The continuous femoral nerve block catheter for postoperative analgesia: bacterial colonization, infectious rate and adverse effects

Effect of liposomal bupivacaine for preoperative erector spinae plane block on postoperative pain following video-assisted thoracoscopic lung surgery: a protocol for a multicenter, randomized, double-blind, clinical trial

Background

There is still a controversy about the superiority of liposomal bupivacaine (LB) over traditional local anesthetics in postoperative analgesia after thoracic surgery. This study aims to determine the effect of LB versus bupivacaine hydrochloride (HCl) for preoperative ultrasound-guided erector spinae plane block (ESPB) on postoperative acute and chronic pain in patients undergoing video-assisted thoracoscopic lung surgery.

Methods

This multicenter, randomized, double-blind, controlled trial will include 272 adult patients scheduled for elective video-assisted thoracoscopic lung surgery. Patients will be randomly assigned, 1:1 and stratified by site, to the liposomal bupivacaine (LB) group or the bupivacaine (BUPI) HCl group. All patients will receive ultrasound-guided ESPB with either LB or bupivacaine HCl before surgery and patient-controlled intravenous analgesia (PCIA) as rescue analgesia after surgery. The numeric rating scale (NRS) score will be assessed after surgery. The primary outcome is the area under the curve of pain scores at rest for 0-72 h postoperatively. The secondary outcomes include the total amount of opioid rescue analgesics through 0-72 h postoperatively, time to the first press on the PCIA device as rescue analgesia, the area under the curve of pain scores on activity for 0-72 h postoperatively, NRS scores at rest and on activity at different time points during the 0-72 h postoperative period, Quality of Recovery 15 scores at 72 h after surgery, and NRS scores on activity on postsurgical day 14 and postsurgical 3 months. Adverse events after the surgery are followed up to the postsurgical day 7, including postoperative nausea and vomiting, fever, constipation, dizziness, headache, insomnia, itching, prolonged chest tube leakage, new-onset atrial fibrillation, severe ventricular arrhythmia, deep venous thrombosis, pulmonary embolism, pulmonary atelectasis, cardiac arrest, ileus, urinary retention, chylothorax, pneumothorax, and organ failure. Analyzes will be performed first according to the intention to treat principle and second with the per-protocol analysis.

Discussion

We hypothesize that LB for preoperative ultrasound-guided ESPB would be more effective than bupivacaine HCl in reducing postoperative pain in video-assisted thoracoscopic lung surgery. Our results will contribute to the optimization of postoperative analgesia regimens for patients undergoing video-assisted thoracoscopic lung surgery.Clinical trial registration:http://www.chictr.org.cn, identifier ChiCTR2300074852.

Safety Assessment of Prolonged Nerve Catheters in Pediatric Trauma Patients: A Case Series Study

INTRODUCTION

Nerve block catheters (NBCs) are increasingly used for pain management in pediatric trauma patients. While short-term efficacy has been well established, the long-term safety of NBCs is unknown. Methods/Cases: The retrospective chart review includes a cohort of nine pediatric trauma patients aged 3-15 years who received 52 peripheral nerve block catheters and epidurals for pain management. This study aimed to investigate the potential risks associated with the prolonged use of NBCs in pediatric trauma cases.

RESULTS

The NBCs (48 peripheral catheters and 4 epidural catheters) were maintained for about 2 weeks. The number of catheters per patient varied from 1 to 11. The study noted a low frequency of catheter-related complications. No catheter-site infection or local anesthetic toxicity symptoms were reported.

DISCUSSION

These findings suggest that NBCs can be safely maintained for extended periods in pediatric trauma patients without significantly increasing complications. Careful monitoring and adherence to infection control practices remain paramount when implementing extended catheter use.

Neurological injury following peripheral nerve blocks: a narrative review of estimates of risks and the influence of ultrasound guidance

BACKGROUND

Peripheral nerve injury or post-block neurological dysfunction (PBND) are uncommon but a recognized complications of peripheral nerve blocks (PNB). A broad range of its incidence is noted in the literature and hence a critical appraisal of its occurrence is needed.

OBJECTIVE

In this review, we wanted to know the pooled estimates of PBND and further, determine its pooled estimates following various PNB over time. Additionally, we also sought to estimate the incidence of PBND with or without US guidance.

EVIDENCE REVIEW

A literature search was conducted in six databases. For the purposes of the review, we defined PBND as any new-onset sensorimotor disturbances in the distribution of the performed PNB either attributable to the PNB (when reported) or reported in the context of the PNB (when association with a PNB was not mentioned). Both prospective and retrospective studies which provided incidence of PBND at timepoints of interest (>48 hours to <2 weeks; >2 weeks to 6 weeks, 7 weeks to 5 months, 6 months to 1 year and >1 year durations) were included for review. Incidence data were used to provide pooled estimates (with 95% CI) of PBND at these time periods. Similar estimates were obtained to know the incidence of PBND with or without the use of US guidance. Additionally, PBND associated with individual PNB were obtained in a similar fashion with upper and lower limb PNB classified based on the anatomical location of needle insertion.

FINDINGS

The overall incidence of PBND decreased with time, with the incidence being approximately 1% at <2 weeks' time (Incidence per thousand (95% CI)= 9 (8; to 11)) to approximately 3/10 000 at 1 year (Incidence per thousand (95% CI)= 0. 3 (0.1; to 0.5)). Incidence of PBND differed for individual PNB with the highest incidence noted for interscalene block.

CONCLUSIONS

Our review adds information to existing literature that the neurological complications are rarer but seem to display a higher incidence for some blocks more than others. Use of US guidance may be associated with a lower incidence of PBND especially in those PNBs reporting a higher pooled estimates. Future studies need to standardize the reporting of PBND at various timepoints and its association to PNB.

Liposomal Bupivacaine Versus Continuous Nerve Block: Liposomal Bupivacaine May be Non-inferior and More Cost Effective

BACKGROUND

Regional anesthesia with adductor canal block has become the standard of care for pain management after total knee arthroplasty (TKA). We hypothesized that liposomal bupivacaine (LB) may be noninferior to continuous nerve block with a pain pump in terms of average pain scores, 30- and 90-day readmissions, and emergency department (ED) visits while reducing cost.

METHODS

A retrospective chart review was performed on primary TKA patients from 2015 to 2020 by 23 orthopaedic surgeons at a single institution. The inclusion criteria was treatment with LB or a pain pump, and exclusion criteria was receipt of both anesthetics and revision surgery. A total of 2,378 patients met the inclusion criteria with 1,640 patients treated with LB and 738 treated with the pain pump. Demographic differences were not statistically significant. Primary outcomes were average pain scores, 30- and 90-day readmissions, and ED visits. Secondary outcomes were average milligram morphine equivalents per admission, hospital lengths of stay , and costs.

RESULTS

There was no significant difference in pain scores on postoperative days 0, 1, 2, or 3 (P = .77, .86, 0.08, and 0.40, respectively), 30- or 90- day readmissions (P = .527 and P = .374), ED visits (P = .129 and P = .108), milligram morphine equivalents utilizations (P = .194), or average hospital LOS (P = .348). We estimated a potential cost savings of $95 per patient and $155,800 over the course of the study.

CONCLUSION

LB was found to be noninferior to a pain pump, and the transition to this medication was associated with cost savings.

Single shot adductor canal block combined with intravenous patient-controlled analgesia can be effective as continuous adductor canal block in reducing opioid consumption and breakthrough pain after total knee arthroplasty

PURPOSE

The aim of this study was to compare the following three analgesic methods after Total knee arthroplasty (TKA): intravenous patient-controlled analgesia (IV-PCA), continuous adductor canal block (C-ACB), and intravenous patient-controlled analgesia combined with single shot adductor canal block (PCA + sACB).

METHODS

Records of 482 patients undergoing primary TKA from September 2019 to September 2020 were analyzed. Patients were divided into three pain control groups: IV-PCA (n = 180), C-ACB (n = 173) and PCA + sACB (n = 129). Single shot adductor canal block was performed 24 h after surgery in the PCA + sACB group. Rescue opioid consumption, breakthrough pain, pain numerical rating scale (NRS), and anti-emetics administration were measured from postoperative day (POD) 1 to POD 5.

RESULTS

Rescue opioid consumption was less in C-ACB or PCA + sACB group than in the IV-PCA group at POD1 (p < 0.001 and p = 0.002, respectively). Patients in C-ACB and PCA + sACB groups had less breakthrough pain (NRS > 5) than the IV-PCA group at POD1 (p = 0.007). On POD2, C-ACB was statistically superior to IV-PCA (p = 0.011) in terms of breakthrough pain. Postoperative pain NRS was lower in the C-ACB and PCA + sACB groups than in the IV-PCA group (p = 0.025 and p = 0.019, respectively). The total number of anti-emetics consumption was lower in C-ACB and PCA + sACB groups than in the IV-PCA group (p = 0.003 and p = 0.002, respectively).

CONCLUSION

PCA + sACB not only reduced patients' need for rescue opioids, but also decreased the number of breakthrough pain and anti-emetics compared to IV-PCA in early postoperative days after TKA. However, C-ACB and PCA + sACB did not differ significantly in analgesic efficacy or opioid-related side effects. PCA + sACB can be as effective as C-ACB for patients undergoing TKA.

LEVEL OF EVIDENCE

Retrospective cohort study, level III.

Review on Nerve Blocks Utilized for Perioperative Total Knee Arthroplasty Analgesia

Total Knee Arthroplasty (TKA) is an increasingly common procedure performed for advanced osteoarthritis. Optimal perioperative pain management strategies are critical for early mobilization and shorter hospital stays in TKA. Peripheral nerve blocks commonly used in TKA perioperative analgesia including individual and combined femoral, obturator, sciatic, lumbar plexus, and adductor canal nerve blocks. Overall, the safety profile varies depending on which block is utilized, but the current evidence suggests when optimally chosen and delivered, peripheral nerve blocks may provide a safe, effective option for perioperative analgesia. Determining optimal analgesic regimens for total knee arthroplasty is critical to improve postoperative pain, patient satisfaction, decreasing opioid usage, recovery times and functional outcomes, and as such, peripheral nerve blocks may represent a viable option to supplement analgesic requirements in the perioperative period.

The Use of Multimodal Perineural Adjuvants in Pediatric Peripheral Nerve Blocks: Technique and Experiences

Background

Postoperative pain management in pediatric population can be very challenging. How to prolong the duration of single-injection peripheral nerve blocks has been widely discussed. Multiple medications are under investigation to accomplish this, yet data specifically focused on their use in pediatric peripheral nerve blocks are limited.

Methods

Anesthetic electronic medical records were queried for any instances where adjuvant drug(s) were used in peripheral nerve blocks during a two-year period at a pediatric surgical specialty hospital. These included buprenorphine, clonidine, dexamethasone, and dexmedetomidine. 

Results

Out of 1,845 blocks placed during the study period, 1,148 (62.2%) utilized perineural adjuvants. Buprenorphine as a sole agent was the most common choice (49.5%), followed by buprenorphine and dexmedetomidine combined (39.9%), dexmedetomidine alone (10.1%), and the rare combination of all three drugs, buprenorphine, dexmedetomidine, and dexamethasone (0.5%). The mean dose of buprenorphine given was 3.6 mcg/kg total, 2.8 mcg/kg/block. The mean dose of dexmedetomidine given was 0.9 mcg/kg total, 0.6 mcg/kg/block. The mean dose of dexamethasone utilized was 2 mg total, 1 mg/block. 

Conclusions

This report examined one institution’s use of multimodal perineural adjuvants in over 1,000 pediatric peripheral nerve blocks. Buprenorphine was the agent most commonly used to prolong the single-injection peripheral nerve block. This highlights the need for future prospective trials evaluating efficacy and safety.

Iatrogenic femoral nerve injuries: Analysis of medico-legal issues through a scoping review approach

Purpose

Accidental femoral nerve injury is a well-known iatrogenic complication of orthopaedic, abdominal, and pelvic surgery. Because of the largely transitory nature of the symptoms associated with nerve damage, its true incidence is in all likelihood underestimated. This work aims to illustrate the surgical contexts within which this nerve injury is reported, based on the evidence obtained from a Scoping Review of the literature of the last 20 years, with specific reference to the underlying etiopathogenetic mechanisms and prognostic outcomes, to highlight the evaluation issues of medico-legal interest related to this pathology.

Methods

We conducted a Scoping Review of iatrogenic femoral nerve injuries reported between 2000 and 2021 by searching the electronic databases Pubmed, Scopus, Ovid Medline, Ovid Emcare, and Web of Science.We conducted the review according to the five-step methodology outlined by Arksey and O'Malley.

Results

The literature search identified 104 papers, including case reports, case series, and retrospective studies. Surgical contexts within which iatrogenic femoral nerve injuries were reported include orthopaedic, abdominal, gynaecological, urological, vascular, and plastic surgery, as well as locoregional anaesthesiological procedures. The long-term prognosis was generally favourable.

Conclusions

Because of its frequent iatrogenic genesis, femoral nerve injury is a topic of intense medico-legal interest. From the perspective of estimating the patient's disability, the mostly favourable nature of the prognosis makes the medico-legal assessment, in some respects, complex, thus requiring a precise evaluation methodology.

Complications Associated with Peripheral Nerve Blocks

Outpatient orthopedic surgery is gradually becoming the standard across the country, as it has been found to significantly lower costs without compromising patient care. Peripheral nerve blocks (PNBs) are largely what have made this transition possible by providing patients excellent pain control in the immediate postoperative period. However, with the increasing use of PNBs, it is important to recognize that they are not without complications. Although rare, these complications can cause patients a significant amount of morbidity. It is important for surgeons to know the risks of peripheral nerve blocks and to inform their patients.

Randomized Double-Blind Controlled Trial Comparing 0.2 mg, 0.1 mg, and No Intrathecal Morphine Combined With Periarticular Injection for Unilateral Total Knee Arthroplasty

Background

The addition of intrathecal morphine (ITM) to neuraxial anesthesia during total knee arthroplasty (TKA) to achieve postoperative analgesia can elicit opioid-related side effects. The other methods of pain alleviation and side effect reduction, including multimodal analgesia, are challenging. This study aimed to determine the efficacy of various ITM dosages for primary unilateral TKA with periarticular injection (PI).

Methods

This randomized double-blind controlled trial was conducted at Vajira Hospital between April 2018 and March 2019. Patients undergoing TKA were randomized into 3 groups: no ITM (M₀), ITM 0.1 mg (M₁), and ITM 0.2 mg (M₂). All patients received PI. Postoperative pain scores, side effects of ITM, and orthopedic outcomes were compared.

Results

The trial enrolled 102 patients: M₀ (n = 32), M₁ (n = 35), and M₂ (n = 35). The postoperative pain scores and rescue analgesic consumption of groups M₁ and M₂ did not differ significantly within the first 24 hours and were significantly lower than those in group M₀. Nausea and vomiting were observed more frequently 4 hours postoperatively in M₂ than in groups M₁ and M₀ (77%, 51%, and 6%, respectively; P < .05), which required second-line antiemetic administration (29%, 9%, and 13%, respectively; P = .09).

Conclusion

Postoperative pain control achieved with PI combined with ITM 0.1 mg after primary unilateral TKA was comparable to that achieved with ITM 0.2 mg. PI without ITM resulted in higher pain scores and rescue analgesic consumption. The frequency and severity of nausea and vomiting 4 hours postoperatively were also lower in patients administered 0.1 mg of ITM than those in patients administered 0.2 mg of ITM.

Two per cent alcoholic chlorhexidine versus alcoholic five per cent povidone-iodine for the prevention of perineural catheter colonisation: The CHLOVEPI randomised, controlled trial

BACKGROUND

Multimodal analgesia, including a regional technique using perineural catheters (PNCs), is recommended for the treatment of moderate-to-severe acute postoperative pain. Perineural catheters are at risk of bacterial colonisation. In this study, we compared the cutaneous antiseptic efficacy of 2% alcoholic chlorhexidine and povidone-iodine-alcohol for preventing the bacterial colonisation of PNCs in orthopaedic surgery.

METHODS

We performed a randomised, controlled trial, comparing two cutaneous antisepsis strategies, one based on 2% alcoholic chlorhexidine and the other on povidone-iodine-5% alcohol, for placed PNCs before orthopaedic surgery. The primary endpoint was the incidence of catheter bacterial colonisation (threshold > 1000 colony-forming units/ml). The secondary endpoints were the incidence of catheter-related infections and the adverse effects of the antiseptic solutions.

RESULTS

From November 2016 to May 2018, we included 113 patients in this study. The use of alcoholic chlorhexidine was associated with a lower incidence of catheter colonisation (15.5% (n = 9) versus 32.7% (n = 18); OR: 0.28 [0.09-0.77], p =  0.01). No catheter-related infections or adverse effects of antiseptic solutions were observed in either group. The risk factors associated with colonisation were a duration of catheter use ≥ 3 days (p =  0.04) and obesity (p = 0.005). The most frequently identified bacterium was Staphylococcus epidermidis.

CONCLUSION

Skin disinfection with 2% alcoholic chlorhexidine decreases bacterial colonisation rates for placed perineural catheters.

The effect of post-operative ultrasound-guided transmuscular quadratus lumborum block on post-operative analgesia after hip arthroplasty in elderly patients: A randomised controlled double-blind study

Background and Aim

The best analgesic technique after hip surgeries is a matter of debate. This clinical trial aimed to assess the effect of transmuscular ultrasound-guided quadratus lumborum (QL) block on post-operative analgesic consumption after hip arthroplasty in elderly patients.

Methods

This prospective randomised double-blind study was carried out on 60 patients aged 60-80 years presented for total hip replacement under unilateral spinal anaesthesia. Patients were randomly allocated to one of two groups: A control group, receiving sham transmuscular QL block (QLB) (1 ml of normal saline), and a QL group, receiving real transmuscular QLB (30 ml of plain bupivacaine 0.25%). Post-operative morphine consumption (primary outcome), post-operative pain score (secondary outcome), time to the first request of rescue analgesia, patient's satisfaction and the occurrence of post-operative complications were measured.

Results

Compared to the control group, the use of QLB in the second group significantly decreased intravenous morphine consumption postoperatively from 8.50 ± 3.06 mg to 5.60 ± 3.22 mg (P = 0.0007) with a significant prolongation of the time to the first call for analgesia (P < 0.0001). It also decreased the post-operative visual analogue score 4 h, 6 h and 8 h postoperatively (P < 0.05). However, there was no difference between both the groups regarding patient's satisfaction and the occurrence of complications (P > 0.05).

Conclusion

The use of transmuscular QLB in patients undergoing total hip replacement decreased post-operative analgesic consumption and post-operative pain score and prolonged post-operative analgesia. It did not affect patients' satisfaction and occurrence of post-operative complications.

Efficacy of Periarticular Cocktail Injection in Rheumatoid Patients Undergoing Total Knee Replacement

BACKGROUND

Pain control after total knee replacement (TKR) is of primary importance to joint replacement surgeons to achieve good functional outcome post-surgery. This becomes even more challenging when these major procedures are done in immunocompromised patients like rheumatoid arthritis. Good peri-operative analgesia facilitates early rehabilitation, improves patient satisfaction, and reduces the hospital stay. The adverse effects caused by epidural analgesia or parenteral opioids can be avoided by replacing it with an analgesic cocktail locally. Our prospective study was to evaluate the benefits of a periarticular cocktail injection which was given in rheumatoid patients undergoing bilateral TKR in single sitting with respect to pain and knee motion recovery.

METHODS

Sixty-four rheumatoid arthritis patients undergoing simultaneous primary total knee replacement were included in the study. A total of 128 knees were randomized either to receive a periarticular intra-operative injection containing ropivacaine, fentanyl, clonidine, cefuroxime and epinephrine (Group A) on one knee and to receive plain ropivacaine (Group B) on the opposite knee. The perioperative and post-operative analgesic regimens were standardized. All patients received the same standard analgesia protocol. Visual analog scores for pain, knee range of motion and quadriceps function were recorded on the day of surgery, first post-operative day, second post-operative day, day of discharge, and 2 weeks and 6 weeks during follow-up. The need for rescue analgesic requirement and adverse effects to the cocktail injection were also noted during the study period.

RESULTS

The patients who received the periarticular cocktail fared better in terms of pain scores and functional recovery. Additional rescue agents used were significantly less at 6 h, at 12 h, and over the first 24 h after the surgery in group A when compared with group B. No cardiac or central nervous system toxicity was observed.

CONCLUSIONS

Periarticular cocktail injection significantly reduces the requirements for post-operative analgesia and also improves patient satisfaction, with no apparent risks, following total knee arthroplasty in rheumatoid arthritis.

SBA 2020: Regional anesthesia safety recommendations update

The purpose of the Brazilian Society of Anesthesiology (SBA)’s Regional Anesthesia Safety Recommendations Update is to provide new guidelines based on the current relevant clinical aspects related to safety in regional anesthesia and analgesia. The goal of the present article is to provide a broad overview of the current knowledge regarding pre-procedure asepsis and antisepsis, risk factors, diagnosis and treatment of infectious complications resulting from anesthetic techniques. It also aims to shed light on the use of reprocessed materials in regional anesthesia practice to establish the effects of aseptic handling of vials and ampoules, and to show cost-effectiveness in the preparation of solutions to be administered continuously in regional blockades. Electronic databases were searched between January 2011 (final date of the literature search for the past SBA recommendations for safety in regional anesthesia) and September 2019. A total of 712 publications were found, 201 of which were included for further analysis, and 82 new publications were added into the review. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the quality of each study and to classify the strength of evidence. The present review was prepared by members of the SBA Technical Standards Committee.

Femoral nerve block at time of ACL reconstruction causes lasting quadriceps strength deficits and may increase short-term risk of re-injury

PURPOSE

To determine whether femoral nerve blockade (FNB) at the time of primary ACL reconstruction is associated with meeting isokinetic extension strength return to sport criteria near completion of physical therapy and whether FNB affects 1-year or 2-year risk of ipsilateral ACL graft rupture or contralateral native ACL injury.

METHODS

Three-hundred and sixty patients (n = 244 with FNB, n = 116 no FNB) underwent primary ACL reconstruction. All patients completed rehabilitation and underwent functional strength testing towards the end of knee rehabilitation (mean 5.6 months post-surgery). Association between FNB and isokinetic extension strength limb symmetry index (LSI) (goal LSI ≥ 90% for return to sport) as well as risk of recurrent ACL injury within first or second year after surgery was evaluated.

RESULTS

Ipsilateral or contralateral ACL injury within 2 years occurred in 11.2% of patients with FNB and 5.7% without FNB (p = 0.01). Patients with FNB had higher incidence of ipsilateral graft rupture within the first year after surgery but no difference in graft rupture during the second. Two-year risk of contralateral ACL injury was similar in both groups. At the time of initial testing, patients who received FNB had lower fast isokinetic extension LSI versus patients without FNB and were less likely achieve a goal ≥ 90% LSI; slow extension LSI was unaffected.

CONCLUSION

Use of FNB at the time of primary ACL reconstruction can negatively affect achievement of isokinetic extension strength return to sport criteria. FNB increases risk of graft rupture within the first year after surgery but does not affect re-injury risk during the second. FNB may not be appropriate for use in patients already at high risk of ACL re-injury.

LEVEL OF EVIDENCE

III.

[SBA 2020: Regional anesthesia safety recommendations update]

The purpose of the Brazilian Society of Anesthesiology's (SBA) Regional Anesthesia Safety Recommendations Update is to provide new guidelines based on the current relevant clinical aspects related to safety in regional anesthesia and analgesia. The goal of the present article is to provide a broad overview of the current knowledge regarding pre-procedure asepsis and antisepsis, risk factors, diagnosis and treatment of infectious complications resulting from anesthetic techniques. It also aims to shed light on the use of reprocessed materials in regional anesthesia practice to establish the effects of aseptic handling of vials and ampoules, and to show cost-effectiveness in the preparation of solutions to be administered continuously in regional blockades. Electronic databases were searched between January 2011 (final date of the literature search for the past SBA recommendations for safety in regional anesthesia) and September 2019. A total of 712 publications were found, 201 of which were included for further analysis, and 82 new publications were added into the review. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the quality of each study and to classify the strength of evidence. The present review was prepared by members of the SBA Technical Standards Committee.

Is continuous catheter adductor canal block better than single-shot canal adductor canal block in primary total knee arthroplasty?: A GRADE analysis of the evidence through a systematic review and meta-analysis

BACKGROUND

The adductor canal block (ACB) has emerged as an alternative to the femoral nerve block (FNB) after total knee arthroplasty. This meta-analysis was conducted to investigate which ACB method provides better pain relief and functional recovery after total knee arthroplasty METHODS:: We conducted a meta-analysis to identify randomized controlled trials involving single-shot adductor canal block (SACB) and continuous catheter ACB (CACB) after TKA up to December 2019 by searching databases including the PubMed, Web of Science, Embase, Cochrane Controlled Trials Register, Cochrane Library, CBM, CNKI, VIP, and Wanfang databases. Finally, we included 8 randomized controlled trials involving 702 knees in our study. We used Review Manager Software and Grading of Recommendations Assessment, Development, and Evaluation profiler to perform the meta-analysis.

RESULTS

Compared with SACB, CACB can achieve better postoperative pain relief at 24 and 48 h both at rest and after mobilization, lower amount of opioid consumption at 72 h, a shorter length of hospital stay (LOH) and larger range of motion (ROM). In addition, the Timed Up and Go (TUG) test results; quadriceps strength; and incidence of complications, including postoperative nausea and vomiting, DVT, catheter-related infections, catheter dislodgement and neurologic deficits, showed no significant difference between the two ACB methods.

CONCLUSION

The results of this study demonstrate that CACB is an effective alternative to SACB and can provide better pain relief, a shorter LOH, more degrees of maximum flexion and a lower amount of opioid consumption over time, but it provides a comparable level of recovery of quadriceps strength and mobility with a similar risk of catheter-related complications. Thus, CACB may be a better analgesia strategy than SACB after TKA at present.

Implementing Regional Nerve Blocks in Hip Fracture Programs: A Review of Regional Nerve Blocks, Protocols in the Literature, and the Current Protocol at The Queen's Medical Center in Honolulu, HI

Hip fractures are a common cause of acute pain in elderly patients. However, pain may be undertreated due medical comorbidities. Strong evidence supports the use of regional nerve blocks to reduce preoperative pain after hip fracture. Despite recommendations for their use, regional nerve blocks may not be in widespread practice in the United States. To help promote the addition of regional nerve blocks into hip fracture protocols, this paper will provide an overview of two commonly used regional nerve blocks for hip fracture (fascia iliaca compartment block and femoral nerve block), review the regional nerve block protocols presented in 12 studies, and present the detailed protocol currently in use at The Queen's Medical Center in Honolulu, HI.

Descriptive observational study on early functional recovery and postoperative pain in knee joint replacement surgery

INTRODUCTION

The management of postoperative pain in joint replacement surgery represents a challenge. Therefore, the advent of new strategies in the management of pain such as local infiltration analgesia (LIA) and the adductor canal block, allowed an adequate postoperative pain control and early rehabilitation of the patient in total knee arthroplasty.

MATERIALS AND METHODS

A descriptive, observational and longitudinal study of a prospective cohort of patients operated by the group of joint replacements between September 29, 2017 and November 30, 2017 was conducted. They were evaluated with the analog pain scale for postoperative pain at 5 different times (1:Upon leaving recovery; 2:On the first postoperative day; 3:Before initiating in-hospital physical therapy; 4:At the end of physical therapy, and 5:Upon departure from the clinic).

RESULTS

Of the 141 patients operated on, 70.9% of the patients were managed with LIA and 29.1% with adductor canal block. There were no differences between groups in postoperative pain assessment during the 5 different times (P≥.45).

DISCUSSION

Our results indicate that LIA and the adductor canal blockade demonstrated the same efficacy for the control of postoperative pain and rehabilitation.

Continuous adductor canal block following total knee arthroplasty provides a better analgesia compared to single shot: A prospective randomized controlled trial

OBJECTIVE

The aim of this study was to compare single-shot adductor canal block and continuous infusion adductor canal block techniques in total knee arthroplasty patients.

METHODS

We prospectively randomized 123 patients who were scheduled for unilateral primary total knee arthroplasty surgery into single shot (n = 60; mean age: 67.1 ± 6.9 years) and continuous (n = 63; mean age: 66.9 ± 6.8 years) adductor canal block groups. Postoperative visual analog scale pain scores, need for additional opioids and functional results as; timed up and go test, the 30-s chair stand test, 5 times sit-to-stand test, the 6-min walking test, the time to active straight leg raise, time to walking upstairs, maximal flexion at the time of discharge, duration of stay in hospital were compared between the two groups.

RESULTS

Pain scores were lower in the continuous adductor canal block group as compared to the single-shot adductor canal block group throughout the postoperative period (p = 0.001). Rescue analgesia was required for 6 (10%) patients in the single shot group and for 1 (1.59%) patient in the continuous group (p = 0.044). Patients in the continuous adductor canal block group displayed better functional results than the single-shot adductor canal block group with respect to active straight-leg rise time (25.52 ± 4.56 h vs 30.47 ± 8.07 h, p = 0.001), 6-min walking test (74.52 ± 29.38 m vs 62.18 ± 33.32 m, p = 0.035) and maximal knee flexion degree at discharge (104.92 ± 5.35° vs 98.5 ± 7.55°, p = 0.001). There was no significant difference between the two groups for other functional and ambulation scores.

CONCLUSION

Pain control following total knee arthroplasty was found to be better in those patients treated with continuous adductor canal block as compared to those treated with single-shot adductor canal block. Patients treated with continuous adductor canal block also displayed better ambulation and functional recovery following total knee arthroplasty.

LEVEL OF EVIDENCE

Level I, Therapeutic Study.

Knotted Femoral Nerve Catheter

We describe a case of knotting of a femoral nerve catheter which prevented removal by traction after knee replacement surgery. In this context, early surgical removal should be performed as bacterial colonization of femoral catheters is common. Radiological imaging of the catheter may assist decision-making about whether to persist with traction and what surgical approach is required. Minimizing the length of catheter inserted to less than 10 cm makes knotting unlikely, but will decrease the chance of achieving lumbar plexus blockade which could improve analgesia if the catheter passes centrally.

Lower extremity regional anesthesia: essentials of our current understanding

The advent of ultrasound guidance has led to a renewed interest in regional anesthesia of the lower limb. In keeping with the American Society of Regional Anesthesia and Pain Medicine's ongoing commitment to provide intensive evidence-based education, this article presents a complete update of the 2005 comprehensive review on lower extremity peripheral nerve blocks. The current review article strives to (1) summarize the pertinent anatomy of the lumbar and sacral plexuses, (2) discuss the optimal approaches and techniques for lower limb regional anesthesia, (3) present evidence to guide the selection of pharmacological agents and adjuvants, (4) describe potential complications associated with lower extremity nerve blocks, and (5) identify informational gaps pertaining to outcomes, which warrant further investigation.

The analgesic efficacy of the continuous adductor canal block compared to continuous intravenous fentanyl infusion with a single-shot adductor canal block in total knee arthroplasty: a randomized controlled trial

Background

The adductor canal block (ACB) is an effective intervention for postoperative analgesia following total knee arthroplasty (TKA). However, the ideal ACB regimen has not yet been established. We compared the analgesic effects between a continuous ACB group and fentanyl-based intravenous patient-controlled analgesia (IV-PCA) with a single-shot ACB group.

Methods

Patients who underwent TKA were randomly allocated to either a continuous ACB group (Group CACB) or IV-PCA with a single-shot ACB group (Group IVACB). Before the surgery, ultrasound guided ACB with 0.5% ropivacaine 20 cc was provided to all patients. Before skin incision, the infusion system (0.2% ropivacaine through an adductor canal catheter in group CACB vs. intravenous fentanyl in group IVACB) was connected. The postoperative pain severity; the side effects of local anesthetics and opioids; administration of rescue analgesics and anti-emetics; and sensorimotor deficits were measured.

Results

Postoperative pain severity was significantly higher in the IVACB group at 30 min, 4 h, 24 h, and 48 h after surgery. The averages and standard deviations (SD) of the NRS score of postoperative pain were 0.14 ± 0.37, 4.57 ± 2.37, 6.00 ± 1.63, and 4.28 ± 1.49, respectively in the IVACB group. Rescue analgesic requirements and quadriceps muscle strength were not statistically different between the groups throughout the postoperative period. Moreover, rescue antiemetic requirements were higher in group IVACB than group CACB.

Conclusions

In this study, the continuous ACB provided superior analgesia and fewer side effects without any significant motor deficit than the IV-PCA with a single-shot ACB.

Validating the Role of Steroid in Analgesic Cocktail Preparation for Local Infiltration in Total Knee Arthroplasty: A Comparative Study

BACKGROUND

Pain control after total knee arthroplasty (TKA) through local analgesic cocktail preparation has gained widespread popularity in recent times. Local steroids have potent anti-inflammatory effect leading to reduced postoperative swelling and pain which might increase the efficacy and duration of local infiltration analgesia.

AIM

The aim is to evaluate whether the addition of local steroid to an injectable analgesic cocktail for periarticular infiltration leads to better pain control and knee range of motion (ROM) in the immediate postoperative period compared to patients who do not receive steroid in their cocktail.

SETTINGS AND DESIGNS

A prospective study was conducted in a group of 140 patients undergoing unilateral TKA between June 2017 and December 2017.

MATERIALS AND METHODS

All the patients in the study group received either periarticular infiltration with an analgesic cocktail (Group I, n = 70) or analgesic cocktail with 100 mg methylprednisolone (Group II, n = 70) for postoperative pain with ultrasound-guided adductor canal block (ACB). Patients were evaluated with visual analog scale (VAS) for pain at 8, 24, and 48 h postoperatively and ROM at 48 h after surgery.

STATISTICAL ANALYSIS

The SPSS 19.0 software (SPSS Inc., Chicago, IL, USA) was used for the statistical analysis. Student t-test has been used to find the pairwise significance.

RESULTS

Group II had a statistically significant decrease in VAS scores at 8 h (P = 0.096), first postoperative day (P = 0.0001) and second postoperative day (P = 0.0001) as compared to Group I. However, there was no statistically significant difference seen with early ROM in both the groups at 48 h (P < 0.361).

CONCLUSION

Patients who received steroid cocktail infiltration plus ACB had an improved and better postoperative analgesia in an early postoperative period of 24-48 h; however, there was no significant difference in clinical ROM and functional outcome when compared to the study group.

Psoas Versus Femoral Blocks: A Registry Analysis of Risks and Benefits

BACKGROUND AND OBJECTIVES

Psoas blocks are an alternative to femoral nerve blocks and have the potential advantage of blocking the entire lumbar plexus. However, the psoas muscle is located deeply, making psoas blocks more difficult than femoral blocks. In contrast, while femoral blocks are generally easy to perform, the inguinal region is prone to infection. We thus tested the hypothesis that psoas blocks are associated with more insertion-related complications than femoral blocks but have fewer catheter-related infections.

METHODS

We extracted 22,434 surgical cases from the German Network for Regional Anesthesia registry (2007-2014) and grouped cases as psoas (n = 7593) and femoral (n = 14,841) blocks. Insertion-related complications (including single-shot blocks and catheter) and infectious complications (including only catheter) in each group were compared with χ tests. The groups were compared with multivariable logistic models, adjusted for potential confounding factors.

RESULTS

After adjustment for potential confounding factors, psoas blocks were associated with more complications than femoral blocks including vascular puncture 6.3% versus 1.1%, with an adjusted odds ratio (aOR) of 3.6 (95% confidence interval [CI], 2.9-4.6; P < 0.001), and multiple skin punctures 12.6% versus 7.7%, with an aOR of 2.6 (95% CI, 2.1-3.3; P <0.001). Psoas blocks were also associated with fewer catheter-related infections: 0.3% versus 0.9% (aOR of 0.4; 95% CI, 0.2-0.8; P = 0.016), and with improved patient satisfaction (mean ± SD 0- to 10-point scale score, 9.6 ± 1.2 vs 8.4 ± 2.9; P < 0.001). Results from a propensity-matched sensitivity analysis were similar.

CONCLUSIONS

Psoas blocks are associated with more insertion-related complications but fewer infectious complications.

CLINICAL TRIAL REGISTRATION

ID NCT02846610.

Regional Anesthesia and Analgesia for Acute Trauma Patients

Regional anesthesia for the acute trauma patient is increasing due to the growing appreciation of its benefits, development of newer techniques and equipment, and more robust training. Block procedures are expanding beyond perioperative interventions performed exclusively by anesthesiologists to paramedics on scene, emergency medicine physicians, and nurse-led services using these techniques early in trauma pain management. Special considerations and indications apply to trauma victims compared with the elective patient and must be appreciated to optimize safety and clinical outcomes. This review discusses current literature and future directions in the growing role of regional anesthesia in acute trauma care.

The Prolonged Analgesic Efficacy of an Ultrasound-Guided Single-Shot Adductor Canal Block in Patients Undergoing Total Knee Arthroplasty

In this prospective, randomized, placebo-controlled study, the authors compared the analgesic efficacy of the single-shot adductor canal block (SS-ACB) vs the continuous adductor canal block (C-ACB) with intermittent boluses during the 72-hour postoperative period. Seventy-five patients randomly received the following: a single shot of 20 mL of 0.5% ropivacaine preoperatively followed by intermittent saline boluses at 12 hours and 24 hours postoperatively (SS-ACB group); 20 mL of 0.5% ropivacaine preoperatively and 12 hours and 24 hours postoperatively (C-ACB group); or saline preoperatively and postoperatively (control group). The primary outcome was visual analog scale pain scores with movement on postoperative day 1. The dynamic pain scores of the 2 ACB groups were equivalent and were lower than those of the control group on postoperative day 1. Compared with the control group, the 2 ACB groups were less likely to use opioids on the operative day and the first 2 postoperative days. The patients in the control group and the C-ACB group exhibited less quadriceps muscle strength than those in the SS-ACB group on postoperative day 1. The time required for an SS-ACB was markedly shorter than that required for an indwelling adductor canal catheter. Further, each adductor canal catheter cost $80. Patients who received a single block reported more satisfaction with their pain-relief treatment. Given the similar analgesic effect but better quadriceps muscle strength, easier execution, and higher patient satisfaction, the SS-ACB may be more suitable for total knee arthroplasty patients than the C-ACB. [Orthopedics. 2018; 41(5):e607-e614.].

A Summary of the Anatomy and Current Regional Anesthesia Practices for Postoperative Pain Management in Total Knee Arthroplasty

The planning and implementation of an effective postoperative pain management program depend on the surgical technique for total knee arthroplasty (TKA), the type of regional anesthesia, and the multimodal analgesia regimen. It is imperative to understand the surgical anatomy of TKA and the relevant nerve supply of the knee for optimum perioperative patient satisfaction with respect to pain management in the patient undergoing TKA. The commonly used regional techniques have their own specific benefits and limitations. The ideal postoperative pain management should be customized for a patient to achieve the goals of effective pain control, early ambulation, faster recovery, and discharge.

Single-Shot Femoral Nerve Block Does Not Cause Long-Term Strength and Functional Deficits Following Anterior Cruciate Ligament Reconstruction

PURPOSE

To determine if patients treated with a single-shot femoral nerve block have strength and functional deficits at 9-month follow-up.

METHODS

Forty-three patients who underwent primary anterior cruciate ligament reconstructions were randomized to receive either a preoperative single-shot femoral nerve block or local infiltration anesthesia for primary pain control. All patients underwent a standardized comprehensive rehabilitation program postoperatively. Isokinetic strength and function was tested using a Biodex machine at 9 months or more postoperatively comparing the operative and nonoperative extremity.

RESULTS

No significant difference in strength was found at an average of 10.6 months postoperatively (range, 9-15 months) between the femoral nerve block and control groups. In comparing strength deficits, we found no difference in slow isokinetic extension strength (22.4% vs 27.8%, P = .51), fast isokinetic extension strength (18.5% vs 12.5%, P = .41), slow isokinetic flexion strength (11.0% vs 15.1%, P = .55), and fast isokinetic flexion strength (8.2% vs 4.9%, P = .56) in the femoral nerve block versus control groups, respectively. In terms of functional outcomes, there also was no difference in deficits for single-leg hop distance (P = .12), timed single-leg hop (P = .74), and single-leg triple hop distance (P = .94). Maximal strength noted to be within 15% of the contralateral limb was achieved in 40% of patients and maximal function in 63% of patients at an average of 10.6 months postoperatively. A 13% complication rate was found in patients who received a femoral nerve block (1 with prolonged quadriceps inhibition and 2 with prolonged sensory disturbances).

CONCLUSIONS

Our study found a 13% motor/sensory complication rate in patients who underwent femoral nerve block for pain control after anterior cruciate ligament reconstruction. Although these deficits may persist, they are not permanent and are not different when compared with controls at 9-month follow-up. However, maximal strength and function are not fully restored at normal return to play time and rehabilitation should continue long term to maximize recovery.

LEVEL OF EVIDENCE

Level I, prospective randomized trial.

Adductor Canal Block Versus Femoral Nerve Block for Analgesia After Total Knee Arthroplasty: A Systematic Review and Meta-analysis

OBJECTIVES

The efficacy and safety of adductor canal block (ACB) as compared with femoral nerve block (FNB) for postoperative pain management in total knee arthroplasty (TKA) remains controversial. We therefore performed a meta-analysis of randomized-controlled trials (RCTs) to compare ACB with FNB in TKA.

MATERIALS AND METHODS

Databases, including Pubmed, Medline, Embase, Web of Science, and Cochrane library were searched to identify RCTs comparing ACB with FNB for pain management in patients undergoing TKA. The primary outcomes included pain score with rest or activity and opioid consumption. Secondary outcomes were mobilization ability, quadriceps strength and grade, length of hospital stay, and complications (nausea or vomiting).

RESULTS

A total of 573 TKAs in 514 patients from 7 RCTs were included in the meta-analysis. Two studies with 155 TKAs reported the mobilization ability assessed by Timed Up and Go Test. The ACB patients performed significantly faster than the FNB patients in the early postoperative period (mean difference=-5.08; 95% confidence interval, -6.03 to -4.13; P<0.00001). The subgroup analysis showed that the outcomes of pain, morphine consumption, quadriceps strength, and length of hospital stay in single shot and continuous subgroups were not statistically different between the 2 groups (P>0.05).

DISCUSSION

ACB may achieve faster mobilization ability recovery for patients after TKA without a reduction in analgesia when compared with FNB in the early postoperative period. However, due to the variations in the included studies, additional studies are needed to validate these conclusions.

The Effect of Femoral Nerve Block on Quadriceps Strength in Anterior Cruciate Ligament Reconstruction: A Systematic Review

PURPOSE

To assess the isokinetic, functional, and patient-reported outcomes of femoral nerve block (FNB) compared with traditional multimodal anesthesia for FNB in anterior cruciate ligament (ACL) reconstruction.

METHODS

A systematic search of PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature, Cochrane Reviews, and Google Scholar was conducted according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Effects of FNB on quadriceps function were evaluated by isokinetic testing, functional scoring systems, range of motion, and patient self-report questionnaires. Heterogeneous reporting of outcomes precluded a formal meta-analysis. The methodologic merit of all studies included was evaluated by the Coleman Methodology Score.

RESULTS

Six studies were identified with outcome measures reported between 7 days and 6 months postoperatively. At 6 months, 2 of 4 studies that reported isokinetic testing found significantly greater deficits among patients who received a nerve block; one of the remaining studies showed a deficit at 6 weeks but not 6 months. Limited data showed no significant differences in functional or patient-reported outcomes at 6 months after reconstruction, and data regarding the impact of FNB on return to sport were inconclusive. The mean Coleman Methodology Score for the included studies was 53, indicating poor overall methodologic quality of the available literature.

CONCLUSIONS

The limited data available suggest that FNB causes a measurable deficit in quadriceps isokinetic strength during the early postoperative period but has no effect on functional outcomes or return to sport at 6 months after ACL reconstruction. However, current clinical evidence is not sufficient to draw any valid or definitive conclusions regarding the effect of FNB on postoperative outcomes after ACL reconstruction.

LEVEL OF EVIDENCE

Level IV, systemic review of Level I through IV studies.

Primary anterior cruciate ligament reconstruction: perioperative considerations and complications

Anterior cruciate ligament (ACL) injuries are among the most commonly studied orthopaedic injuries. Despite having an excellent prognosis, complications do occur. The timely recognition and management of complications is imperative to ensure the success of reconstruction. Avoiding such complications requires thorough preoperative planning, proficient technical skills to properly manage intraoperative complications, and an extensive knowledge of possible postoperative complications.

Pain Management After Outpatient Anterior Cruciate Ligament Reconstruction: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Effective pain management after anterior cruciate ligament (ACL) reconstruction improves patient satisfaction and function.

PURPOSE

To collect and evaluate the available evidence from randomized controlled trials (RCTs) on pain control after ACL reconstruction.

STUDY DESIGN

Systematic review.

METHODS

A systematic literature review was performed using PubMed, Medline, Google Scholar, UpToDate, Cochrane Reviews, CINAHL, and Scopus following PRISMA guidelines (July 2014). Only RCTs comparing a method of postoperative pain control to another method or placebo were included.

RESULTS

A total of 77 RCTs met inclusion criteria: 14 on regional nerve blocks, 21 on intra-articular injections, 4 on intramuscular/intravenous injections, 12 on multimodal regimens, 6 on oral medications, 10 on cryotherapy/compression, 6 on mobilization, and 5 on intraoperative techniques. Single-injection femoral nerve blocks provided superior analgesia to placebo for up to 24 hours postoperatively; however, this also resulted in a quadriceps motor deficit. Indwelling femoral catheters utilized for 2 days postoperatively provided superior analgesia to a single-injection femoral nerve block. Local anesthetic injections at the surgical wound site or intra-articularly provided equivalent analgesia to regional nerve blocks. Continuous-infusion catheters of a local anesthetic provided adequate pain relief but have been shown to cause chondrolysis. Cryotherapy improved analgesia compared to no cryotherapy in 4 trials, while in 4 trials, ice water and water at room temperature provided equivalent analgesic effects. Early weightbearing decreased pain compared to delayed weightbearing. Oral gabapentin given preoperatively and oral zolpidem given for the first week postoperatively each decreased opioid consumption as compared to placebo. Ibuprofen reduced pain compared to acetaminophen. Oral ketorolac reduced pain compared to hydrocodone-acetaminophen.

CONCLUSION

Regional nerve blocks and intra-articular injections are both effective forms of analgesia. Cryotherapy-compression appears to be beneficial, provided that intra-articular temperatures are sufficiently decreased. Early mobilization reduces pain symptoms. Gabapentin, zolpidem, ketorolac, and ibuprofen decrease opioid consumption. Despite the vast amount of high-quality evidence on this topic, further research is needed to determine the optimal multimodal approach that can maximize recovery while minimizing pain and opioid consumption.

CLINICAL RELEVANCE

These results provide the best available evidence from RCTs on pain control regimens after ACL reconstruction.

Liposome Bupivacaine Femoral Nerve Block for Postsurgical Analgesia after Total Knee Arthroplasty

Background

The authors evaluated the efficacy of liposome bupivacaine in a femoral nerve block (FNB) after total knee arthroplasty.

Methods

Part 1: subjects received FNB with 20 ml liposome bupivacaine (67, 133, or 266 mg) or placebo. Part 2: subjects were randomized to FNB with liposome bupivacaine 266 mg or placebo. The primary outcome measure was area under the curve of the numeric rating scale score for pain intensity at rest through 72 h (AUC NRS-R0–72) with imputed scores after rescue medication.

Results

In part 1, FNB with liposome bupivacaine 266 mg (n = 24) resulted in analgesia similar to that obtained with 133 mg and was chosen for part 2. In part 2, least-squares mean (standard error) AUC NRS-R0–72 was lower with liposome bupivacaine 266 mg (n = 92) than with placebo (n = 91; 419 [17] vs. 516 [17]; P &lt; 0.0001). This outcome remained unchanged in a post hoc analysis without score imputation (221 [12] vs. 282 [12]; P = 0.0005). Least-squares mean AUC NRS-R with imputed scores was lower with liposome bupivacaine during each 24-h interval (0 to 24, 24 to 48, and 48 to 72 h) after surgery; AUC NRS-R without imputed scores was lower during the 0- to 24-h and 24- to 48-h intervals. The liposome bupivacaine group had lower mean total opioid use (76 vs. 103 mg morphine; P = 0.0016). Pain was sufficiently severe to require second-step rescue with opioids via intravenously administered patient-controlled analgesia in 92% of liposome bupivacaine patients and 81% of placebo patients. With patient-controlled analgesia and other forms of rescue analgesia, mean NRS scores with activity were moderate in both liposome bupivacaine and placebo groups throughout the part 2 study period. Incidence of adverse events was similar between the groups (part 1: 90 vs. 96%; part 2: 96 vs. 96%, respectively).

Conclusion

FNB with liposome bupivacaine (266 mg) resulted in modestly lower pain scores and reduced opioid requirements after surgery, with an adverse event profile similar to placebo.

Use of ultrasound guidance to remove entrapped stimulating popliteal catheters

Peripheral nerve catheters are beneficial for continuous pain relief following surgery or trauma to an extremity. However, spring-loaded peripheral nerve catheters can become uncoiled and entrapped, resulting in difficulty in catheter removal. We present two cases where ultrasound guidance provided significant assistance in the safe removal of entrapped peripheral nerve catheters without neurologic sequelae. One of the catheters was adhered to nearby tissue, and one had become uncoiled and anchored in place by the distal tip. Guidelines for the safe management of entrapped catheters are suggested, including the use of saline injections through the catheter under ultrasound guidance to assist in the evaluation and removal of the catheters.

Local Infiltration Analgesia Versus Continuous Femoral Nerve Block in Pain Relief After Total Knee Arthroplasty: A Randomized Controlled Trial

BACKGROUND

Although both local infiltration analgesia (LIA) and continuous femoral nerve block (FNB) are common analgesic modalities for pain relief after total knee arthroplasty (TKA), we are aware of no parallel-group, randomized controlled trial that has solely compared the efficacy of LIA and continuous FNB.

METHODS

We conducted a prospective, 2-arm, parallel-group, randomized controlled trial involving patients scheduled for TKA. A total of 45 patients were randomly assigned to either the LIA or the continuous FNB group. Except for the analgesic modality, perioperative managements were identical in both groups. The primary outcome was postoperative pain score at rest 1 day after surgery, measured using a 100-mm visual analog scale.

RESULTS

Patients in the LIA group had a significantly lower visual analog scale score at rest 1 day after surgery than those in the continuous FNB group (34 ± 10 vs 42 ± 13 mm; P = .028). The opioid consumption during the initial 24 hours was significantly lower in the LIA group (12 ± 4 vs 16 ± 7 mg; P = .031). There were no differences in the rate of complications between the groups.

CONCLUSION

LIA was associated with better pain relief with a comparable complications rate for patients undergoing TKA than FNB. We recommend LIA for pain relief after TKA.

Protocol for a single-centre randomised controlled trial of multimodal periarticular anaesthetic infiltration versus single-agent femoral nerve blockade as analgesia for total knee arthroplasty: Perioperative Analgesia for Knee Arthroplasty (PAKA)

INTRODUCTION

Total knee arthroplasty (TKA) surgery causes postoperative pain. The use of perioperative injections around the knee containing local anaesthetic, opiates and non-steroidal anti-inflammatory drugs has increased in popularity to manage pain. Theoretical advantages include reduced requirements for analgesia and earlier mobilisation. We propose a single-centre randomised controlled trial of multimodal periarticular anaesthetic infiltration versus femoral nerve anaesthetic blockade as analgesia for TKA. The aim is to determine, in patients undergoing TKA, if there is a difference in patient-reported pain scores on the visual analogue scale (VAS) prior to physiotherapy on day 1 postoperatively between treatment groups.

METHODS AND ANALYSIS

Patients undergoing a primary unilateral TKA at University Hospitals Coventry and Warwickshire Hospitals will be assessed for eligibility. A total of 264 patients will provide 90% power to detect a difference of 12 mm on the VAS on day 1 postoperatively at the 5% level. The trial will use 1:1 randomisation, stratified by mode of anaesthetic. Primary outcome measure will be the VAS for pain prior to physiotherapy on day 1. Secondary outcome measures include VAS on day 2, total use of opiate analgesia up to 48 h, ordinal pain scores up to 40 min after surgery, independent functional knee physiotherapist assessment on days 1 and 2. Oxford knee Scores (OKS), EuroQol (EQ-5D) and Douleur Neuropathic Pain Scores (DN2) will be recorded at baseline, 6 weeks and 12 months. Adverse events will be recorded up to 12 months. Analysis will investigate differences in VAS on day 1 between the two treatment groups on an intention-to-treat basis. Tests will be two-sided and considered to provide evidence for a significant difference if p values are less than 0.05.

ETHICS AND DISSEMINATION

NRES Committee West Midlands, 23 September 2013 (ref: 13/WM/0316). The results will be disseminated via peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBERS

ISRCTN 60611146 and EUDRACT Number 2013-002439-10 (protocol code number PAKA-33601-AS117013); Pre-results.

Regional anesthesia for an upper extremity amputation for palliative care in a patient with end-stage osteosarcoma complicated by a large anterior mediastinal mass

Tumor progression during end-of-life care can lead to significant pain, which at times may be refractory to routine analgesic techniques. Although regional anesthesia is commonly used for postoperative pain care, there is limited experience with its use during home hospice care. We present a 24-year-old male with end-stage metastatic osteosarcoma who required anesthetic care for a right-sided above-the-elbow amputation. The anesthetic management was complicated by the presence of a large mediastinal mass, limited pulmonary reserve, and severe chronic pain with a high preoperative opioid requirement. Intraoperative anesthesia and postoperative pain management were provided by regional anesthesia using an interscalene catheter. He was discharged home with the interscalene catheter in place with a continuous local anesthetic infusion that allowed weaning of his chronic opioid medications and the provision of effective pain control. The perioperative applications of regional anesthesia in palliative and home hospice care are discussed.

Regional anesthesia for the trauma patient: improving patient outcomes

Trauma is a significant health problem and a leading cause of death in all age groups. Pain related to trauma is frequently severe, but is often undertreated in the trauma population. Opioids are widely used to treat pain in injured patients but have a broad range of undesirable effects in a multitrauma patient such as neurologic and respiratory impairment and delirium. In contrast, regional analgesia confers excellent site-specific pain relief that is free from major side effects, reduces opioid requirement in trauma patients, and is safe and easy to perform. Specific populations that have shown benefits (including morbidity and mortality advantages) with regional analgesic techniques include those with fractured ribs, femur and hip fractures, and patients undergoing digital replantation. Acute compartment syndrome is a potentially devastating sequela of soft-tissue injury that complicates high-energy injuries such as proximal tibia fractures. The use of regional anesthesia in patients at risk for compartment syndrome is controversial; although the data is sparse, there is no evidence that peripheral nerve blocks delay the diagnosis, and these techniques may in fact facilitate the recognition of pathologic breakthrough pain. The benefits of regional analgesia are likely most influential when it is initiated as early as possible, and the performance of nerve blocks both in the emergency room and in the field has been shown to provide quality pain relief with an excellent safety profile.

Adductor Canal Blockade Following Total Knee Arthroplasty-Continuous or Single Shot Technique? Role in Postoperative Analgesia, Ambulation Ability and Early Functional Recovery: A Randomized Controlled Trial

Total knee arthroplasty (TKA) can be associated with severe pain in early postoperative period. Adductor canal block may provide optimal analgesia following TKA. However, ideal regimen for administration whether continuous or single shot is yet undefined. We prospectively randomized 90 patients in continuous and single shot adductor canal blockade groups. Postoperative VAS (visual analog scale for pain) score was significantly better at all times in continuous than single shot technique (P<0.001). However, ambulation ability (Timed Up & Go, 10m walk, 30s chair) and early functional recovery (active SLR, ambulation with walker, staircase competency, ambulation distance and maximal flexion at discharge) showed no statistical significant difference. Continuous adductor canal blockade was superior to single shot block in terms of pain control but was similar for early functional recovery.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Comparison of Periarticular Multimodal Drug Injection and Femoral Nerve Block for Postoperative Pain Management in Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

The analgesic efficacy and safety of periarticular multimodal drug injection (PMDI) compared with femoral nerve block (FNB) for postoperative pain management in total knee arthroplasty (TKA) still remains controversial. We therefore conducted a meta-analysis to quantitatively compare PMDI to FNB in TKA. 10 randomized controlled trials (RCTs) with 744 TKAs in 728 patients were included in this study. The meta-analysis showed that single shot FNB may have better pain relief in the early postoperative period compared with single shot PMDI, and continuous PMDI provided postoperative analgesia comparable to that of continuous FNB. No significant difference was seen in regard to the complications between the two groups. However, due to the variation of the included studies, no firm conclusions can be drawn.

Effects of continuous fascia iliaca compartment blocks for postoperative analgesia in patients with hip fracture

Orthopedic surgery patients often experience severe postoperative pain, and effective analgesia is essential. In this study, the authors compared continuous fascia iliaca compartment block with patient-controlled intravenous analgesia using fentanyl postoperatively in patients with hip fractures. Changes in pain scores as well as delirium and postoperative nausea and vomiting were evaluated.

BACKGROUND:

Effective analgesia is essential for the postoperative care of orthopedic patients.

OBJECTIVES:

To evaluate the efficacy of continuous fascia iliaca compartment block (FIB) as postoperative analgesia after hip fracture surgery, and to compare FIB with patient-controlled intravenous analgesia (PCIA) using fentanyl for 48 h postoperatively.

METHODS:

Patients with hip fractures who were scheduled for open reduction and internal fixation surgery using the antirotation proximal femoral nail technique were randomly assigned to the FIB or PCIA groups. Postoperative pain was assessed using a numeral rating scale at 2 h, 4 h, 6 h, 12 h, 24 h and 48 h after analgesia was started. Delirium, postoperative nausea and vomiting (PONV), and pruritus were also monitored.

RESULTS:

Patients in the FIB group reported less pain than those in the PCIA group (P=0.039, d=−0.3). The change in pain scores over time was similar between the two groups. There were six patients with PONV and five patients with pruritus in the PCIA group, while no PONV or pruritus was noticed in the FIB group (P=0.013). Ten (19.6%) patients in the FIB group and three (5.7%) patients in the PCIA group developed postoperative delirium (P=0.032, d=0.77).

CONCLUSION:

Continuous FIB is a safe and effective technique for postoperative analgesia after hip fracture surgery, making it an option for pain management in elderly patients with hip fractures.