedregional anesthesia.8BoththeACBandthelocal infiltrationtechniqueallowfor localanalgesiadistal tothemotor innervationtothequadricepsmuscle. Comparisonsof ultrasound-guidedACB up tonowhaveshownsimilar analgesicefficacy to thefemoral nerveblock1,9,10 whilesparing(and, inthisarticle, evenenhancing) motor function.Theevolvingknowledgebaseregardinganalgesiafor TKA seemstobefollowingavery commonparadigminanesthesiaresearch. That paradigmisofever-increasing target specificity. The“shotgun” approachtopainmanagement withaheavy relianceonsystemicopioidshasevolvedtoamoreprecisetargetingof aparticular subset of nervefibers. Al-thoughthisarticleisfar fromthefinal chapter in thisbody of work, it isnonethelessanexcellentadditiontothistopicandanother stepforwardwithinthisparadigmof specificity.

Aswehaveseenafter recenthealthcare–relatedlegislativechangesintheUnitedStates,paradigmscananddoshift.Thedeliveryof surgical careiscurrentlyat thebeginningof whatwill likelybeamajorparadigmshift. Thecurrent model of surgical careisfragmentedandcommonly associatedwithwidevariability inbothquality andcost. TheAmericanSociety of Anesthesiologistshasrecently declareditssupport forasignificantchangeinparadigmstoreducebothvariabilityandcosts.Thisisviatheperi-operativesurgical home (PSH). The PSH is a “patient-centered and physician-led multidisciplinaryteam–based system of coordinated care that guides the patient through the entire surgical experi-ence.”11,12 ThePSHhasbeenproposedanddemonstratedby our institution tobeaviablealternativetotheexistingsystemof surgical caredelivery inimprovingpatient outcomes, reducinglengthof stay,improving patient satisfaction, and reducing cost.13 Implementation of thePSH involves expandingthetraditional roleof theintraoperativeanesthesiologist tothat of aperioperativephysician.

ThePSHmodel,bydefinition, leveragesdataasameanstoevaluateandimproveall interventionsandtheirefficacyinacontinuousmanner.Theopportunityfordataanalysiswill beconsiderableconsid-eringthevast amount of informationcollectedfromexistinginformationtechnology infrastructure. Ashift tothePSHmodel alsomandatesarethinkingof relevant researchmetricsandoutcomesrelevanttoour specialty. Maximumvoluntary contractionof thequadricepsmuscleasanoutcomemay indeedbeasurrogatefor analgesiawithout motor block, but isthisarelevant outcomeinour newhealthcare

FromtheDepartment of Anesthesiology, School of Medicine, Universityof CaliforniaIrvine, Irvine, CA.Acceptedfor publicationNovember 4, 2014.Addresscorrespondenceto:ZeevKain,MD,MBA,Universityof CaliforniaIrvineSchool of Medicine,Departmentof Anesthesiology,333CityDriveWestOrange,

CA 92868(e‐mail: [email protected]).Theauthorsdeclarenoconflict of interest.Copyright ©2015by AmericanSocietyof Regional AnesthesiaandPainMedicineISSN: 1098-7339DOI: 10.1097/AAP.0000000000000200

EDITORIAL

Regional AnesthesiaandPainMedicine • Volume40, Number 1, January-February2015 1

Copyright © 2014 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.

Pain Management and thePerioperativeSurgical Home

Getting theDesiredOutcomeRight

JamesCyriac, MD, MaximeCannesson, MD, PhD, andZeevKain, MD, MBA

Inthisissueof Regional AnesthesiaandPainMedicine, Grevstadet al1 present theresultsof astudycomparingquadricepsstrengthafter total kneearthroplasty (TKA) after either asingle-injectionfem-

oral nerveblock or asingle-injection adductor canal block (ACB). Weapplaud theauthorson theirimportantworkandstudydesignandexecution.Thisarticleisparticularlyrelevantbecausethemanage-mentof acutepainafterTKAcontinuestobeasubjectof intenseinterestbecauseof thesignificantpainburdenassociatedwiththissurgical procedureandthegrowingnumberof TKAsperformedworldwide.IntheUnitedStatesalone, in2010,morethan700,000primaryTKAswereperformed,2anumber that isexpectedtoreachastaggering3.4millionannuallyby2030.3Theneedisclear toestablishaneffectiveand reliableanalgesic protocol that can effectively managethesepatientswith maximal efficacy andminimal sideeffects, andthisstudy isanother stepforwardinthiseffort.

Goldstandardanalgesic techniquesarenotoriously difficult todefine, and theoptimal analgesicprotocol for TKA isno exception. Perioperativepain management strategies for thisoperation haveevolvedconsiderablyfromheavyrelianceonintravenousopioidstomultimodal analgesiaincorporatingepidural analgesia4 and/or peripheral nerveblocks.5 Inrecent years, concernshaveemergedregardingtheuseof femoral nerveblocksforpost-TKAanalgesia.Themotor innervationof thequadricepsmuscleisinvariablycompromisedwithfemoral nerveblock,potentiallycausingdelaysinphysical therapypar-ticipationaswell ascasereportsof falls.6 Twodiscretemotor-sparingalternativestothefemoral nerveblock weredevelopedasameanstoprovideanalgesiawhilelimitingquadricepsweakness. A local in-filtration techniquedevelopedby Kerr et al7 involvestheintraoperativeperiarticular injectionof localanesthetic around the knee joint. The ACB was also defined around the same time by pioneers inultrasound-guidedregional anesthesia.8BoththeACBandthelocal infiltrationtechniqueallowfor localanalgesiadistal tothemotor innervationtothequadricepsmuscle. Comparisonsof ultrasound-guidedACB up tonow haveshownsimilar analgesicefficacy to thefemoral nerveblock1,9,10 whilesparing(and, inthisarticle, evenenhancing) motor function.Theevolvingknowledgebaseregardinganalgesiafor TKA seemstobefollowingavery commonparadigminanesthesiaresearch. That paradigmisofever-increasing target specificity. The“shotgun” approach topainmanagement withaheavy relianceonsystemicopioidshasevolvedtoamoreprecisetargetingof aparticular subset of nervefibers. Al-thoughthisarticleisfar fromthefinal chapter in thisbody of work, it isnonethelessanexcellentadditiontothistopicandanother stepforwardwithinthisparadigmof specificity.

Aswehaveseenafter recenthealthcare–relatedlegislativechangesintheUnitedStates,paradigmscananddoshift.Thedeliveryof surgical careiscurrentlyat thebeginningof whatwill likelybeamajorparadigmshift. Thecurrent model of surgical careisfragmentedandcommonly associatedwithwidevariability inbothquality andcost. TheAmericanSociety of Anesthesiologistshasrecently declareditssupport forasignificantchangeinparadigmstoreducebothvariabilityandcosts.Thisisviatheperi-operative surgical home (PSH). The PSH is a “patient-centered and physician-led multidisciplinaryteam–based system of coordinated care that guides the patient through the entire surgical experi-ence.”11,12 ThePSH hasbeenproposedanddemonstratedby our institution tobeaviablealternativetotheexistingsystemof surgical caredelivery inimprovingpatient outcomes, reducinglengthof stay,improving patient satisfaction, and reducing cost.13 Implementation of thePSH involves expandingthetraditional roleof theintraoperativeanesthesiologist tothat of aperioperativephysician.

ThePSHmodel,bydefinition, leveragesdataasameanstoevaluateandimproveall interventionsandtheirefficacyinacontinuousmanner.Theopportunityfordataanalysiswill beconsiderableconsid-eringthevast amount of informationcollectedfromexisting information technology infrastructure. Ashift to thePSHmodel alsomandatesarethinkingof relevant researchmetricsandoutcomesrelevanttoour specialty. Maximumvoluntary contractionof thequadricepsmuscleasanoutcomemay indeedbeasurrogatefor analgesiawithout motor block, but isthisarelevant outcomeinour newhealthcare

FromtheDepartment of Anesthesiology, School of Medicine, Universityof CaliforniaIrvine, Irvine, CA.Acceptedfor publicationNovember 4, 2014.Addresscorrespondenceto:ZeevKain,MD,MBA,Universityof CaliforniaIrvineSchool of Medicine,Departmentof Anesthesiology,333CityDriveWestOrange,

CA 92868(e‐mail: [email protected]).Theauthorsdeclarenoconflict of interest.Copyright ©2015by AmericanSocietyof Regional AnesthesiaandPainMedicineISSN: 1098-7339DOI: 10.1097/AAP.0000000000000200

EDITORIAL

Regional AnesthesiaandPainMedicine • Volume40, Number 1, January-February2015 1

Copyright © 2014 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.

Quel est notre objectif ?

BNP continus à domicile : cadre réglementaire

BNP continus à domicile:

cadre réglementaire

Des recommandations ont été publiées par ANSM en 2012

Ropivacaine 2 mg/ml

Débit basal max 10 ml/h

Bolus max = 5 ml

Dose maximale autorisée est de 20 mg/heure

ANSM 2012




Ropivacaine 2 mg/ml


Bolus max = 5 ml


ANSM 2012

BNP continus à domicile : Cadre réglementaire




Ropivacaine 2 mg/ml


Bolus max = 5 ml


ANSM 2012




Ropivacaine 2 mg/ml


Bolus max = 5 ml


ANSM 2012




• Durée jusqu’à 72 heures

• Surveillance quotidienne ou biquotidienne par une IDE

ANSM 2012




Ropivacaine 2 mg/ml


Bolus max = 5 ml


ANSM 2012




Ropivacaine 2 mg/ml


Bolus max = 5 ml


ANSM 2012




• Anesthésiste et chirurgien peuvent être contactés 24/7

• Dossier de surveillance comprenant le geste chirurgical,

type de cathétérisme et le protocole de mis en oeuvre.

• Formation spécifique des IDE à la surveillance des

cathéters périnerveux

ANSM 2012





Ropivacaine 2 mg/ml


Bolus max = 5 ml


ANSM 2012




Ropivacaine 2 mg/ml


Bolus max = 5 ml


ANSM 2012




La surveillance comprend:

• Les paramètres communs à tous les blocs péri-nerveux efficacité analgésique, bloc moteur etc..

• Une surveillance spécifique selon le bloc réalisé dépistage d’un bloc phrénique etc..

• Retrait du cathéter sur prescription médicale

ANSM 2012


Création d’un réseau de soins Création d’un réseau de soins

lien entre l’équipe médicale et le patient doit être maintenu

après la chirurgie

Le réseau de soins Organisation de la prise en charge




Prise en charge IDEL Surveillance spécifique

Prise en charge IDEL: Surveillance spécifique

Paramètres communs à tous les blocs péri-nerveux

• constantes hémodynamiques, température • efficacité analgésique, • évaluation d’un bloc moteur, • points d’appui ou de compression • signes de surdosage • site d’insertion du cathéter (fuites et signes d’infection) • bon fonctionnement du système de perfusion

(volume perfusé)

ANSM 2012




Ropivacaine 2 mg/ml


Bolus max = 5 ml


ANSM 2012




Ropivacaine 2 mg/ml


Bolus max = 5 ml


ANSM 2012

Prise en charge IDEL Surveillance spécifique selon le bloc




Ropivacaine 2 mg/ml


Bolus max = 5 ml


ANSM 2012




Ropivacaine 2 mg/ml


Bolus max = 5 ml


ANSM 2012

Prise en charge IDEL:

Surveillance spécifique selon le bloc

• Dépistage d’un bloc phrénique avec les BIS,

• Dépistage d’une extension péridurale ou récurrentielle avec

BIS

• Dépistage d’un bloc moteur important avec nécessité de

béquillage,

ANSM 2012

Choix des IDEL Droit du patient et les impératifs de suivis

Choix des IDEL: Droit du patient et les impératifs de suivis

Expériences françaises / le + = les réseaux de soins

Choix de l’IDEL : le droit du patient + les impératifs du suivi

Question au patient (Cs Anesthésie) IDEL perso ?

NON OUI

Formée KT ?

OUI NON

Formation Réseau

IDEL n=200

Valorisation de l’acte Il n’existe pas d’actes NGAP spécifique

Valorisation de l’acte: Il n’existe pas d’actes NGAP spécifique

Valorisation de l’acte Il n’existe pas d’actes NGAP spécifique

Valorisation de l’acte: Il n’existe pas d’actes NGAP spécifique

Conclusion

Documents

ALR CONTINUE A DOMICILE Cadre réglementaire et prise en ... · Peri op er at ive pa in ma na ge men t st rat egi es for this ope rat ion ha ve ... ultras ou nd -g ui de d regi ona