Advanced Regional Anesthesia and Analgesia: Military Advanced Regional Anesthesia and Analgesia (MARAA)
Regional anesthesia and specifically peripheral nerve blocks have been part of our practice for many decades, but lately a combination of factors has made these techniques increasingly more relevant, even crucial, in how we approach and treat acute pain. We continue to consider anatomy as the foundation of a sound regional anesthesia practice, but within this field, we have become increasingly more aware of the importance of myofascial compartments and fascial planes, and at the same time, we have developed a better practical understanding of nerve architecture. In terms of how we perform these techniques, we have incorporated, relatively recently, ultrasound-imaging technology, which has given us not only the ability to visualize, in real time, the desired anatomical targets but also the capacity to determine spread of local anesthetic in relationship to them. The image of spread provide us, for the first time in the history of our specialty, with a tool that has the ability, albeit potential, to predict success by associating patterns of local anesthetic spread with technique success. Lately we also have developed an increased awareness of the role that successful acute pain management plays in the pathophysiology and prevention of chronic pain syndromes. What makes all these advances all the more important is that they are taking place in the midst of what has been denominated the “opioid epidemics.” This crisis, and its impact on patients, families, society, and economics, has made us reevaluate the strategies used in acute pain management and forced us to develop new and better techniques, with emphasis on narcotic-spearing modalities. In this context, a manual dedicated to the techniques of peripheral nerve blocks with emphasis on multimodal approach to acute pain is certainly welcome.
The first edition of the Military Advanced Regional Anesthesia and Analgesia (MARAA) manual was enriched by a preface written by the late Alon P Winnie, a giant in our field and a visionary in pain management, who with much foresight understood that treating acute pain goes beyond the basic and noble cause of alleviating pain in the short term.
This second edition of the MARAA manual is an improved effort to describe the relevant anatomy and procedural details of the most common techniques of regional anesthesia, within a context of modern multimodal analgesia. Although written by, and aimed primarily for the military anesthesiologist, its importance transcends any boundaries for its descriptions and recommendations are applicable to any busy center in the United States and around the world. It is, in other words, a practical tool for the modern and busy anesthesiologist looking for practical and straightforward guidelines on how to approach acute pain management. The manual itself, and the military pain initiative behind it, are the creative efforts of Dr. Chester “Trip” Buckenmaier III, a practicing anesthesiologist and a retired colonel in the Unites States Army. Dr. Buckenmaier has been a leader in the field of acute pain management and was a pioneer of military pain initiatives that have benefited our wounded soldiers in the field and during their evacuation from it. The importance of these initiatives transcends the military for they apply as well to the civilian environment. His vision, knowledge of the subject, and relentless dedication in pursuit of his goals have made him a great warrior in the noble cause of relieving our patients’ pain and suffering.
I am honored to have been invited by Dr. Buckenmaier to write this foreword, and I salute the efforts that went into writing this manual. I am sure that it will be an invaluable tool for anesthesia practitioners, military and civilian, everywhere. In a time when traditional ways of alleviating pain are being questioned, and we struggle to devise newer and better ways of dealing with acute pain and its chronic implications, the MARAA book is certainly a great tool in that fight.
Almost 50 years ago a seminal observation in the renaissance and subsequent explosive development of regional anesthesia was made by a resident prosector preparing a cadaver for a nerve block course taught by the resident’s chairman. Although the dissection was primarily focused on the nerves, the resident noted a consistent relationship between the nerves, muscles, and fascia: the brachial plexus, for example, was surrounded by a fascial sheath, provided in large part by the surrounding muscles, throughout its development and distribution to the upper extremity. As the dissection continued, he noted a similar fascial envelope surrounding the other major plexuses, cervical, lumbar, and sacral. As a result, the resident theorized that it might be possible to block an entire plexus by injecting local anesthetic through a needle inserted into its sheath, just as in producing epidural anesthesia. He tried it clinically and it worked. After his first few successful single-injection blocks, he commented to his fellow residents how useful such single injection techniques would be on the battlefield, especially since the use of a catheter would allow analgesia to last as long as necessary.
Over the subsequent half century, many (perhaps too many!) approaches to these “fascial envelopes” have been described, and many of them have become popular throughout the world. Furthermore, technological advances have kept pace with the increasing use of regional anesthesia, making all the techniques simpler to learn, safe to administer, and much more successful. Although regional anesthesia was being utilized frequently in hospital clinical practice, it took the Military Advanced Regional Anesthesia and Analgesia (MARAA) group’s vision to recognize the unique value of these techniques during wartime; for centuries, morphine has been the traditional painkiller on the battlefield, despite producing a high incidence of nausea and vomiting, bringing the possibility of abuse and dependence, and never completely abolishing the pain. Continuous plexus or peripheral blocks can relieve pain completely and can maintain relief as long as necessary. Colonel Chester C. Buckenmaier III, the founder of MARAA, personally provided the first successful application of a continuous peripheral nerve block on the battlefield: he placed a continuous catheter in the leg of a soldier who had sustained a severe shrapnel injury to his left calf from a rocket-propelled grenade. This one catheter with a continuous infusion of local anesthetic provided complete pain relief during this soldier’s entire evacuation, the initial surgery at the combat support hospital in Iraq, transport to Germany, a second surgical procedure there, transport home to Walter Reed Army Medical Center, and four additional surgical procedures there, the last being amputation. The catheter was finally removed after the last procedure, 16 days after its insertion!
As impressive as this approach is to the management of the acute pain of battlefield injuries and subsequent surgical procedures, its advantages may go even further: evidence is accumulating that neural blockade of acute pain may prevent the subsequent development of chronic pain (complex regional pain syndrome I and II, phantom limb pain, etc.); researchers are even predicting that the absence of excruciating pain following devastating injuries could prevent the development of posttraumatic stress syndrome. Only time and the data being obtained by MARAA will tell.
Military anesthesiologists should be proficient in regional anesthesia techniques, which will undoubtedly play an increasingly important role in providing pain relief and recovery during wartime. MARAA hopes to make this possible by providing this excellent, brief but complete synopsis of regional anesthesia as a resource for anesthesiologists serving in the armed forces. Not intended for the beginner or trainee, this book is carefully structured to provide a quick review of the anatomy and technique of each nerve block, formatted for easy reference on the battlefield or in the operating room. Because of the variable circumstances under which a block may be carried out on the battlefield, each technique is described using paresthesia, nerve stimulation, and ultrasound. I am certain not only that this book will go a long way toward integrating continuous plexus and peripheral nerve blocks into military medicine but also, ultimately (because soldiers aren’t soldiers forever), that both the manual and MARAA will have a positive impact on civilian medicine and, in particular, the way we manage painful trauma in large-scale civilian disasters.
Alon P. Winnie
The Military Advanced Regional Anesthesia and Analgesia (MARAA) Handbook was originally developed as a supplement to Emergency War Surgery, Third United States Revision. In Emergency War Surgery, regional anesthesia is described as “a ‘field friendly’ anesthetic requiring minimal logistical support while providing quality anesthesia and analgesia on the battlefield.” The first MARAA text has become a popular standard for military healthcare personnel deploying in support of the past 18 years of conflict. This popularity has, in part, been due to the general realization of the importance of aggressive acute pain management following trauma for the successful recovery and rehabilitation of wounded warriors. Although the MARAA text was conceived and executed in support of military healthcare providers caring for combat wounded, the lessons and techniques herein are no less effective or important for civilian trauma. The contributors to this MARAA handbook 2nd edition and the original text have collaborated to provide a useful resource for managing the pain of battlefield and civilian trauma.
Rapid advancement in medical science has been the hallmark of US military medicine throughout the nation’s history. The recent wars in Iraq and Afghanistan are no exception. Life-saving advances in body armor, rapid medical evacuation from point of injury, availability of blood products, improved far-forward surgical and critical care capability, and rapid air evacuation of casualties to level IV medical facilities have contributed to a less than 10 percent died-of-wounds rate in the current conflicts. The military medical triumph represented by this statistic is undeniable, although the achievement has resulted in other problems, particularly in the management of acute pain. Since the US Civil War, morphine has been the accepted standard for battlefield pain control because options for pain management in previous conflicts were limited, comprehension of pain mechanisms nascent, and casualties, when they survived, tended to remain near the battlefield while they recovered. Modern combat casualty care now emphasizes rapid evacuation to progressively higher levels of medical care with critical care support provided at all times (including transport). Casualties who earlier were kept in a war zone for days to weeks until they were stable for transport are now transported by plane from Iraq to Germany within eight to 72 hours of injury. The environment of evacuation aircraft—crowded, deafening, jolting, poorly lit, with limited monitoring capabilities—only magnifies the difficulties of using opioid-only pain control therapy. Healthcare providers placed in this situation are less likely to use adequate doses of morphine because of valid patient safety concerns. The large numbers of healthcare providers in the evacuation chain and long evacuation distances further complicate opioid use in these patients. Furthermore, the need for advanced techniques in the management of trauma pain is heightened with the realities of the ongoing opioid crisis in the United States that impacts all Americans both civilian and military.
Fortunately, among the medical advances arising from the current conflicts are improved understanding and management of pain in war casualties. Through the MARAA and later DVCIPM (Defense and Veterans Center for Integrative Pain Management) organizations (see Chapter 1), like-minded pain management providers from the Air Force, Army, Navy, Veterans Administration, and civilian medicine have greatly improved the management of pain in combat wounded through the application of modern pain treatment medications and technologies, including advanced regional anesthesia. In the US military, chronic pain is now recognized as a disease process of the nervous system, not just a symptom of trauma. This text celebrates this advancement, preserving what has been learned to serve as a new, higher standard for pain management in this and forthcoming conflicts.
The primary goal of this handbook is to assist with the education of anesthesiology residents, fellows, and other allied medical professionals (Special Forces’ medics, nurse anesthetists, emergency room physicians, and others) in the art and science of acute pain medicine and regional anesthesia. As John J. Bonica stated in The Management of Pain, “The proper management of pain remains, after all, the most important obligation, the main objective, and the crowning achievement of every physician.” This handbook is dedicated to the US military professionals who have been wounded in the service of this country. It is our hope that the knowledge within this text will be used to ease the burden of their wounds.
Chester C. Buckenmaier III