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Admiraal M, Smulders PSH, Rutten MVH, de Groot EK, Heine Y, Baumann HM, van der Vegt VHC, Halm JA, Hermanns H, Schepers T, Hollmann MW, Hermanides J, Ten Hoope W. The effectiveness of ambulatory continuous popliteal sciatic nerve blockade on patient-reported overall benefit of analgesia in patients undergoing foot or ankle surgery (CAREFREE trial); a randomized, open label, non-inferiority trial. J Clin Anesth 2024; 95:111451. [PMID: 38574504 DOI: 10.1016/j.jclinane.2024.111451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 12/22/2023] [Accepted: 03/18/2024] [Indexed: 04/06/2024]
Abstract
STUDY OBJECTIVE Management of pain after foot and ankle surgery remains a concern for patients and healthcare professionals. This study determined the effectiveness of ambulatory continuous popliteal sciatic nerve blockade, compared to standard of care, on overall benefit of analgesia score (OBAS) in patients undergoing foot or ankle surgery. We hypothesized that usage of ambulatory continuous popliteal sciatic nerve blockade is non-inferior to standard of care. DESIGN Single center, randomized, non-inferiority trial. SETTING Tertiary hospital in the Netherlands. PATIENTS Patients were enrolled if ≥18 years and scheduled for elective inpatient foot or ankle surgery. INTERVENTION Patients were randomized to ambulatory continuous popliteal sciatic nerve blockade or standard of care. MEASUREMENTS The primary outcome was the difference in OBAS, which includes pain, side effects of analgesics, and patient satisfaction, measured daily from the first to the third day after surgery. A non-inferiority margin of 2 was set as the upper limit for the 90% confidence interval of the difference in OBAS score. Mixed-effects modeling was employed to analyze differences in OBAS scores over time. Secondary outcome was the difference in opioid consumption. MAIN RESULTS Patients were randomized to standard of care (n = 22), or ambulatory continuous popliteal sciatic nerve blockade (n = 22). Analyzing the first three postoperative days, the OBAS was significantly lower over time in the ambulatory continuous popliteal sciatic nerve blockade group compared to standard of care, demonstrating non-inferiority (-1.9 points, 90% CI -3.1 to -0.7). During the first five postoperative days, patients with ambulatory continuous popliteal sciatic nerve blockade consumed significantly fewer opioids over time compared to standard of care (-8.7 oral morphine milligram equivalents; 95% CI -16.1 to -1.4). CONCLUSIONS Ambulatory continuous popliteal sciatic nerve blockade is non-inferior to standard of care with single shot popliteal sciatic nerve blockade on patient-reported overall benefit of analgesia.
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Affiliation(s)
- Manouk Admiraal
- Department of Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Pascal S H Smulders
- Department of Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Martin V H Rutten
- Department of Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Eelko K de Groot
- Department of Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Yvonne Heine
- Department of Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Holger M Baumann
- Department of Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Vincent H C van der Vegt
- Department of Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Jens A Halm
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Henning Hermanns
- Department of Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
| | - Tim Schepers
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Jeroen Hermanides
- Department of Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Werner Ten Hoope
- Department of Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Department of Anesthesiology, Rijnstate Hospital, Wagnerlaan 55, 6815 AD Arnhem, the Netherlands
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Deiling B, Mullen K, Shilling AM. Continuous Catheter Techniques. Anesthesiol Clin 2024; 42:317-328. [PMID: 38705679 DOI: 10.1016/j.anclin.2023.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Continuous peripheral nerve block catheters are simple in concept: percutaneously inserting a catheter adjacent to a peripheral nerve. This procedure is followed by local anesthetic infusion via the catheter that can be titrated to effect for extended anesthesia or analgesia in the perioperative period. The reported benefits of peripheral nerve catheters used in the surgical population include improved pain scores, decreased narcotic use, decreased nausea/vomiting, decreased pruritus, decreased sedation, improved sleep, and improved patient satisfaction.
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Affiliation(s)
- Brittany Deiling
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908-0710, USA.
| | - Kenneth Mullen
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908-0710, USA
| | - Ashley M Shilling
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908-0710, USA
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Schwartz G, Gadsden JC, Gonzales J, Hutchins J, Song J, Brady O, DiGiorgi M, Winston R. A phase 3 active-controlled trial of liposomal bupivacaine via sciatic nerve block in the popliteal fossa after bunionectomy. J Clin Anesth 2024; 94:111402. [PMID: 38340677 DOI: 10.1016/j.jclinane.2024.111402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 12/22/2023] [Accepted: 01/23/2024] [Indexed: 02/12/2024]
Abstract
STUDY OBJECTIVE To investigate the efficacy, safety, pharmacodynamics, and pharmacokinetics of liposomal bupivacaine (LB) administered via ultrasound-guided sciatic nerve block in the popliteal fossa in participants undergoing bunionectomy. DESIGN Two-part, randomized, double-blind, active-controlled trial (NCT05157841). SETTING Operating room, postanesthesia care unit, and health care facility (6 sites). PATIENTS Adults with American Society of Anesthesiologists physical status classification ≤3 and body mass index ≥18 to <40 kg/m2 undergoing elective distal metaphyseal osteotomy. INTERVENTIONS Part A participants were randomized 1:1:1 to LB 266 mg, LB 133 mg, or bupivacaine hydrochloride 50 mg (BUPI). Part B participants were randomized 1:1 to LB (at the dose established by part A) or BUPI. MEASUREMENTS The primary endpoint was area under the curve (AUC) of numerical rating scale (NRS) pain intensity scores 0-96 h after surgery. Secondary endpoints included total postsurgical opioid consumption, opioid-free status 0-96 h after surgery, and pharmacokinetic endpoints. MAIN RESULTS Part A enrolled 22 participants per group. In part B, additional participants were randomized to LB 133 mg (n = 59) and BUPI (n = 60) (185 total). LB 133 mg had significant reductions versus BUPI in the AUC of NRS pain intensity score (least squares mean [LSM], 207.4 vs 371.4; P < 0.00001) and total opioid consumption 0-96 h after surgery (LSM, 17.7 [95% confidence interval (CI), 13.7, 22.8] morphine milligram equivalents [MMEs] vs 45.3 [95% CI, 35.1, 58.5] MMEs; P < 0.00001) and an increased proportion of opioid-free participants (24.4% vs 6%; odds ratio, 5.04 [95% CI, 2.01, 12.62]; P = 0.0003) in parts A + B. Adverse events were similar across groups. CONCLUSIONS LB 133 mg administered via sciatic nerve block in the popliteal fossa after bunionectomy demonstrated superior and long-lasting postsurgical pain control versus BUPI. The clinical relevance of these findings is supported by concurrent reductions in pain and opioid consumption over 4 days after surgery and a significantly greater percentage of participants remaining opioid-free.
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Affiliation(s)
| | - Jeffrey C Gadsden
- Duke University Medical Center, 2301 Erwin Rd, Durham 27710, NC, USA.
| | - Jeffrey Gonzales
- Guardian Anesthesia Services and Enhanced Recovery Anesthetic Consultants, 9395 Crown Crest Blvd, Parker 80138, CO, USA.
| | - Jacob Hutchins
- University of Minnesota Medical Center, 420 Delaware St SE, Minneapolis 55455, MN, USA.
| | - Jia Song
- Pacira BioSciences, Inc., 5401 West Kennedy Blvd, Lincoln Center Ste 890, Tampa 33609, FL, USA.
| | - O'Dane Brady
- Pacira BioSciences, Inc., 5401 West Kennedy Blvd, Lincoln Center Ste 890, Tampa 33609, FL, USA.
| | - Mary DiGiorgi
- Pacira BioSciences, Inc., 5401 West Kennedy Blvd, Lincoln Center Ste 890, Tampa 33609, FL, USA.
| | - Roy Winston
- Pacira BioSciences, Inc., 5401 West Kennedy Blvd, Lincoln Center Ste 890, Tampa 33609, FL, USA.
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Sharrow CM, Elmore B. Anesthesia for the Patient Undergoing Foot and Ankle Surgery. Anesthesiol Clin 2024; 42:263-280. [PMID: 38705675 DOI: 10.1016/j.anclin.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Modern anesthetic management for foot and ankle surgery includes a variety of anesthesia techniques including general anesthesia, neuraxial anesthesia, or MAC in combination with peripheral nerve blocks and/or multimodal analgesic agents. The choice of techniques should be tailored to the nature of the procedure, patient comorbidities, anesthesiologist skill level, intensity of anticipated postoperative pain, and surgeon preference.
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Affiliation(s)
- Christopher M Sharrow
- Department of Anesthesiology, University of Virginia Health, PO Box 800710, Charlottesville, VA 22908-0710, USA
| | - Brett Elmore
- Department of Anesthesiology, University of Virginia Health, PO Box 800710, Charlottesville, VA 22908-0710, USA.
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Kinjo S, Chernin T, Siegmueller C, Sharrow CM, Shilling A. Advances in regional anesthesia for ambulatory surgery. Int Anesthesiol Clin 2024; 62:54-61. [PMID: 37990922 DOI: 10.1097/aia.0000000000000429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Affiliation(s)
- Sakura Kinjo
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California
| | - Tyler Chernin
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California
| | - Claas Siegmueller
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California
| | | | - Ashley Shilling
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
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Onay M, Kiremitçi TT, Kayhan GE, Algın Dİ, Güleç MS. Infraclavicular Catheter in MELAS Syndrome for Analgesic Purposes. Neurol India 2023; 71:764-766. [PMID: 37635512 DOI: 10.4103/0028-3886.383869] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
MELAS syndrome is defined as mitochondrial myopathy accompanied by encephalopathy, lactic acidosis, myoclonus, stroke-like episodes. It has a progressive course, multi-systemic effects and severe complications. Myoclonic contractions are unresponsive to many anti-epileptic drugs; these contractions and spasms may lead to severe pain. Systemic analgesic drugs are not sufficient to control pain. Therefore, continuous brachial plexus blockage may be preferred. Infraclavicular brachial plexus catheter is placed in our case. Local anesthetic injections through this catheter may be effective in pain management and results are to be discussed here.
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Affiliation(s)
- M Onay
- Department of Anesthesiology and Reanimation, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - T Tanyel Kiremitçi
- Department of Algology, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - G Erdoğan Kayhan
- Department of Anesthesiology and Reanimation, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - D İlhan Algın
- Department of Neurology, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - M S Güleç
- Department of Algology, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
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Regional anaesthesia: what surgical procedures, what blocks and availability of a “block room”? Curr Opin Anaesthesiol 2022; 35:698-709. [PMID: 36302208 DOI: 10.1097/aco.0000000000001187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
PURPOSE OF REVIEW With an expected rise in day care procedures with enhanced recovery programs, the use of specific regional anaesthesia can be useful. In this review, we will provide insight in the used regional block and medication so far known and its applicability in a day care setting. RECENT FINDINGS Regional anaesthesia has been improved with the aid of ultrasound-guided placement. However, it is not commonly used in the outpatient setting. Old, short acting local anaesthetics have found a second life and may be especially beneficial in the ambulatory setting replacing more long-acting local anaesthetics such as bupivacaine.To improve efficiency, a dedicated block room may facilitate the performance of regional anaesthesia. However, cost-efficacy for improved operating time, patient care and hospital efficiency has to be established. SUMMARY Regional anaesthesia has proven to be beneficial in ambulatory setting. Several short acting local anaesthetics are favourable over bupivacaine in the day care surgery. And if available, there are reports of the benefit of an additional block room used in a parallel (monitored) care of patients.
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Nickl R, Vicent O, Müller T, Osmers A, Schubert K, Koch T, Richter T. Impact of self-coiling catheters for continuous popliteal sciatic block on postoperative pain level and dislocation rate: a randomized controlled trial. BMC Anesthesiol 2022; 22:159. [PMID: 35610566 PMCID: PMC9128226 DOI: 10.1186/s12871-022-01700-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 05/19/2022] [Indexed: 11/30/2022] Open
Abstract
Background Dislocation of catheters within the tissue is a challenge in continuous regional anesthesia. A novel self-coiling catheter design is available and has demonstrated a lower dislocation rate in a cadaver model. The dislocation rate and effect on postoperative pain of these catheters in vivo has yet to be determined and were the subjects of this investigation. Methods After ethics committee approval 140 patients undergoing elective distal lower limb surgery were enrolled in this prospective randomized controlled trial. Preoperatively, patients were randomly assigned and received either the conventional (n = 70) or self-coiling catheter (n = 70) for ultrasound-guided popliteal sciatic nerve block in short axis view and by the in-plane approach from lateral to medial. The primary outcome was pain intensity after surgery and on the following three postoperative days. Secondary outcomes investigated were dislocation rate in situ determined by sonography, catheter movement visible from outside, opioid consumption as well as leakage at the puncture site. Results All catheters were successfully inserted. The study population of self-coiling catheters had significantly lower mean numeric rating scale values than the reference cohort on the first (p = 0.01) and second postoperative days (p < 0.01). Sonographic evaluation demonstrated, 42 standard catheters (60%) and 10 self-coiling catheters (14.3%) were dislocated in situ within the first three postoperative days. The externally visible movement of the catheters at insertion site did not differ significantly between groups through the third postoperative day. The opioid consumption was significantly lower in the self-coiling catheter group on the day of surgery and on the second and third postoperative days (p = 0.04, p = 0.03 and p = 0.04, respectively). Conclusion The self-coiling catheter offers a better postoperative pain control and a lower dislocation rate within the tissue when blocking the popliteal sciatic nerve compared to a conventional catheter. Further trials in large patient cohorts are warranted to investigate the potential beneficial effects of self-coiling catheters for other localisations and other application techniques. Trial registration The trial was registered at German Clinical Trials Register (DRKS) on 08/04/2020 (DRKS00020938, retrospectively registered).
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Affiliation(s)
- Rosa Nickl
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Fetscherstr 74, 01307, Dresden, Germany.
| | - Oliver Vicent
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Fetscherstr 74, 01307, Dresden, Germany
| | - Thomas Müller
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Fetscherstr 74, 01307, Dresden, Germany
| | - Anne Osmers
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Fetscherstr 74, 01307, Dresden, Germany
| | - Konrad Schubert
- Institute for Medical Informatics and Biometry, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Fetscherstr 74, 01307, Dresden, Germany
| | - Thea Koch
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Fetscherstr 74, 01307, Dresden, Germany
| | - Torsten Richter
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Fetscherstr 74, 01307, Dresden, Germany
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Deiling B, Mullen K, Shilling AM. Continuous Catheter Techniques. Clin Sports Med 2022; 41:317-328. [PMID: 35300843 DOI: 10.1016/j.csm.2021.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Continuous peripheral nerve block catheters are simple in concept: percutaneously inserting a catheter adjacent to a peripheral nerve. This procedure is followed by local anesthetic infusion via the catheter that can be titrated to effect for extended anesthesia or analgesia in the perioperative period. The reported benefits of peripheral nerve catheters used in the surgical population include improved pain scores, decreased narcotic use, decreased nausea/vomiting, decreased pruritus, decreased sedation, improved sleep, and improved patient satisfaction.
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Affiliation(s)
- Brittany Deiling
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908-0710, USA.
| | - Kenneth Mullen
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908-0710, USA
| | - Ashley M Shilling
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908-0710, USA
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Anesthesia for the Patient Undergoing Foot and Ankle Surgery. Clin Sports Med 2022; 41:263-280. [PMID: 35300839 DOI: 10.1016/j.csm.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Modern anesthetic management for foot and ankle surgery includes a variety of anesthesia techniques including general anesthesia, neuraxial anesthesia, or MAC in combination with peripheral nerve blocks and/or multimodal analgesic agents. The choice of techniques should be tailored to the nature of the procedure, patient comorbidities, anesthesiologist skill level, intensity of anticipated postoperative pain, and surgeon preference.
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Basal Infusion versus Automated Boluses and a Delayed Start Timer for "Continuous" Sciatic Nerve Blocks following Ambulatory Foot and Ankle Surgery A Randomized, Clinical Trial. Anesthesiology 2022; 136:970-982. [PMID: 35226724 DOI: 10.1097/aln.0000000000004189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND. The common technique using a basal infusion for an ambulatory continuous peripheral nerve blocks frequently results in exhaustion of the local anesthetic reservoir prior to resolution of surgical pain. We sought to improve and prolong analgesia by delaying initiation using an integrated timer and delivering a lower hourly volume of local anesthetic as automated boluses. We hypothesized that, compared with a traditional continuous infusion, ropivacaine administered with automated boluses at a lower dose and 5-hour delay would (1) provide at least noninferior analgesia [difference in average pain no greater than 1.7 points] while both techniques were functioning [average pain score day after surgery]; and, (2) result in a longer duration [dual primary outcomes]. METHODS. Participants (n = 70) undergoing foot or ankle surgery with a popliteal-sciatic catheter received an injection of ropivacaine 0.5% with epinephrine (20 mL) then were randomized to receive ropivacaine (0.2%) as either continuous infusion (6 mL/h) initiated prior to discharge, or automated boluses (8 mL every 2 h) initiated 5 hours following discharge using a timer. Both groups could self-deliver supplemental boluses (4 mL, lockout 30 min); participants and outcomes assessors were blinded to randomization. All randomized participants were included in data analysis. RESULTS. The day following surgery, participants with automated boluses had a median [IQR] pain score of 0.0 [0.0 to 3.0] vs. 3.0 [1.8 to 4.8] for the continuous infusion group: odds ratio 3.1 (95% CI 1.23 to 7.84, p=0.033) adjusting for BMI. Reservoir exhaustion in automated boluses group occurred after a median [IQR] of 119 h [109,125] vs. 74 h [57,80] for continuous infusion group: difference 47h (95% CI: 38 to 55), P<0.001 adjusting for BMI. CONCLUSIONS For popliteal-sciatic catheters, replacing a continuous infusion initiated before discharge with automated boluses and a start-delay timer resulted in better analgesia and longer infusion duration.
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Bouchard M, Ross TD. Bony Procedures for Correction of the Flexible Pediatric Flatfoot Deformity. Foot Ankle Clin 2021; 26:915-939. [PMID: 34752244 DOI: 10.1016/j.fcl.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The pediatric flexible flatfoot is a common foot shape that is most often asymptomatic and may be a physiologic variant of normal. Surgery is only indicated when nonoperative interventions have failed to resolve symptoms. The goal of surgery is to alleviate symptoms by improving hindfoot alignment and restoring the medial arch while preserving joint mobility. This article focuses on the common bony techniques for surgical correction of the pediatric flexible flatfoot that has failed nonoperative management, including calcaneal, midfoot, and supramalleolar osteotomies and distal tibial hemiepiphyseodesis.
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Affiliation(s)
- Maryse Bouchard
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, Canada; Department of Surgery, University of Toronto, Toronto, Canada; Division of Orthopaedic Surgery, The University of Toronto, Toronto, Canada.
| | - Tayler Declan Ross
- Division of Orthopaedic Surgery, The University of Toronto, 500 University Avenue #602, Toronto, Ontario M5G 1V7, Canada
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Kim BG, Lee W, Song JH, Yang C, Heo GA, Kim H. Effect of intravenous dexamethasone on the duration of postoperative analgesia for popliteal sciatic nerve block: a randomized, double-blind, placebo-controlled study. Korean J Anesthesiol 2021; 74:317-324. [PMID: 33784802 PMCID: PMC8342835 DOI: 10.4097/kja.20640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 03/28/2021] [Indexed: 12/13/2022] Open
Abstract
Background Intravenous (IV) dexamethasone prolongs the duration of a peripheral nerve block; however, there is little available information about its optimal effective dose. This study aimed to evaluate the effects of three different doses of IV dexamethasone on the duration of postoperative analgesia to determine the optimal effective dose for a sciatic nerve block. Methods Patients scheduled for foot and ankle surgery were randomly assigned to receive normal saline or IV dexamethasone (2.5 mg, 5 mg, or 10 mg). An ultrasound-guided popliteal sciatic nerve block was performed using 0.75% ropivacaine (20 ml) before general anesthesia. The duration of postoperative analgesia was the primary outcome, and pain scores, use of rescue analgesia, onset time, adverse effects, and patient satisfaction were assessed as secondary outcomes. Results Compared with the control group, the postoperative analgesic duration of the sciatic nerve block was prolonged in groups receiving IV dexamethasone 10 mg (P < 0.001), but not in the groups receiving IV dexamethasone 2.5 mg or 5 mg. The use of rescue analgesics was significantly different among the four groups 24 h postoperatively (P = 0.001) and similar thereafter. However, pain scores were not significantly different among the four groups 24 h postoperatively. There were no statistically significant differences in the other secondary outcomes among the four groups. Conclusions This study demonstrated that compared to the controls, only IV dexamethasone 10 mg increased the duration of postoperative analgesia following a sciatic nerve block for foot and ankle surgery without the occurrence of adverse events.
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Affiliation(s)
- Byung-Gun Kim
- Department of Anesthesiology and Pain Medicine, Inha University School of Medicine, Incheon, Korea
| | - Woojoo Lee
- Department of Public Health Science, Graduate School of Public Health, Seoul National University, Seoul, Korea
| | - Jang Ho Song
- Department of Anesthesiology and Pain Medicine, Inha University School of Medicine, Incheon, Korea
| | - Chunwoo Yang
- Department of Anesthesiology and Pain Medicine, Inha University School of Medicine, Incheon, Korea
| | - Gyung A Heo
- Department of Anesthesiology and Pain Medicine, Inha University School of Medicine, Incheon, Korea
| | - Hongseok Kim
- Department of Anesthesiology and Pain Medicine, Inha University School of Medicine, Incheon, Korea
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Breebaart MB, Branders J, Sermeus L, Termurziev S, Camerlynck H, Van Putte L, Van Putte Minelli M, De Hert S. Levobupivacaine Consumption in Automated Intermittent Bolus in Ultrasound Guided Subparaneural Sciatic Nerve Catheters: A Prospective Double-Blind Randomized Trial. Local Reg Anesth 2021; 14:43-50. [PMID: 33790643 PMCID: PMC8007557 DOI: 10.2147/lra.s299870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 03/03/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Continuous sciatic nerve blocks have proven benefits for postoperative analgesia after foot surgery. However, the optimal mode of administration remains a point of debate. Ultrasound guided subparaneural injection accelerates onset time and increases duration after a single shot sciatic nerve block. This double blind prospective randomized trial compares the 48-hour local anesthetic (LA) dose consumption of an automated intermittent bolus technique to a continuous infusion regimen in a subparaneural sciatic nerve catheter after hallux valgus surgery. Patients and Methods Patients scheduled for hallux valgus surgery were randomized to receive either a continuous infusion of levobupivacaine 0.125% at 5mL/h (group A) or an intermittent automated bolus of 9.8 mL every 2 hours with a background of 0.1 mL/h (group B), both with a PCA bolus of 6 mL and lockout of 30 minutes. The 48 hour LA consumption, PCA boluses, Numeric Rating Scale (NRS), satisfaction and return of normal sensation were recorded. Results Sixteen patients were excluded because of protocol violation or technical problems and 42 patients remained for analysis. The 48 hour ropivacaine consumption was higher in group A (293 ±60 mL) than group B (257±33 mL). The median and highest NRS scores and patient satisfaction were not statistically different between groups. Normal sensation returned after 75 ± 22 hours (group A) and 70 ± 17 hours (group B). Conclusion Programmed bolus administration in subparaneural sciatic nerve catheters reduces LA consumption 48 hours after surgery with equal analgesia and patient satisfaction. Return of sensation is variable and can last more than 75 hours.
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Affiliation(s)
- Margaretha B Breebaart
- Faculty of Medicine and Health Sciences, Antwerp University, Wilrijk, Belgium.,Department of Anesthesia, Antwerp University Hospital, Edegem, Belgium
| | - Jordi Branders
- Department of Anesthesia, Antwerp University Hospital, Edegem, Belgium
| | - Luc Sermeus
- Department of Anesthesiology, St. Luc University Hospital, Brussels, Belgium
| | - Sultan Termurziev
- Department of Anesthesia, Antwerp University Hospital, Edegem, Belgium
| | - Helene Camerlynck
- Department of Anesthesia, Antwerp University Hospital, Edegem, Belgium
| | - Lennert Van Putte
- Faculty of Medicine and Health Sciences, Antwerp University, Wilrijk, Belgium
| | | | - Stefan De Hert
- Department of Anesthesia and Perioperative Medicine, Ghent University Hospital, Ghent, Belgium
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15
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Fernandes HDS, Ximenes JLS, Taguchi PK, Espada EB, Gouvêa ÁL, Vieira JE, Ashmawi HA. Continuous peripheral nerve block for in-patients with lower limb ischemic pain. Clinics (Sao Paulo) 2021; 76:e2805. [PMID: 35116081 PMCID: PMC8128081 DOI: 10.6061/clinics/2021/e2805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/01/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Demonstrate that continuous peripheral nerve block (CPNB) may be an alternative with adequate analgesia and a lower incidence of side effects for ischemic pain due peripheral obstructive arterial disease (POAD). METHODS Retrospective cohort study with 21 patients with POAD, Fontaine IV graded, with foot pain. Patients were submitted to continuous sciatic nerve block (CSNB), through a perineural catheter. Primary outcomes were pain intensity (by numerical rating scale) and opioid consumption (in oral morphine equivalents). RESULTS During CSNB, pain scores markedly decreased in comparison to the pre-block period. CONCLUSIONS CPNB may be a good option for ischemic pain treatment in in-patients, as it provides effective pain control with fewer adverse effects.
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Affiliation(s)
- Hermann dos Santos Fernandes
- Divisao de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding authors. E-mail: /
| | - Jorge Luiz Saraiva Ximenes
- Divisao de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Paloma Kiyomi Taguchi
- Divisao de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Eloisa Bonetti Espada
- Divisao de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Áquila Lopes Gouvêa
- Divisao de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Joaquim Edson Vieira
- Divisao de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Hazem Adel Ashmawi
- Divisao de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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16
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Shapira J, Chen SL, Rosinsky PJ, Maldonado DR, Lall AC, Domb BG. Outcomes of outpatient total hip arthroplasty: a systematic review. Hip Int 2021; 31:4-11. [PMID: 32157903 DOI: 10.1177/1120700020911639] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Similar to other total joint arthroplasty procedures, total hip arthroplasty (THA) is shifting to an outpatient setting. The purpose of this study was to analyse outcomes following outpatient THA. METHODS A comprehensive literature search was performed in April 2019 according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines using the PubMed, Embase, and Cochrane databases to identify articles that reported functional outcomes following outpatient total hip arthroplasty (THA). RESULTS 9 articles, with 683 hips and a collective study period of 1988 to 2016, were included in this analysis. The mean age across all studies was 58.9 years and the follow-up period ranged from 4 weeks to 10 years. 4 studies reported Harris Hip Scores (HHSs) for their patient populations and in 3 studies, the average HHSs were excellent (>90) by 6 weeks postoperatively. The fourth study reported fair HHS scores for the outpatient and inpatient THA groups (75 ± 18, 75 ± 14, p = 0.77, respectively) at 4 weeks postoperatively. VAS scores improved significantly in two studies and NRS at rest and during activity improved significantly (p < 0.001) in a separate study. Overall, 88.1% of the enrolled patients were discharged the same day of surgery, as expected. Out of the 6 studies reporting on readmissions rate, there were two (0.34%) readmissions within 3 months of surgery. CONCLUSION In patients with no significant comorbidities, outpatient THA leads to favourable outcomes as well as low readmission rates in the short term.
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Affiliation(s)
- Jacob Shapira
- American Hip Institute Research Foundation, Des Plaines, IL, USA
| | - Sarah L Chen
- Sidney Kimmel Medical College, Philadelphia, PA, USA
| | | | | | - Ajay C Lall
- American Hip Institute Research Foundation, Des Plaines, IL, USA
| | - Benjamin G Domb
- American Hip Institute Research Foundation, Des Plaines, IL, USA
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17
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Chen S, Xu Z, Liu H, Zhang Y, Zhang J, Chen Y, Zheng Y, Huang Y. Perioperative patient-controlled regional analgesia versus patient-controlled intravenous analgesia for patients with critical limb ischaemia: a study protocol for a randomised controlled trial. BMJ Open 2020; 10:e037879. [PMID: 33033091 PMCID: PMC7545635 DOI: 10.1136/bmjopen-2020-037879] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Both regional analgesia and intravenous analgesia are frequently used perioperatively for patients with critical limb ischaemia (CLI). Nevertheless, the comparison of perioperative effect of regional and intravenous analgesia has not yet been thoroughly illustrated. This study will comprehensively compare patient-controlled regional analgesia (PCRA) and patient-controlled intravenous analgesia (PCIA) as two different perioperative analgesia approaches for patients with CLI. It investigates their effects on analgesia, reperfusion and the quality of recovery perioperatively, also aims to provide clinical evidence to those non-surgical patients with non-reconstructable arteries. METHODS AND ANALYSIS This trial is a randomised, single-centre, open-label, parallel trial with target sample size of 52 in total. Eligible participants will be randomly allocated to the PCRA group (group R) or the PCIA group (group I) after admission. Participants in group R will receive ultrasound-guided subgluteal sciatic catheterisation, followed by continuous PCRA infusion (0.2% ropivacaine 15 mL as loading dose, 8 mL/hour as background with a patient-controlled bolus of 6 mL). Participants in group I will receive PCIA (morphine is given in boluses of 1 mg as needed, background infusion at 1 mg/hour). Data will be collected at baseline (T0), 2 hours before revascularisation treatment (T1) and 2 hours before discharge (T2). The primary outcomes include the Numerical Rating Scale pain score at T1 and T2. The secondary outcomes include the perioperative transcutaneous oxygen pressure, the Tissue Haemoglobin Index, Hospital Anxiety and Depression Scale at T1 and T2; the Patient Global Impression of Change and patient satisfaction at T1 and T2; the perioperative cumulative morphine consumption, the length of postoperative hospital stay and adverse events. ETHICS AND DISSEMINATION This study received authorisation from the Institutional Review Board of Peking Union Medical College Hospital on 21 March 2017 (approval no. ZS-1289X). Study findings will be disseminated through presentations at scientific conferences or publications in peer-reviewed journals. TRIAL REGISTRATION NUMBER Chinese Clinical Trial Registry (ChiCTR2000029298). PROTOCOL VERSION V.4CP.B2 (15 June 2020).
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Affiliation(s)
- Si Chen
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - Zhonghuang Xu
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - Hongju Liu
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - Yuelun Zhang
- Medical Research Center, Peking Union Medical College Hospital, Beijing, China
| | - Jiao Zhang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - Yuexin Chen
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Yuehong Zheng
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
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18
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A National Registry Analysis of the Association of Perioperative Regional Anesthesia with hospital length of stay following open reduction and internal fixation of the ankle. J Clin Anesth 2020; 67:110008. [PMID: 32829110 DOI: 10.1016/j.jclinane.2020.110008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/22/2020] [Accepted: 07/24/2020] [Indexed: 10/23/2022]
Abstract
STUDY OBJECTIVES To evaluate if using regional anesthesia for post-operative pain control for patients who underwent ankle ORIF is associated with a decrease in length of stay. DESIGN Multicenter retrospective cohort study. SETTING Inpatient perioperative. PATIENTS 12,468 inpatients (2007 to 2016) who received ankle ORIF with and without regional anesthesia for pain control. INTERVENTIONS Regional Anesthesia for postoperative pain control. MEASUREMENTS Hospital length of stay along with multiple covariates. MAIN RESULTS The median [quartiles] hospital length of stay of the non-regional anesthesia and regional anesthesia cohorts were 1 day [0, 2 days] and 0 days [0, 1 day], respectively (p < 0.0001). On multivariable Cox regression analysis, the use of regional anesthesia was associated with decreased time to hospital discharge (HR 1.09, 95% CI 1.03-1.14, p = 0.002). Using 1:2 propensity score matching, the median [quartiles] hospital length of stay between the non-regional anesthesia and regional anesthesia matched cohorts were 0 days [0, 1 day] (range = 0-56 days) and 0 day [0, 1 day] (range = 0-33 days), respectively (p = 0.013). CONCLUSION The use of regional anesthesia for post-operative pain control was associated with a decreased length of stay for patients undergoing ankle ORIF.
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19
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Abstract
The scope of pediatric regional anesthesia is expanding, with increased safety and efficacy data over the past few years. As familiarity and expertise has developed with ultrasonography, regional anesthesia has played an important role in the management of acute pain in the postsurgical population.
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20
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Abstract
Anesthesia management during hallux valgus surgery trends toward multimodal pain control. Locoregional anesthesia with peripheral nerve blocks and wound instillation increase pain control. Peripheral nerve blocks as first-line analgesia are effective with minimal side effects. Local wound instillation has a variable but positive effect with minimal negative side effects. Nonsteroidal anti-inflammatory drugs in bone-to-bone healing remain controversial; however, they reduce opiate requirements and enhance patient satisfaction. Opiate agonists remain the mainstay for postoperative pain; long-acting formulations minimize pain crises. Multimodal analgesia with locoregional anesthesia facilitate the progress of hallux valgus surgery as an outpatient procedure.
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Affiliation(s)
- Max Seiter
- Sports Medicine Orthopaedic Surgery, Steadman Philippon Research Institute, 181 W Meadow Dr., Vail, CO 81657, USA
| | - Amiethab Aiyer
- Orthopaedic Surgery, University of Miami, Jackson Memorial Hospital, 900 NW 17th Street, Miami, FL 33136, USA.
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21
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Effect of Intraoperative Sedation with Dexmedetomidine Versus Propofol on Acute Postoperative Pain Following Major Foot Surgery under Popliteal Sciatic Nerve Block: A Randomized Controlled Trial. J Clin Med 2020; 9:jcm9030654. [PMID: 32121242 PMCID: PMC7141289 DOI: 10.3390/jcm9030654] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/12/2020] [Accepted: 02/24/2020] [Indexed: 11/28/2022] Open
Abstract
Intravenous (IV) dexmedetomidine is reported to prolong analgesia following peripheral nerve blocks. Popliteal sciatic nerve block provides effective postoperative analgesia, but some patients still experience severe pain during the early postoperative period. We aimed to evaluate the postoperative analgesic effects of IV dexmedetomidine versus propofol in patients undergoing foot surgeries under popliteal sciatic nerve block. Forty patients were enrolled and randomly assigned to receive either IV propofol (n = 20) or IV dexmedetomidine (n = 20) for intraoperative sedation. All the patients received continuous popliteal sciatic nerve block. The corresponding drug infusion rate was adjusted to achieve a modified observer’s assessment of alertness/sedation score of 3 or 4. The primary outcome was postoperative cumulative opioid consumption during the first 24 h after surgery. Thirty-nine patients were analyzed. The median (interquartile ranges) postoperative cumulative opioid consumption during the first 24 h after surgery was significantly lower in the dexmedetomidine group (15 (7.5–16.9) mg) than in the propofol group (17.5 (15–25) mg) (p = 0.019). The time to first rescue analgesic request was significantly greater in the dexmedetomidine group than in the propofol group (11.8 ± 2.2 h vs. 10.0 ± 2.7 h, p = 0.030) without the prolonged motor blockade (p = 0.321). Intraoperative sedation with dexmedetomidine reduced postoperative opioid consumption and prolonged analgesic duration after a popliteal sciatic nerve block.
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22
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Ultrasound-guided continuous popliteal sciatic nerve block improves healing of trophic ulcers of lower limbs. J Clin Anesth 2020; 62:109733. [PMID: 31986434 DOI: 10.1016/j.jclinane.2020.109733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 12/17/2019] [Accepted: 01/18/2020] [Indexed: 11/20/2022]
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23
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Ma HH, Chou TFA, Tsai SW, Chen CF, Wu PK, Chen WM. The efficacy and safety of continuous versus single-injection popliteal sciatic nerve block in outpatient foot and ankle surgery: a systematic review and meta-analysis. BMC Musculoskelet Disord 2019; 20:441. [PMID: 31601208 PMCID: PMC6788034 DOI: 10.1186/s12891-019-2822-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 09/10/2019] [Indexed: 01/15/2023] Open
Abstract
Background Continuous popliteal sciatic nerve block (CPSNB) has been performed in outpatient foot and ankle surgery as a regional anesthesia method to relieve postoperative pain. Its efficacy as well as safety is yet to be established. There are two purposes of this study: (1) to validate the efficacy of CPSNB with regards to better pain relief and reduced analgesics consumption; (2) to assess the safety of CPSNB. Methods We performed a comprehensive literature review on Web of Science, the Cochrane Library, PubMed and Embase and only included randomized controlled trials (RCTs). Five RCTs that compared the efficacy and safety of CPSNB with the single-injection popliteal sciatic nerve block group were included. The primary outcome parameters were visual analog scale (VAS) scores at postoperative 24, 48 and 72 h. The secondary outcome parameters were amount of oral analgesics consumed, overall patient satisfaction and need of admission after surgery. A sensitivity analysis was performed to explore the consistency of the results. Results In comparison with the single-injection group, CPSNB was associated with a lower VAS score at postoperative 24 and 48 h (p < 0.05). There were no neuropathic symptoms or infection events after the nerve block. However, there were several minor complications associated with the pump and catheter system, with drug leakage being the most common complication (N = 26 of 187, 13.9%). Conclusion CPSNB is an effective method in pain management for outpatient foot and ankle surgery. Both methods appear to be safe as none of the patients experienced neuropathic symptoms or infection. Further studies with larger sample size are needed to compare the risk of major complications between the two methods. Level of evidence I; meta-analysis.
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Affiliation(s)
- Hsuan-Hsiao Ma
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec 2, Shi-Pai Road, Taipei, 112, Taiwan.,Department of Orthopaedics, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Te-Feng Arthur Chou
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec 2, Shi-Pai Road, Taipei, 112, Taiwan.,Department of Orthopaedics, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shang-Wen Tsai
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec 2, Shi-Pai Road, Taipei, 112, Taiwan. .,Department of Orthopaedics, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
| | - Cheng-Fong Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec 2, Shi-Pai Road, Taipei, 112, Taiwan.,Department of Orthopaedics, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Po-Kuei Wu
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec 2, Shi-Pai Road, Taipei, 112, Taiwan.,Department of Orthopaedics, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Ming Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec 2, Shi-Pai Road, Taipei, 112, Taiwan.,Department of Orthopaedics, School of Medicine, National Yang-Ming University, Taipei, Taiwan
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24
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Short AJ, Ghosh M, Jin R, Chan VWS, Chin KJ. Intermittent bolus versus continuous infusion popliteal sciatic nerve block following major foot and ankle surgery: a prospective randomized comparison. Reg Anesth Pain Med 2019:rapm-2018-100301. [PMID: 31570495 DOI: 10.1136/rapm-2018-100301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 09/07/2019] [Accepted: 09/18/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVES Foot and ankle surgery is associated with severe pain that can be reduced with continuous popliteal sciatic nerve block. We tested the hypothesis that programmed intermittent bolus (PIB) delivery of local anesthetic provides superior analgesia to a continuous infusion (CI) regimen. METHODS 60 patients undergoing major foot and ankle surgery were randomized to receive PIB (10 mL of ropivacaine 0.2% every 2 hours) or CI (5 mL/hour) continuous popliteal sciatic nerve block with patient-controlled regional analgesia (5 mL every 30 min as needed) provided for all. Primary outcome was the average of static and dynamic numerical rating scale (NRS) pain scores through 48 hours. Secondary outcomes included rest and movement NRS pain scores at different timepoints, opioid consumption, local anesthetic consumption, intensity of sensory and motor block, patient satisfaction and the incidence of opioid-related side effects. RESULTS There was no significant difference in the primary outcome of average NRS pain score through 48 hours, opioid consumption or the volume of local anesthetic administered. Patients in group PIB had significantly decreased strength of toe dorsiflexion at 6 hours (p=0.007) and 12 hours (p=0.001) and toe plantarflexion at 12 hours (p=0.004). Patient satisfaction and the incidence of side effects was similar between groups. CONCLUSIONS Both CI and PIB regimens provided excellent analgesia, low opioid consumption and high patient satisfaction. While there was no difference in analgesic outcomes, PIB dosing resulted in a more profound motor block. TRIAL REGISTRATION NUMBER NCT02707874.
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Affiliation(s)
- Anthony James Short
- Department of Anaesthetics, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Meela Ghosh
- Department of Anaesthetics, Freeman Hospital, Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - Rongyu Jin
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Vincent W S Chan
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Ki Jinn Chin
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
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25
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Exposto FG, Arima T, Svensson P. Sleep Disorders and Chronic Orofacial Pain. CURRENT SLEEP MEDICINE REPORTS 2019. [DOI: 10.1007/s40675-019-00152-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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26
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Sztain JF, Finneran JJ, Monahan AM, Khatibi B, Nguyen PL, Madison SJ, Bellars RH, Gabriel RA, Ahmed SS, Schwartz AK, Kent WT, Donohue MC, Padwal JA, Ilfeld BM. Continuous Popliteal-Sciatic Blocks for Postoperative Analgesia: Traditional Proximal Catheter Insertion Superficial to the Paraneural Sheath Versus a New Distal Insertion Site Deep to the Paraneural Sheath. Anesth Analg 2019; 128:e104-e108. [PMID: 31094804 DOI: 10.1213/ane.0000000000003693] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We tested the hypothesis that during a continuous popliteal-sciatic nerve block, postoperative analgesia is improved with the catheter insertion point "deep" to the paraneural sheath immediately distal to the bifurcation between the tibial and common peroneal branches, compared with the traditional approach "superficial" to the paraneural sheath proximal to the bifurcation. The needle tip location was determined to be accurately located with a fluid bolus visualized with ultrasound; however, catheters were subsequently inserted without a similar fluid injection and visualization protocol (visualized air injection was permitted and usually implemented, but not required per protocol). The average pain (0-10 scale) the morning after surgery for subjects with a catheter inserted at the proximal subparaneural location (n = 31) was a median (interquartile) of 1.5 (0.0-3.5) vs 1.5 (0.0-4.0) for subjects with a catheter inserted at the distal supraparaneural location (n = 32; P = .927). Secondary outcomes were similarly negative.
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Affiliation(s)
- Jacklynn F Sztain
- From the Department of Anesthesiology, University of California, San Diego, California
| | - John J Finneran
- From the Department of Anesthesiology, University of California, San Diego, California
- OUTCOMES RESEARCH Consortium, Cleveland, Ohio
| | - Amanda M Monahan
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Bahareh Khatibi
- From the Department of Anesthesiology, University of California, San Diego, California
| | - Patrick L Nguyen
- From the Department of Anesthesiology, University of California, San Diego, California
| | - Sarah J Madison
- Department of Anesthesiology, Stanford University, Stanford, California
| | - Richard H Bellars
- From the Department of Anesthesiology, University of California, San Diego, California
| | - Rodney A Gabriel
- From the Department of Anesthesiology, University of California, San Diego, California
- OUTCOMES RESEARCH Consortium, Cleveland, Ohio
| | - Sonya S Ahmed
- Department of Orthopedics, University of California, San Diego, California
| | | | - William T Kent
- Department of Orthopedics, University of California, San Diego, California
| | - Michael C Donohue
- Department of Neurology, University of Southern California, Los Angeles, California
| | - Jennifer A Padwal
- School of Medicine, University of California, San Diego, San Diego, California
| | - Brian M Ilfeld
- From the Department of Anesthesiology, University of California, San Diego, California
- OUTCOMES RESEARCH Consortium, Cleveland, Ohio
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27
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Byun S, Pather N. Pediatric regional anesthesia: A review of the relevance of surface anatomy and landmarks used for peripheral nerve blockades in infants and children. Clin Anat 2019; 32:803-823. [DOI: 10.1002/ca.23406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/08/2019] [Accepted: 05/09/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Sarang Byun
- Department of AnatomySchool of Medical Sciences, Medicine, UNSW Sydney Sydney Australia
| | - Nalini Pather
- Department of AnatomySchool of Medical Sciences, Medicine, UNSW Sydney Sydney Australia
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Carles M, Beloeil H, Bloc S, Nouette-Gaulain K, Aveline C, Cabaton J, Cuvillon P, Dadure C, Delaunay L, Estebe JP, Hofliger E, Martinez V, Olivier M, Robin F, Rosencher N, Capdevila X. Anesthésie loco-régionale périnerveuse (ALR-PN). ANESTHÉSIE & RÉANIMATION 2019. [DOI: 10.1016/j.anrea.2019.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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29
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Tran DQ, Salinas FV, Benzon HT, Neal JM. Lower extremity regional anesthesia: essentials of our current understanding. Reg Anesth Pain Med 2019; 44:rapm-2018-000019. [PMID: 30635506 DOI: 10.1136/rapm-2018-000019] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/14/2018] [Accepted: 05/23/2018] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- De Q Tran
- Department of Anesthesiology, McGill University, Montreal, Quebec, Canada
| | - Francis V Salinas
- Department of Anesthesiology, US Anesthesia Partners-Washington, Swedish Medical Center, Seattle, Washington, USA
| | - Honorio T Benzon
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Joseph M Neal
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington, USA
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30
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Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation: Neuromodulation of the Sciatic Nerve for Postoperative Analgesia Following Ambulatory Foot Surgery, a Proof-of-Concept Study. Reg Anesth Pain Med 2019; 43:580-589. [PMID: 29905630 PMCID: PMC6092098 DOI: 10.1097/aap.0000000000000819] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND OBJECTIVES Percutaneous peripheral nerve stimulation (PNS) is an analgesic modality involving the insertion of a lead through an introducing needle followed by the delivery of electric current. This modality has been reported to treat chronic pain as well as postoperative pain the day following knee surgery. However, it remains unknown if this analgesic technique may be used in ambulatory subjects following foot procedures beginning within the recovery room immediately following surgery, and with only short series of patients reported to date, the only available data are derived from strictly observational studies. The purposes of this proof-of-concept study were to demonstrate the feasibility of using percutaneous sciatic nerve PNS to treat postoperative pain following ambulatory foot surgery in the immediate postoperative period and provide the first available data from a randomized controlled study design to provide evidence of analgesic effect. METHODS Preoperatively, an electrical lead (SPRINT; SPR Therapeutics, Inc, Cleveland, Ohio) was percutaneously inserted posterior to the sciatic nerve between the subgluteal region and bifurcation with ultrasound guidance. Following hallux valgus osteotomy, subjects received 5 minutes of either stimulation or sham in a randomized, double-masked fashion followed by a 5-minute crossover period and then continuous stimulation until lead removal on postoperative days 14 to 28. RESULTS During the initial 5-minute treatment period, subjects randomized to stimulation (n = 4) experienced a downward trajectory in their pain over the 5 minutes of treatment, whereas those receiving sham (n = 3) reported no such change until their subsequent 5-minute stimulation crossover. During the subsequent 30 minutes of stimulation, pain scores decreased to 52% of baseline (n = 7). Three subjects (43%) used a continuous popliteal nerve block for rescue analgesia during postoperative days 0 to 3. Overall, resting and dynamic pain scores averaged less than 1 on the numeric rating scale, and opioid use averaged less than 1 tablet daily with active stimulation. One lead dislodged, 2 fractured during use, and 1 fractured during intentional withdrawal. CONCLUSIONS This proof-of-concept study demonstrates that percutaneous sciatic nerve PNS is feasible for ambulatory foot surgery and suggests that this modality provides analgesia and decreases opioid requirements following hallux valgus procedures. However, lead dislodgement and fracture are concerns. CLINICAL TRIAL REGISTRATION This study was registered at Clinicaltrials.gov, identifier NCT02898103.
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The Importance of the Saphenous Nerve Block for Analgesia Following Major Ankle Surgery: A Randomized, Controlled, Double-Blind Study. Reg Anesth Pain Med 2019; 43:474-479. [PMID: 29667940 DOI: 10.1097/aap.0000000000000764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Major ankle surgery causes intense postoperative pain, and whereas the importance of a sciatic nerve block is well established, the clinical significance of a supplemental saphenous nerve block has never been determined in a prospective, randomized, double-blind, placebo-controlled trial. We hypothesized that a saphenous nerve block reduces the proportion of patients experiencing significant clinical pain after major ankle surgery. METHODS Eighteen patients were enrolled and received a popliteal sciatic nerve block. Patients were randomized to single-injection saphenous nerve block with 10 mL 0.5% bupivacaine with 1:200,000 epinephrine or 10 mL saline (Fig. 1). Primary outcome was the proportion of patients reporting significant clinical pain, defined as a score greater than 3 on the numerical rating scale. Secondary outcomes were maximal pain and analgesia of the cutaneous territory of the infrapatellar branch of the saphenous nerve. RESULTS Eight of 9 patients in the placebo group reported significant clinical pain versus 1 of 9 patients in the bupivacaine-epinephrine group (P = 0.003). Maximal pain was significantly lower in the active compared with the placebo group (median, 0 [0-0] vs 5 [4-6]; P = 0.001). Breakthrough pain from the saphenous territory began within 30 minutes after surgery in all cases. Sensory testing of the cutaneous territory of the infrapatellar branch of the saphenous nerve showed correlation between pain reported in the anteromedial ankle region and the intensity of cutaneous sensory block in the anteromedial knee region. CONCLUSIONS The saphenous nerve is an important contributor to postoperative pain after major ankle surgery, with significant clinical pain appearing within 30 minutes after surgery. CLINICAL TRIALS REGISTRATION This study has been registered at ClinicalTrials.gov, identifier NCT02697955.
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Abstract
The concept of fast-track or ambulatory surgery appeared to facilitate early recovery and discharge from the hospital and early resumption of normal daily activities after elective surgical procedures as well to reduce the health-care costs. Multimodal/balanced analgesia is an increasingly popular approach for this. The use of conventional modalities including central neuraxial blockade and opioids cannot be extended to patients undergoing fast-track surgery. Hence, an aggressive perioperative analgesic regimen/protocol is required for effective pain relief, with minimal side effects and which could be managed easily by the patient or the relatives at home away from the hospital setting. Pharmacological therapy and regional anesthesia techniques have been utilized for postoperative pain management. The use of perineural, incisional, and intra-articular catheters and local anesthetic administration through elastomeric and electronic pumps is promising approach for effective pain management at home. The key to successful pain management of such procedures requires individually tailored education to patients or caregivers including information on treatment options for postoperative pain and use of multimodal analgesia. This review provides an overview of the current armamentarium of drugs and modalities available for effective management of patients undergoing day care surgeries and sheds light on newer modalities available.
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Affiliation(s)
- Anudeep Jafra
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sukanya Mitra
- Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
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Effect of Perineural Dexamethasone on the Duration of Single Injection Saphenous Nerve Block for Analgesia After Major Ankle Surgery: A Randomized, Controlled Study. Reg Anesth Pain Med 2018; 42:210-216. [PMID: 28033159 DOI: 10.1097/aap.0000000000000538] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients undergoing major elective ankle surgery often experience pain from the saphenous nerve territory persisting beyond the duration of a single-injection saphenous nerve block. We hypothesized that perineural dexamethasone as an adjuvant for the saphenous nerve block prolongs the duration of analgesia and postpones as well as reduces opioid-requiring pain. METHODS Forty patients were included in this prospective, randomized, controlled study. All patients received a continuous sciatic catheter and were randomized to receive a single-injection saphenous nerve block with 10 mL of 0.5% bupivacaine with 1:200,000 epinephrine with addition of 1 mL of saline or 1 mL of 0.4% (ie, 4 mg) dexamethasone. The primary outcome was duration of saphenous nerve block estimated as the time until the first opioid request. Secondary outcomes were opioid consumption and pain. RESULTS The mean (SD) duration of the saphenous nerve block until first opioid request was 29.4 (8.4) hours in the dexamethasone group and 23.2 (10.3) hours in the control group (P = 0.048). The median opioid consumption [interquartile range] during the first 24 hours was 0 mg [0-0] versus 1.5 mg [0-14.2] in the dexamethasone and control groups, respectively. Nonparametric comparison of opioid consumption from 0 to 24 hours was statistically significant. The opioid consumption was similar in the two groups in the time interval 24 to 48 postoperative hours. CONCLUSION Perineural dexamethasone as an adjuvant for the single-injection subsartorial saphenous nerve block can prolong analgesia and reduce opioid-requiring pain after major ankle surgery.
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Jarrell K, McDonald E, Shakked R, Nicholson K, Kasper V, Raikin SM. Combined Popliteal Catheter With Single-Injection vs Continuous-Infusion Saphenous Nerve Block for Foot and Ankle Surgery. Foot Ankle Int 2018; 39:332-337. [PMID: 29254445 DOI: 10.1177/1071100717744331] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The increasing scope and complexity of foot and ankle procedures performed in an outpatient setting require more intensive perioperative analgesia. Regional anesthesia (popliteal and saphenous nerve blocks) has been proven to provide satisfactory pain management, decreased postoperative opioid use, and earlier patient discharge. This can be further augmented with the placement of a continuous-flow catheter, typically inserted into the popliteal nerve region. This study investigated the use of a combined popliteal and saphenous continuous-flow catheter nerve block compared to a single popliteal catheter and single-injection saphenous nerve block in postoperative pain management after ambulatory foot and ankle surgery. METHODS A prospective study was conducted using 60 patients who underwent foot and ankle surgery performed in an outpatient setting. Demographic data, degree of medial operative involvement, American Society of Anesthesiologists physical classification system, anesthesia time, and postanesthesia care unit time were recorded. Outcome measures included pain satisfaction, numeric pain scores (NPS) at rest and with activity, and opioid intake. Patients were also classified by degree of saphenous nerve involvement in the operative procedure, by the surgeon who was blinded to the anesthesia randomization. RESULTS Patients in the dual-catheter group took significantly less opioid medication on the day of surgery and postoperative day 1 (POD 1) compared to the single-catheter group ( P = .02). The dual-catheter group reported significantly greater satisfaction with pain at POD 1 and POD 3 and a significantly lower NPS at POD 1, 2, and 3. This trend was observed in all 3 subgroups of medial operative involvement. CONCLUSION Patients in the single-catheter group reported more pain, less satisfaction with pain control, and increased opioid use on POD 1, suggesting dual-catheter use was superior to single-injection nerve blocks with regard to managing early postoperative pain in outpatient foot and ankle surgery. LEVEL OF EVIDENCE Level II, prospective cohort study.
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Affiliation(s)
- Kathleen Jarrell
- 1 Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Elizabeth McDonald
- 2 Rothman Institute Department of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Rachel Shakked
- 2 Rothman Institute Department of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Kristen Nicholson
- 2 Rothman Institute Department of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | | | - Steven M Raikin
- 2 Rothman Institute Department of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Kumar K, Kirksey MA, Duong S, Wu CL. A Review of Opioid-Sparing Modalities in Perioperative Pain Management. Anesth Analg 2017; 125:1749-1760. [DOI: 10.1213/ane.0000000000002497] [Citation(s) in RCA: 176] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Henningsen MJ, Sort R, Møller AM, Herling SF. Peripheral nerve block in ankle fracture surgery: a qualitative study of patients’ experiences. Anaesthesia 2017; 73:49-58. [DOI: 10.1111/anae.14088] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2017] [Indexed: 11/27/2022]
Affiliation(s)
- M. J. Henningsen
- Department of Anaesthesiology; Herlev and Gentofte University Hospital; Herlev Denmark
| | - R. Sort
- Department of Anaesthesiology; Herlev and Gentofte University Hospital; Herlev Denmark
| | - A. M. Møller
- Department of Anaesthesiology; Herlev and Gentofte University Hospital; Herlev Denmark
| | - S. F. Herling
- Department of Anaesthesiology; Herlev and Gentofte University Hospital; Herlev Denmark
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Bromberg AL, Dennis JA, Gritsenko K. Exparel/Peripheral Catheter Use in the Ambulatory Setting and Use of Peripheral Catheters Postoperatively in the Home Setting. Curr Pain Headache Rep 2017; 21:13. [PMID: 28271332 DOI: 10.1007/s11916-017-0605-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE OF REVIEW With the increasing number of ambulatory surgeries being performed, regional anesthesia has become an increasingly popular anesthetic modality, and many choices exist to provide efficient, effective quality perioperative analgesia. In this paper, we will review the various regional anesthesia options in addition to the advantages and disadvantages of each. Lastly, we will discuss liposomal bupivicaine, a long acting local anesthetic, and its future role in the anesthesiologist's armamentarium. The aim of the publication is to provide a general overview of regional anesthesia as well as to discuss the advantages and disadvantages of this modality. Additionally, we sought to review the basics of liposomal bupivicaine as well as the relevant literature. RECENT FINDINGS The results regarding liposomal bupivicaine are mixed and mainly focuses on local infiltration and intra-articular injections. There are no known studies specifically comparing liposomal bupivicaine to bupivicaine hydrochloride in ultrasound-guided nerve blocks. There is some encouraging data regarding liposomal bupivicaine, but further studies are needed before it is adopted as a mainstay of treatment. In addition to efficacy, additional investigations are needed to evaluate cost as this could be a major impediment to its implementation.
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Affiliation(s)
- Adam L Bromberg
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 E 210 Street, 4th Floor, Bronx, NY, 10467, USA
| | - Jeremy A Dennis
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 E 210 Street, 4th Floor, Bronx, NY, 10467, USA
| | - Karina Gritsenko
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 E 210 Street, 4th Floor, Bronx, NY, 10467, USA. .,Department of Family & Social Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, 111 E 210 Street, 4th Floor, Bronx, NY, 10467, USA. .,Department of Physical Medicine and Rehabilitation, Montefiore Medical Center, Albert Einstein College of Medicine, 111 E 210 Street, 4th Floor, Bronx, NY, 10467, USA.
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Carles M, Beloeil H, Bloc S, Nouette-Gaulain K, Aveline C, Cabaton J, Cuvillon P, Dadure C, Delaunay L, Estebe JP, Hofliger E, Martinez V, Olivier M, Robin F, Rosencher N, Capdevila X. Anesthésie locorégionale périnerveuse. ANESTHESIE & REANIMATION 2017. [DOI: 10.1016/j.anrea.2017.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Marolf V, Spadavecchia C, Fouché N, Rohrbach H. Repeated perineural administrations of ropivacaine at the tibial nerve following a degloving injury in a horse. VETERINARY RECORD CASE REPORTS 2017. [DOI: 10.1136/vetreccr-2016-000322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Vincent Marolf
- Vetsuisse‐FacultyDivision of Anaesthesiology and Pain treatmentDepartment of Clinical Veterinary ScienceUniversity of BernBernSwitzerland
- Faculty of Veterinary MedicineDepartment of Clinical SciencesUniversity of LiègeLiègeBelgium
| | - Claudia Spadavecchia
- Vetsuisse‐FacultyDivision of Anaesthesiology and Pain treatmentDepartment of Clinical Veterinary ScienceUniversity of BernBernSwitzerland
| | - Nathalie Fouché
- Vetsuisse‐FacultySwiss Institute of Equine Medicine (ISME)University of Bern and AgroscopeBernSwitzerland
| | - Helene Rohrbach
- Vetsuisse‐FacultyDivision of Anaesthesiology and Pain treatmentDepartment of Clinical Veterinary ScienceUniversity of BernBernSwitzerland
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Catheter Taping Methods—Single-Layer Versus Reinforced Double-Layer Technique. Reg Anesth Pain Med 2017; 42:128-130. [DOI: 10.1097/aap.0000000000000512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Potential superiority of periarticular injection in analgesic effect and early mobilization ability over femoral nerve block following total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2017; 25:291-298. [PMID: 25627004 DOI: 10.1007/s00167-015-3519-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 01/16/2015] [Indexed: 01/09/2023]
Abstract
PURPOSE Pain management after total knee arthroplasty (TKA) should permit early knee mobilization with minimal pain. Periarticular injection (PAI) with local anaesthetics has been recently discussed as a protocol of pain control. The purpose of this review of the literature was to evaluate the efficacy of PAI in comparison with femoral nerve block (FNB). METHODS A literature search was performed in PubMed, EMBASE, the OVID database and the Cochrane Library databases. Risk of bias was assessed using the Cochrane collaboration tool. Outcomes of interest included narcotic consumption, pain score, early mobilization ability, length of stay and adverse effects or events. RESULTS Research identified 918 articles, of which six with a total of 284 knees, met the inclusion criteria and were eligible for the current study. Conflicting evidence was found in terms of narcotic consumption on the postoperative day 1 and early mobilization ability. Total narcotic consumption, pain score in the first 2 days after surgery, length of stay and adverse effects or events showed no difference between two groups. Lower pain score on the day of surgery was detected after PAI. When compared to continuous FNB, patients in PAI group showed a tendency to achieving better ability of early mobilization. CONCLUSIONS In consideration of its relatively simple practice and its potential in analgesic effects or early mobilization ability, PAI had superiority to FNB in the management of pain control after TKA. Before PAI could be widely used in clinical practice after TKAs, further investigations would be necessary to confirm or refute our observed results and to unify the protocol of PAI. LEVEL OF EVIDENCE I.
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Howell R, Hill B, Hoffman C, Treacy E, Mulcahey MK. Peripheral Nerve Blocks for Surgery About the Knee. JBJS Rev 2016; 4:01874474-201612000-00001. [DOI: 10.2106/jbjs.rvw.16.00003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Hanson NA, Lee PH, Yuan SC, Choi DS, Allen CJ, Auyong DB. Continuous ambulatory adductor canal catheters for patients undergoing knee arthroplasty surgery. J Clin Anesth 2016; 35:190-194. [DOI: 10.1016/j.jclinane.2016.07.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 06/07/2016] [Accepted: 07/08/2016] [Indexed: 01/01/2023]
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Oh J, Perlas A, Lau J, Gandhi R, Chan VW. Functional outcome and cost-effectiveness of outpatient vs inpatient care for complex hind-foot and ankle surgery. A retrospective cohort study. J Clin Anesth 2016; 35:20-25. [DOI: 10.1016/j.jclinane.2016.07.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 06/21/2016] [Accepted: 07/05/2016] [Indexed: 10/21/2022]
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Saporito A, Calciolari S, Ortiz LG, Anselmi L, Borgeat A, Aguirre J. A cost analysis of orthopedic foot surgery: can outpatient continuous regional analgesia provide the same standard of care for postoperative pain control at home without shifting costs? THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2016; 17:951-961. [PMID: 26467165 DOI: 10.1007/s10198-015-0738-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 10/01/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Same-day surgery is common for foot surgery. Continuous regional anesthesia for outpatients has been shown effective but the economic impact on the perioperative process-related healthcare costs remains unclear. METHODS One hundred twenty consecutive patients were included in this assessor-blinded, prospective cohort study and allocated according to inclusion criteria in the day-care or in the in-patient group. Standardized continuous popliteal sciatic nerve block was performed in both groups for 48 h using an elastomeric pump delivering ropivacaine 0.2 % at a rate of 5 ml/h with an additional 5 ml bolus every 60 min. Outpatients were discharged the day of surgery and followed with standardized telephone interviews. The total direct health costs of both groups were compared. Moreover, the difference in treatment costs and the difference in terms of quality of care and effectiveness between the groups were compared. RESULTS Total management costs were significantly reduced in the day-care group. There was no difference between the groups regarding pain at rest and with motion, persistent pain after catheter removal and the incidence of PONV. Persistent motor block and catheter inflammation/infection were comparable in both groups. There was neither a difference in the number of unscheduled ambulatory visits nor in the number of readmissions. CONCLUSIONS Day-care continuous regional analgesia leads to an overall positive impact on costs by decreasing the incidence of unplanned ambulatory visits and unscheduled readmissions, without compromising on the quality of analgesia, patients' satisfaction, and safety.
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Affiliation(s)
- Andrea Saporito
- Anaesthesiology Department, Bellinzona Regional Hospital, Bellinzona, Switzerland.
| | - Stefano Calciolari
- Mecop Institut, University of Italian Switzerland (USI), Lugano, Switzerland
| | | | - Luciano Anselmi
- Anaesthesiology Department, Bellinzona Regional Hospital, Bellinzona, Switzerland
| | - Alain Borgeat
- Anaesthesiology Division, Balgrist University Hospital, Zurich, Switzerland
| | - José Aguirre
- Anaesthesiology Division, Balgrist University Hospital, Zurich, Switzerland
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Steffel L, Howard SK, Borg L, Mariano ER, Leng JC, Kim TE. Randomized comparison of popliteal-sciatic perineural catheter tip migration and dislocation in a cadaver model using two catheter designs. Korean J Anesthesiol 2016; 70:72-76. [PMID: 28184270 PMCID: PMC5296391 DOI: 10.4097/kjae.2017.70.1.72] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 09/02/2016] [Accepted: 09/13/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND New catheter-over-needle (CON) technology for continuous peripheral nerve blockade has emerged, but its effect on the risk of perineural catheter tip dislocation is unknown. Less flexible catheters may be more likely to migrate away from the nerve with simulated patient movement. In the present study, we evaluated catheter tip migration between CON catheters and traditional catheter-through-needle (CTN) catheters during ultrasound-guided short-axis in-plane (SAX-IP) insertion. METHODS We evaluated the migration of popliteal-sciatic catheters in a prone, unembalmed male cadaver. Thirty catheter placement trials were divided randomly into two groups based on the catheter type: CON or CTN. A single anesthesiology resident placed the catheters by SAX-IP insertion, and the catheters were then examined by ultrasound before and after ipsilateral knee range of motion (ROM) exercises (0°-130° flexion). A blinded expert regional anesthesiologist performed caliper measurements on the ultrasound images before and after the ROM exercises. The primary outcome was the change in distance from the catheter tip to the center of the nerve (cm) between before and after the ROM exercises. RESULTS The change in the tip-to-nerve distance (median [10th-90th percentile]) was 0.06 (-0.16 to 0.23) cm for the CTN catheter and 0.00 (-0.12 to 0.69) for the CON catheter (P = 0.663). However, there was a statistically significant increase in dislocation out of the nerve compartment for the CON catheter (4/15; 0/15 for CTN) (P = 0.043). CONCLUSIONS Although the use of different catheter designs had no effect on the change in the measured migration distance of popliteal-sciatic catheters, 27% of the CON catheters were dislocated out of the nerve compartment. These results may influence the choice of catheter design when using SAX-IP perineural catheter insertion.
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Affiliation(s)
- Lauren Steffel
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, USA
| | - Steven K Howard
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Lindsay Borg
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, USA
| | - Edward R Mariano
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Jody C Leng
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - T Edward Kim
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
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Ambrosoli AL, Guzzetti L, Chiaranda M, Cuffari S, Gemma M, Cappelleri G. A randomised controlled trial comparing two popliteal nerve catheter tip positions for postoperative analgesia after day-case hallux valgus repair. Anaesthesia 2016; 71:1317-1323. [DOI: 10.1111/anae.13577] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2016] [Indexed: 11/29/2022]
Affiliation(s)
- A. L. Ambrosoli
- Department of Anaesthesia; Ospedale di Circolo di Varese; Varese Italy
| | - L. Guzzetti
- Department of Anaesthesia; Ospedale di Circolo di Varese; Varese Italy
| | - M. Chiaranda
- Department of Anaesthesia and Intensive Care; Università degli Studi Insubria di Varese; Varese Italy
| | - S. Cuffari
- Department of Anaesthesia and Intensive Care; Università degli Studi Insubria di Varese; Varese Italy
| | - M. Gemma
- Department of Anaesthesia; IRCCS Ospedale San Raffaele; Milano Italy
| | - G. Cappelleri
- Department of Anaesthesia; Istituto Ortopedico G. Pini; Milano Italy
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Monahan AM, Madison SJ, Loland VJ, Sztain JF, Bishop ML, Sandhu NS, Bellars RH, Khatibi B, Schwartz AK, Ahmed SS, Donohue MC, Nomura ST, Wen CH, Ilfeld BM. Continuous Popliteal Sciatic Blocks: Does Varying Perineural Catheter Location Relative to the Sciatic Bifurcation Influence Block Effects? A Dual-Center, Randomized, Subject-Masked, Controlled Clinical Trial. Anesth Analg 2016; 122:1689-95. [PMID: 26962712 DOI: 10.1213/ane.0000000000001211] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Multiple studies have demonstrated that, for single-injection popliteal sciatic nerve blocks, block characteristics are dependent upon local anesthetic injection relative to the sciatic nerve bifurcation. In contrast, this relation remains unexamined for continuous popliteal sciatic nerve blocks. We, therefore, tested the hypothesis that postoperative analgesia is improved with the perineural catheter tip at the level of the bifurcation compared with 5 cm proximal to the bifurcation. METHODS Preoperatively, subjects having moderately painful foot or ankle surgery were randomly assigned to receive an ultrasound-guided subepimyseal perineural catheter inserted either at or 5 cm proximal to the sciatic nerve bifurcation. Subjects received a single injection of mepivacaine 1.5% either via the insertion needle preoperatively or the perineural catheter postoperatively, followed by an infusion of ropivacaine 0.2% (6 mL/h basal, 4 mL bolus, and 30-min lockout) for the study duration. The primary end point was the average pain measured on a numeric rating scale (0-10) in the 3 hours before a data collection telephone call the morning after surgery. RESULTS The average numeric rating scale of subjects with a catheter inserted at the sciatic nerve bifurcation (n = 64) was a median (10th, 25th to 75th, and 90th quartiles) of 3.0 (0.0, 2.4-5.0, and 7.0) vs 2.0 (0.0, 1.0-4.0, and 5.0) for subjects with a catheter inserted proximal to the bifurcation (n = 64; P = 0.008). Similarly, maximum pain scores were greater in the group at the bifurcation: 6.0 (3.0, 4.4-8.0, and 9.0) vs 5.0 (0.0, 3.0-8.0, and 10.0) (P = 0.019). Differences between the groups for catheter insertion time, opioid rescue dose, degree of numbness in the foot/toes, catheter dislodgement, and fluid leakage did not reach statistical significance. CONCLUSIONS For continuous popliteal sciatic nerve blocks, a catheter inserted 5 cm proximal to the sciatic nerve bifurcation provides superior postoperative analgesia in subjects having moderately painful foot or ankle surgery compared with catheters located at the bifurcation. This is in marked contrast with single-injection popliteal sciatic nerve blocks for which benefits are afforded to local anesthetic injection distal, rather than proximal, to the bifurcation.
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Affiliation(s)
- Amanda M Monahan
- From the *Department of Anesthesiology, University of California San Diego, San Diego, California; †Department of Orthopedics, University of California San Diego, San Diego, California; ‡Division of Biostatistics and Bioinformatics, University of California San Diego, San Diego, California; §School of Medicine, University of California San Diego, San Diego, California; ‖Department of Ophthalmology, University of California San Diego, San Diego, California; and ¶OUTCOMES RESEARCH Consortium, Cleveland, Ohio
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Saporito A, Anselmi L, Borgeat A, Aguirre JA. Can the choice of the local anesthetic have an impact on ambulatory surgery perioperative costs? Chloroprocaine for popliteal block in outpatient foot surgery. J Clin Anesth 2016; 32:119-26. [DOI: 10.1016/j.jclinane.2016.02.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 11/09/2015] [Accepted: 02/02/2016] [Indexed: 11/15/2022]
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