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Janiak M, Kowalczyk R, Gorniewski G, Olczyk-Miiller K, Kowalski M, Nowakowski P, Trzebicki J. Efficacy and Side Effect Profile of Intrathecal Morphine versus Distal Femoral Triangle Nerve Block for Analgesia following Total Knee Arthroplasty: A Randomized Trial. J Clin Med 2022; 11:jcm11236945. [PMID: 36498519 PMCID: PMC9739122 DOI: 10.3390/jcm11236945] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 11/08/2022] [Accepted: 11/22/2022] [Indexed: 11/27/2022] Open
Abstract
(1) Background: The management of postoperative pain after knee replacement is an important clinical problem. The best results in the treatment of postoperative pain are obtained using multimodal therapy principles. Intrathecal morphine (ITM) and single-shot femoral nerve block (SSFNB) are practiced in the treatment of postoperative pain after knee replacement, with the most optimal methods still under debate. The aim of this study was to compare the analgesic efficacy with special consideration of selected side effects of both methods. (2) Materials and methods: Fifty-two consecutive patients undergoing knee arthroplasty surgery at the Department of Orthopedics and Traumatology of the Medical University of Warsaw were included in the study. Patients were randomly allocated to one of two groups. In the ITM group, 100 micrograms of intrathecal morphine were used, and in the SSFNB group, a femoral nerve block in the distal femoral triangle was used as postoperative analgesia. The other elements of anesthesia and surgery did not differ between the groups. (3) Results: The total dose of morphine administered in the postoperative period and the effectiveness of pain management did not differ significantly between the groups (cumulative median morphine dose in 24 h in the ITM group 31 mg vs. SSFNB group 29 mg). The incidence of nausea and pruritus in the postoperative period differed significantly in favor of patients treated with a femoral nerve block. (4) Conclusions: Although intrathecal administration of morphine is similarly effective in the treatment of pain after knee replacement surgery as a single femoral triangle nerve block, it is associated with a higher incidence of cumbersome side effects, primarily nausea and pruritus.
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Affiliation(s)
- Marek Janiak
- 1st Department of Anesthesiology and Intensive Care, Medical University of Warsaw, 02-091 Warszawa, Poland
- Correspondence: ; Tel.: +48-22-502-1724
| | - Rafal Kowalczyk
- 1st Department of Anesthesiology and Intensive Care, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Grzegorz Gorniewski
- Department of Anesthesiology and Intensive Care Education, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Kinga Olczyk-Miiller
- 1st Department of Anesthesiology and Intensive Care, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Marcin Kowalski
- Department of Orthopedics and Traumatology, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Piotr Nowakowski
- Department of Anesthesiology and Intensive Care, Gruca Orthopaedic and Trauma Teaching Hospital, 05-400 Otwock, Poland
| | - Janusz Trzebicki
- 1st Department of Anesthesiology and Intensive Care, Medical University of Warsaw, 02-091 Warszawa, Poland
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2
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Lavand'homme PM, Kehlet H, Rawal N, Joshi GP. Pain management after total knee arthroplasty: PROcedure SPEcific Postoperative Pain ManagemenT recommendations. Eur J Anaesthesiol 2022; 39:743-757. [PMID: 35852550 PMCID: PMC9891300 DOI: 10.1097/eja.0000000000001691] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The PROSPECT (PROcedure SPEcific Postoperative Pain ManagemenT) Working Group is a global collaboration of surgeons and anaesthesiologists formulating procedure-specific recommendations for pain management after common operations. Total knee arthroplasty (TKA) is associated with significant postoperative pain that is difficult to treat. Nevertheless, pain control is essential for rehabilitation and to enhance recovery. OBJECTIVE To evaluate the available literature and develop recommendations for optimal pain management after unilateral primary TKA. DESIGN A narrative review based on published systematic reviews, using modified PROSPECT methodology. DATA SOURCES A literature search was performed in EMBASE, MEDLINE, PubMed and Cochrane Databases, between January 2014 and December 2020, for systematic reviews and meta-analyses evaluating analgesic interventions for pain management in patients undergoing TKA. ELIGIBILITY CRITERIA Each randomised controlled trial (RCT) included in the selected systematic reviews was critically evaluated and included only if met the PROSPECT requirements. Included studies were evaluated for clinically relevant differences in pain scores, use of nonopioid analgesics, such as paracetamol and nonsteroidal anti-inflammatory drugs and current clinical relevance. RESULTS A total of 151 systematic reviews were analysed, 106 RCTs met PROSPECT criteria. Paracetamol and nonsteroidal anti-inflammatory or cyclo-oxygenase-2-specific inhibitors are recommended. This should be combined with a single shot adductor canal block and peri-articular local infiltration analgesia together with a single intra-operative dose of intravenous dexamethasone. Intrathecal morphine (100 μg) may be considered in hospitalised patients only in rare situations when both adductor canal block and local infiltration analgesia are not possible. Opioids should be reserved as rescue analgesics in the postoperative period. Analgesic interventions that could not be recommended were also identified. CONCLUSION The present review identified an optimal analgesic regimen for unilateral primary TKA. Future studies to evaluate enhanced recovery programs and specific challenging patient groups are needed.
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Affiliation(s)
- Patricia M Lavand'homme
- From the Department of Anaesthesiology and Perioperative Pain Service, Cliniques Universitaires St Luc, University Catholic of Louvain (UCL), Brussels, Belgium (PML), Section of Surgical Pathophysiology 7621, Rigshospitalet, Copenhagen, Denmark (HK), Department of Anaesthesiology, Orebro University, Orebro, Sweden (NR) and Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, United States (GPJ)
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3
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Memtsoudis SG, Cozowicz C, Bekeris J, Bekere D, Liu J, Soffin EM, Mariano ER, Johnson RL, Go G, Hargett MJ, Lee BH, Wendel P, Brouillette M, Kim SJ, Baaklini L, Wetmore DS, Hong G, Goto R, Jivanelli B, Athanassoglou V, Argyra E, Barrington MJ, Borgeat A, De Andres J, El-Boghdadly K, Elkassabany NM, Gautier P, Gerner P, Gonzalez Della Valle A, Goytizolo E, Guo Z, Hogg R, Kehlet H, Kessler P, Kopp S, Lavand'homme P, Macfarlane A, MacLean C, Mantilla C, McIsaac D, McLawhorn A, Neal JM, Parks M, Parvizi J, Peng P, Pichler L, Poeran J, Poultsides L, Schwenk ES, Sites BD, Stundner O, Sun EC, Viscusi E, Votta-Velis EG, Wu CL, YaDeau J, Sharrock NE. Peripheral nerve block anesthesia/analgesia for patients undergoing primary hip and knee arthroplasty: recommendations from the International Consensus on Anesthesia-Related Outcomes after Surgery (ICAROS) group based on a systematic review and meta-analysis of current literature. Reg Anesth Pain Med 2021; 46:971-985. [PMID: 34433647 DOI: 10.1136/rapm-2021-102750] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/09/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Evidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery. METHODS A systematic review and meta-analysis: randomized controlled and observational studies investigating the impact of PNB utilization on major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications.Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, were queried from 1946 to August 4, 2020.The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess evidence quality and for the development of recommendations. RESULTS Analysis of 122 studies revealed that PNB use (compared with no use) was associated with lower ORs for (OR with 95% CIs) for numerous complications (total hip and knee arthroplasties (THA/TKA), respectively): cognitive dysfunction (OR 0.30, 95% CI 0.17 to 0.53/OR 0.52, 95% CI 0.34 to 0.80), respiratory failure (OR 0.36, 95% CI 0.17 to 0.74/OR 0.37, 95% CI 0.18 to 0.75), cardiac complications (OR 0.84, 95% CI 0.76 to 0.93/OR 0.83, 95% CI 0.79 to 0.86), surgical site infections (OR 0.55 95% CI 0.47 to 0.64/OR 0.86 95% CI 0.80 to 0.91), thromboembolism (OR 0.74, 95% CI 0.58 to 0.96/OR 0.90, 95% CI 0.84 to 0.96) and blood transfusion (OR 0.84, 95% CI 0.83 to 0.86/OR 0.91, 95% CI 0.90 to 0.92). CONCLUSIONS Based on the current body of evidence, the consensus group recommends PNB use in THA/TKA for improved outcomes. RECOMMENDATION PNB use is recommended for patients undergoing THA and TKA except when contraindications preclude their use. Furthermore, the alignment of provider skills and practice location resources needs to be ensured. Evidence level: moderate; recommendation: strong.
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Affiliation(s)
- Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA .,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Crispiana Cozowicz
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical Private University, Salzburg, Austria
| | - Janis Bekeris
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical Private University, Salzburg, Austria
| | - Dace Bekere
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical Private University, Salzburg, Austria
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Ellen M Soffin
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Edward R Mariano
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Rebecca L Johnson
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - George Go
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Mary J Hargett
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Bradley H Lee
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Pamela Wendel
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Mark Brouillette
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Sang Jo Kim
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Lila Baaklini
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Douglas S Wetmore
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Genewoo Hong
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Rie Goto
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Bridget Jivanelli
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Vassilis Athanassoglou
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Eriphili Argyra
- Faculty of Medicine, Aretaieion University Hospital, Athens, Greece
| | - Michael John Barrington
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Alain Borgeat
- Anesthesiology, Balgrist University Hospital, Zurich, Switzerland
| | - Jose De Andres
- Anesthesia, Critical Care and Multidisciplinary Pain Management Department, Valencia University General Hospital, Valencia, Spain.,Anesthesia Unit, Surgical Specialties Department, School of Medicine, University of Valencia, Valencia, Spain
| | | | - Nabil M Elkassabany
- Anesthesiology and Critical Care, University Of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Philippe Gautier
- Department of Anesthesiology and Resuscitation, Clinique Sainte-Anne Saint-Remi, Brussels, Belgium
| | - Peter Gerner
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical Private University, Salzburg, Austria
| | - Alejandro Gonzalez Della Valle
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.,Department of Orthopedic Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Enrique Goytizolo
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Zhenggang Guo
- Department of Anesthesiology, Peking Universtiy Shougang Hospital, Beijing, China
| | - Rosemary Hogg
- Department of Anaesthesia, Belfast Health and Social Care Trust, Belfast, UK
| | - Henrik Kehlet
- Department of Clinical Medicine, Rigshosp, Copenhagen, Denmark
| | - Paul Kessler
- Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Hessen, Germany
| | - Sandra Kopp
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Alan Macfarlane
- School of Medicine, Dentistry & Nursing, Glasgow Royal Infirmary and Stobhill Ambulatory Hospital, Glasgow, UK
| | - Catherine MacLean
- Center for the Advancement of Value in Musculoskeletal Care, Hospital for Special Surgery, New York, New York, USA.,Center for the Advancement of Value in Musculoskeletal Care, Weill Cornell Medical College, New York, New York, USA
| | - Carlos Mantilla
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Dan McIsaac
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Alexander McLawhorn
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.,Department of Orthopedic Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Joseph M Neal
- Anesthesiology, Virginia Mason Medical Center, Seattle, Washington, USA.,Benaroya Research Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Michael Parks
- Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Javad Parvizi
- Orthopedic Surgery, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | - Philip Peng
- Anesthesia, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Lukas Pichler
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical Private University, Salzburg, Austria
| | - Jashvant Poeran
- Orthopaedics/Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lazaros Poultsides
- Department of Orthopaedic Surgery, New York Langone Orthopaedic Hospital, New York, New York, USA
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brian D Sites
- Anesthesiology, Dartmouth Medical School, Hanover, New Hampshire, USA
| | - Ottokar Stundner
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical Private University, Salzburg, Austria.,Department of Anesthesiology and Intensive Care, Medical University of Innsbruck, Innsbruck, Tyrol, Austria
| | - Eric C Sun
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Eugene Viscusi
- Department of Anesthesiology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Effrossyni Gina Votta-Velis
- Department of Anesthesiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, USA
| | - Christopher L Wu
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Jacques YaDeau
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Nigel E Sharrock
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
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Bigalke S, Maeßen TV, Schnabel K, Kaiser U, Segelcke D, Meyer-Frießem CH, Liedgens H, Macháček PA, Zahn PK, Pogatzki-Zahn EM. Assessing outcome in postoperative pain trials: are we missing the point? A systematic review of pain-related outcome domains reported in studies early after total knee arthroplasty. Pain 2021; 162:1914-1934. [PMID: 33492036 DOI: 10.1097/j.pain.0000000000002209] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/21/2020] [Indexed: 01/04/2023]
Abstract
ABSTRACT The management of acute postoperative pain remains suboptimal. Systematic reviews and Cochrane analysis can assist with collating evidence about treatment efficacy, but the results are limited in part by heterogeneity of endpoints in clinical trials. In addition, the chosen endpoints may not be entirely clinically relevant. To investigate the endpoints assessed in perioperative pain trials, we performed a systematic literature review on outcome domains assessing effectiveness of acute pain interventions in trials after total knee arthroplasty. We followed the Cochrane recommendations for systematic reviews, searching PubMed, Cochrane, and Embase, resulting in the screening of 1590 potentially eligible studies. After final inclusion of 295 studies, we identified 11 outcome domains and 45 subdomains/descriptors with the domain "pain"/"pain intensity" most commonly assessed (98.3%), followed by "analgesic consumption" (88.8%) and "side effects" (75.3%). By contrast, "physical function" (53.5%), "satisfaction" (28.8%), and "psychological function" (11.9%) were given much less consideration. The combinations of outcome domains were inhomogeneous throughout the studies, regardless of the type of pain management investigated. In conclusion, we found that there was high variability in outcome domains and inhomogeneous combinations, as well as inconsistent subdomain descriptions and utilization in trials comparing for effectiveness of pain interventions after total knee arthroplasty. This points towards the need for harmonizing outcome domains, eg, by consenting on a core outcome set of domains which are relevant for both stakeholders and patients. Such a core outcome set should include at least 3 domains from 3 different health core areas such as pain intensity, physical function, and one psychological domain.
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Affiliation(s)
- Stephan Bigalke
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
- Clinic for Anaesthesiology, Intensive and Pain Medicine, Ruhr-University Bochum, BG-University Hospital Bergmannsheil gGmbH, Bochum, Germany
| | - Timo V Maeßen
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
| | - Kathrin Schnabel
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
| | - Ulrike Kaiser
- University Pain Centre, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Daniel Segelcke
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
| | - Christine H Meyer-Frießem
- Clinic for Anaesthesiology, Intensive and Pain Medicine, Ruhr-University Bochum, BG-University Hospital Bergmannsheil gGmbH, Bochum, Germany
| | | | - Philipp A Macháček
- Faculty of Electrical Engineering and Information Technology, Ruhr-University Bochum, Bochum, Germany
| | - Peter K Zahn
- Clinic for Anaesthesiology, Intensive and Pain Medicine, Ruhr-University Bochum, BG-University Hospital Bergmannsheil gGmbH, Bochum, Germany
| | - Esther M Pogatzki-Zahn
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
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5
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Qin L, You D, Zhao G, Li L, Zhao S. A comparison of analgesic techniques for total knee arthroplasty: A network meta-analysis. J Clin Anesth 2021; 71:110257. [PMID: 33823459 DOI: 10.1016/j.jclinane.2021.110257] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/13/2021] [Accepted: 03/15/2021] [Indexed: 01/29/2023]
Abstract
STUDY OBJECTIVE There is no established analgesic method for postoperative total knee arthroplasty. We comprehensively compared the analgesic methods for postoperative total knee arthroplasty. DESIGN A network meta-analysis of randomised controlled trials was used to compare 18 interventions, which were ranked by six outcome indices, to select the best modality. SETTING Postoperative recovery room and inpatient ward. PATIENTS 98 randomised controlled trials involving 7452 patients (ASA I-III) were included in the final analysis. INTERVENTIONS Studies that included the use of at least one of the following 12 nerve block(fascia iliaca compartment block (FIB), FNB, cFNB, single femoral nerve block (sFNB), adductor canal block (ACB), sciatic nerve block (SNB), obturator nerve block (ONB), continuous posterior lumbar plexus block (PSOAS), FNB + SNB, ACB + LIA, FNB + LIA, PCA + FNB). MEASUREMENTS Pain intensity was compared using Visual Analogue Scale (VAS). Also, postoperative complications, function score, hospital length of stay, morphine consumption and patient satisfaction were measured. MAIN RESULTS For visual analogue scale scores, continuous femoral nerve block (FNB) and FNB + sciatic nerve block (SNB) were the the most effective interventions. For reducing postoperative complications, fascia iliaca compartment block, FNB, SNB, and obturator nerve block showed the best results. For reducing postoperative morphine consumption, adductor canal block (ACB) + local infiltration analgesia (LIA) and FNB + SNB were preferred. For function scores (range of motion, Timed-Up-and-Go test), ACB and LIA were optimal choices. For reducing hospital length of stay and patient satisfaction, ACB + LIA and FNB + LIA were best, respectively. CONCLUSIONS Peripheral nerve block, especially FNB and ACB, is a better option than other analgesic methods, and its combination with other methods can be beneficial. Peripheral nerve block is a safe and effective postoperative analgesia method. However, our findings can only provide objective evidence. Clinicians should choose the treatment course based on the individual patient's condition and clinical situation.
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Affiliation(s)
- Lu Qin
- Center for Applied Statistical Research and College of Mathematics, Jilin University, Changchun, China.
| | - Di You
- China-Japan Union Hospital of Jilin University, Changchun, China.
| | - Guoqing Zhao
- China-Japan Union Hospital of Jilin University, Changchun, China; Jilin University, Changchun, China.
| | - Longyun Li
- China-Japan Union Hospital of Jilin University, Changchun, China.
| | - Shishun Zhao
- Center for Applied Statistical Research and College of Mathematics, Jilin University, Changchun, China.
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6
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Pathonsamit C, Onklin I, Hongku N, Chaiyakit P. Randomized Double-Blind Controlled Trial Comparing 0.2 mg, 0.1 mg, and No Intrathecal Morphine Combined With Periarticular Injection for Unilateral Total Knee Arthroplasty. Arthroplast Today 2020; 7:253-259. [PMID: 33786350 PMCID: PMC7987934 DOI: 10.1016/j.artd.2020.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 10/27/2020] [Accepted: 11/15/2020] [Indexed: 12/22/2022] Open
Abstract
Background The addition of intrathecal morphine (ITM) to neuraxial anesthesia during total knee arthroplasty (TKA) to achieve postoperative analgesia can elicit opioid-related side effects. The other methods of pain alleviation and side effect reduction, including multimodal analgesia, are challenging. This study aimed to determine the efficacy of various ITM dosages for primary unilateral TKA with periarticular injection (PI). Methods This randomized double-blind controlled trial was conducted at Vajira Hospital between April 2018 and March 2019. Patients undergoing TKA were randomized into 3 groups: no ITM (M0), ITM 0.1 mg (M1), and ITM 0.2 mg (M2). All patients received PI. Postoperative pain scores, side effects of ITM, and orthopedic outcomes were compared. Results The trial enrolled 102 patients: M0 (n = 32), M1 (n = 35), and M2 (n = 35). The postoperative pain scores and rescue analgesic consumption of groups M1 and M2 did not differ significantly within the first 24 hours and were significantly lower than those in group M0. Nausea and vomiting were observed more frequently 4 hours postoperatively in M2 than in groups M1 and M0 (77%, 51%, and 6%, respectively; P < .05), which required second-line antiemetic administration (29%, 9%, and 13%, respectively; P = .09). Conclusion Postoperative pain control achieved with PI combined with ITM 0.1 mg after primary unilateral TKA was comparable to that achieved with ITM 0.2 mg. PI without ITM resulted in higher pain scores and rescue analgesic consumption. The frequency and severity of nausea and vomiting 4 hours postoperatively were also lower in patients administered 0.1 mg of ITM than those in patients administered 0.2 mg of ITM.
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Affiliation(s)
- Chompunoot Pathonsamit
- Department of Anesthesiology, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Ittiwat Onklin
- Department of Orthopedics, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Natthapong Hongku
- Department of Orthopedics, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Pruk Chaiyakit
- Department of Orthopedics, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
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7
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Kim YM, Kang C, Joo YB, Lee SH. The role of ultrasound-guided single-shot femoral and sciatic nerve blocks on pain management after total knee arthroplasty. Knee 2019; 26:881-888. [PMID: 31171426 DOI: 10.1016/j.knee.2019.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 04/02/2019] [Accepted: 05/06/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Peripheral nerve blocks reduce postoperative pain and opioid consumption after total knee arthroplasty (TKA). The aim of this study was to evaluate the effects of single-shot femoral nerve and sciatic nerve blocks on postoperative pain management and opioid consumption after TKA. METHODS This study included 100 patients who underwent TKA between July 2015 and September 2017. Fifty patients received pre-operative, single-injection, ultrasound-guided femoral and sciatic nerve blocks (Group 1) and 50 did not (Group 2). Multimodal analgesia was otherwise identical, and oxycodone was administered either intravenously or orally if the patients complained of postoperative pain ≥6 on the visual analog scale (VAS). Postoperative VAS scores, opioid consumption, and the fear of future TKA were compared between the groups. RESULTS The mean VAS in the first 18 postoperative hours was significantly lower in Group 1 (P ≤ 0.002). The mean amount of oxycodone taken in the first three postoperative days was significantly lower in Group 1 (P = 0.001). Patient fear of future TKA at 14 days postoperatively was significantly lower in Group 1 (P = 0.027). CONCLUSIONS Pre-operative ultrasound-guided, single-shot femoral and sciatic nerve blocks afforded effective pain control in the first 18 h after TKA, and significantly reduced oxycodone consumption in the first three postoperative days.
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Affiliation(s)
- Young-Mo Kim
- Chungnam National University School of Medicine, Munhwa-dong, Jung-gu, 301-721 Daejeon, South Korea
| | - Chan Kang
- Chungnam National University School of Medicine, Munhwa-dong, Jung-gu, 301-721 Daejeon, South Korea
| | - Yong-Bum Joo
- Chungnam National University School of Medicine, Munhwa-dong, Jung-gu, 301-721 Daejeon, South Korea.
| | - Soong-Hyun Lee
- Chungnam National University School of Medicine, Munhwa-dong, Jung-gu, 301-721 Daejeon, South Korea
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8
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Soffin EM, Gibbons MM, Ko CY, Kates SL, Wick E, Cannesson M, Scott MJ, Wu CL. Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery. Anesth Analg 2019; 128:441-453. [DOI: 10.1213/ane.0000000000003564] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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9
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Seet E, Leong WL, Yeo ASN, Fook-Chong S. Effectiveness of 3-in-1 Continuous Femoral Block of Differing Concentrations Compared to Patient Controlled Intravenous Morphine for Post Total Knee Arthroplasty Analgesia and Knee Rehabilitation. Anaesth Intensive Care 2019; 34:25-30. [PMID: 16494145 DOI: 10.1177/0310057x0603400110] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We assessed the effectiveness of the 3-in-l continuous femoral block as a form of postoperative pain relief for unilateral total knee arthroplasty (TKA). Sixty patients undergoing elective unilateral TKA under subarachnoid block were randomized into three groups. Postoperative analgesia was provided with a continuous 3-in-l femoral nerve catheter with 0.15% ropivacaine in group A, a continuous 3-in-l femoral nerve catheter with 0.2% ropivacaine in group B, or patient controlled intravenous morphine in group C (control group). Groups A and B received patient controlled intravenous morphine pumps for rescue analgesia. Patients in each group were followed for 72 hours postoperatively. Five patients were excluded after randomization. In the remaining 55 patients there was no statistical difference in pain score between the groups. Total morphine use was highest in group C (P< 0.05). No appreciable difference could be found with sensorimotor blockade, morphine usage and satisfaction scores when comparing groups A and B. Femoral catheter dislodgement rate was 7.9%. There was no statistical difference between the groups when comparing the day of first ambulation and the time to discharge from the hospital. Satisfaction scores were higher in group A (P = 0.028) and group B (P = 0.002) compared to group C. We conclude that a continuous 3-in-l femoral nerve block with ropivacaine 0.15% or 0.2% for elective unilateral TKA has an opioid-sparing effect.
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MESH Headings
- Age Factors
- Aged
- Amides/administration & dosage
- Analgesia/adverse effects
- Analgesia/methods
- Analgesia, Patient-Controlled/methods
- Analgesics, Opioid/administration & dosage
- Analysis of Variance
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/methods
- Arthroplasty, Replacement, Knee/rehabilitation
- Dose-Response Relationship, Drug
- Female
- Femoral Nerve
- Follow-Up Studies
- Humans
- Male
- Middle Aged
- Morphine/administration & dosage
- Nerve Block/methods
- Pain Measurement
- Pain, Postoperative/diagnosis
- Pain, Postoperative/drug therapy
- Patient Satisfaction
- Probability
- Prospective Studies
- Risk Assessment
- Ropivacaine
- Severity of Illness Index
- Sex Factors
- Statistics, Nonparametric
- Treatment Outcome
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Affiliation(s)
- E Seet
- Singapore Health Services Pt Ltd, Singapore General Hospital, National Cancer Centre and Dover Park Hospice, Singapore
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10
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Mudumbai SC, Auyong DB, Memtsoudis SG, Mariano ER. A pragmatic approach to evaluating new techniques in regional anesthesia and acute pain medicine. Pain Manag 2018; 8:475-485. [DOI: 10.2217/pmt-2018-0017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Anesthesiologists set up regional anesthesia and acute pain medicine programs in order to improve the patient outcomes and experience. Given the increasing frequency and volume of newly described techniques, applying a pragmatic framework can guide clinicians on how to critically review and consider implementing the new techniques into clinical practice. A proposed framework should consider how a technique: increases access; enhances efficiency; decreases disparities and improves outcomes. Quantifying the relative contribution of these four factors using a point system, which will be specific to each practice, can generate an overall scorecard to help clinicians make decisions on whether or not to incorporate a new technique into clinical practice or replace an incumbent technique within a clinical pathway.
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Affiliation(s)
- Seshadri C Mudumbai
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - David B Auyong
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA
- Departments of Anesthesiology and Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA
| | - Edward R Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Miyamoto S, Sugita T, Aizawa T, Miyatake N, Sasaki A, Maeda I, Kamimura M, Takahashi A. The effect of morphine added to periarticular multimodal drug injection or spinal anesthesia on pain management and functional recovery after total knee arthroplasty. J Orthop Sci 2018; 23:801-806. [PMID: 30213365 DOI: 10.1016/j.jos.2018.04.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 02/19/2018] [Accepted: 04/16/2018] [Indexed: 02/09/2023]
Abstract
BACKGROUND The efficacy of morphine added to periarticular multimodal drug injection (PMDI) for pain management after total knee arthroplasty (TKA) is controversial. Adding morphine to spinal anesthesia has reportedly improved pain relief for the first 24 h. We examined the effect of morphine added to PMDI or spinal anesthesia on pain management and functional recovery after TKA. METHODS A total of 97 patients were randomized into three groups: in Group A (34 patients), 10 mg morphine was added to PMDI; Group B (31 patients), 0.1 mg morphine was added to spinal anesthesia; and Group C (32 patients), morphine was added to neither the PMDI nor spinal anesthetic. To evaluate the efficacy of added morphine for pain management, we assessed rest pain, the number of times analgesics were used, and the time period until the first analgesic use. The adverse effects of morphine were assessed by counting the numbers of times vomiting occurred and antiemetics were used. Functional recovery was evaluated by recording the range of motion of the knee and the date of ability to walk. RESULTS Rest pain was the least in Group B at 6 and 12 h after operation. The number of times analgesics were used was the least in Group B. The time period until the first analgesic use was the longest in Group B. The number of vomiting episodes was the least in Group C. The number of times antiemetics were used was higher in Group A than in Group C. There were no significant differences in the range of motion and date of ability to walk among the three groups. CONCLUSIONS The efficacy of morphine added to PMDI was limited, and that of morphine added to spinal anesthesia disappeared within 20 h postoperatively. Adding morphine to PMDI or spinal anesthesia did not improve functional recovery and caused some adverse effects.
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Affiliation(s)
- Seiya Miyamoto
- Department of Orthopedic Surgery, Tohoku Orthopedic Clinic, 4-9-22 Kamiyagari, Izumi-ku, Sendai, 981-3121, Japan
| | - Takehiko Sugita
- Department of Orthopedic Surgery, Tohoku Orthopedic Clinic, 4-9-22 Kamiyagari, Izumi-ku, Sendai, 981-3121, Japan.
| | - Toshimi Aizawa
- Department of Orthopedic Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Naohisa Miyatake
- Department of Orthopedic Surgery, Tohoku Orthopedic Clinic, 4-9-22 Kamiyagari, Izumi-ku, Sendai, 981-3121, Japan
| | - Akira Sasaki
- Department of Orthopedic Surgery, Tohoku Orthopedic Clinic, 4-9-22 Kamiyagari, Izumi-ku, Sendai, 981-3121, Japan
| | - Ikuo Maeda
- Department of Orthopedic Surgery, Tohoku Orthopedic Clinic, 4-9-22 Kamiyagari, Izumi-ku, Sendai, 981-3121, Japan
| | - Masayuki Kamimura
- Department of Orthopedic Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Atsushi Takahashi
- Department of Orthopedic Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
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Labrum JT, Ilyas AM. The Opioid Epidemic: Postoperative Pain Management Strategies in Orthopaedics. JBJS Rev 2017; 5:e14. [DOI: 10.2106/jbjs.rvw.16.00124] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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13
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Tang Y, Tang X, Wei Q, Zhang H. Intrathecal morphine versus femoral nerve block for pain control after total knee arthroplasty: a meta-analysis. J Orthop Surg Res 2017; 12:125. [PMID: 28814320 PMCID: PMC5559845 DOI: 10.1186/s13018-017-0621-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 07/18/2017] [Indexed: 01/23/2023] Open
Abstract
Background This meta-analysis aims to illustrate the efficacy and safety of intrathecal morphine (ITM) versus femoral nerve block (FNB) for pain control after total knee arthroplasty (TKA). Methods In April 2017, a systematic computer-based search was conducted in PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews, Cami Info. Inc., Casalini databases, EBSCO databases, Verlag database and Google database. Data on patients prepared for TKA surgery in studies that compared ITM versus FNB for pain control after TKA were collected. The main outcomes were the visual analogue scale (VAS) at 6, 12, 24, 48 and 72 and total morphine consumption at 12, 24 and 48 h. The secondary outcomes were complications that included postoperative nausea and vomiting (PONV) and itching. Stata 12.0 was used for pooling the data. Results Five clinical studies with a total of 225 patients (ITM group = 114, FNB group = 111) were ultimately included in the meta-analysis. The results revealed that the ITM group was associated with a reduction of VAS at 6, 12, 24, 48 and 72 h and total morphine consumption at 12, 24 and 48 h. There was no significant difference between the occurrences of PONV. However, the ITM group was associated with an increased occurrence of itching after TKA. Conclusions Some immediate analgesic efficacy and opioid-sparing effects were obtained with the administration of ITM when compared with FNB. The complications of itching in the ITM group were greater than in the FNB group. The sample size and the quality of the included studies were limited. A multi-centre RCT is needed to identify the optimal method for reaching maximum pain control after TKA. Electronic supplementary material The online version of this article (doi:10.1186/s13018-017-0621-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yi Tang
- Department of Orthopedics, People's Hospital of JianYang, No. 180, Yiyuan Road, Jiancheng zhen, Jianyang, Sichuan Province, China
| | - Xu Tang
- Department of Orthopedics, People's Hospital of JianYang, No. 180, Yiyuan Road, Jiancheng zhen, Jianyang, Sichuan Province, China
| | - Qinghua Wei
- Department of Orthopedics, People's Hospital of JianYang, No. 180, Yiyuan Road, Jiancheng zhen, Jianyang, Sichuan Province, China
| | - Hui Zhang
- Department of Orthopedics, People's Hospital of JianYang, No. 180, Yiyuan Road, Jiancheng zhen, Jianyang, Sichuan Province, China.
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14
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Álvarez NER, Ledesma RJG, Hamaji A, Hamaji MWM, Vieira JE. Continuous femoral nerve blockade and single-shot sciatic nerve block promotes better analgesia and lower bleeding for total knee arthroplasty compared to intrathecal morphine: a randomized trial. BMC Anesthesiol 2017; 17:64. [PMID: 28499420 PMCID: PMC5429542 DOI: 10.1186/s12871-017-0355-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 05/08/2017] [Indexed: 12/30/2022] Open
Abstract
Background Knee arthroplasty leads to postoperative pain. This study compares analgesia and postoperative bleeding achieved by intrathecal morphine with a continuous femoral plus single-shot sciatic nerve block. Methods A randomized non-blinded clinical trial enrolled patients aged over 18 years old, ASA I to III who underwent total knee arthroplasty. All patients underwent spinal anesthesia with isobaric bupivacaine, 20 mg. One group received 100 mcg of intrathecal morphine (M group), and the other received a femoral nerve block by continuous infusion plus a "single shot" block of the sciatic nerve at the end of the surgery (FI group). Pain score from verbal numeric rating scale (VNRS) and morphine consumption during the first 72 h, as well as motor blockade, adverse effects, and postoperative bleeding were recorded. Analysis of variance of repeated measures with Bonferroni post-test, t-test and Fisher exact test were used for statistical analysis. Results Thirty nine patients completed the study (M = 20; FI = 19 patients) and were similar except for higher age in the FI group. Motor blockade as well as movement pain during postanesthesia care unit (PACU) staying were not different between the groups, but movement pain was significantly lower in FI group after 24 h. Postoperative bleeding (ml) was lower in FI group. Conclusions Continuous femoral nerve block combined with sciatic nerve block provides effective for postoperative analgesia in patients undergoing total knee arthroplasty, with lower pain scores after 24 h and a lower incidence of adverse effects and bleeding compared to intrathecal morphine. Trial registration Retrospectively registered on https://clinicaltrials.gov/ under identifier NCT02882152, 23rd December, 2016.
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Affiliation(s)
- Nora Elizabeth Rojas Álvarez
- Hospital das Clínicas, Divisão de Anestesia, Rua Dr. Ovídio Pires de Campos, 471, Cerqueira César, São Paulo, SP, Brazil, CEP 05403-010
| | - Rosemberg Jairo Gomez Ledesma
- Hospital das Clínicas, Divisão de Anestesia, Rua Dr. Ovídio Pires de Campos, 471, Cerqueira César, São Paulo, SP, Brazil, CEP 05403-010
| | - Adilson Hamaji
- Institute of Orthopedics and Trauma Surgery, Hospital das Clínicas, Rua Dr. Ovídio Pires de Campos, 333, Cerqueira César, São Paulo, SP, Brazil, CEP 05403-010
| | - Marcelo Waldir Mian Hamaji
- Institute of Orthopedics and Trauma Surgery, Hospital das Clínicas, Rua Dr. Ovídio Pires de Campos, 333, Cerqueira César, São Paulo, SP, Brazil, CEP 05403-010
| | - Joaquim Edson Vieira
- Department of Surgery, University of São Paulo Medical School, Av. Dr. Arnaldo 455, sala 2345, Cerqueira César, São Paulo, SP, Brazil, CEP 01246-903.
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Comparison of intrathecal and local infiltration analgesia by morphine for pain management in total knee and hip arthroplasty: A meta-analysis of randomized controlled trial. Int J Surg 2017; 40:97-108. [PMID: 28254422 DOI: 10.1016/j.ijsu.2017.02.060] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Revised: 02/15/2017] [Accepted: 02/17/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE We performed a meta-analysis from randomized controlled trials to evaluate the efficiency and safety between local infiltration analgesia and intrathecal morphine for pain control in total knee and hip arthroplasty. METHODS We systemically searched electronic databases including Embase (1980-2016.7), Medline (1966-2016.7), PubMed (1966-2016.7), ScienceDirect (1985-2016.7), web of science (1950-2016.7) and Cochrane Library for relevant articles. All calculation was carried out by Stata 11.0. RESULTS Four randomized controlled trials (RCTs) involving 242 patients met the inclusion criteria. The meta-analysis showed that there were significant differences in terms of postoperative pain scores at 24 h during rest (P = 0.008) and mobilization (P = 0.049) following total knee and hip arthroplasty. Significant difference was found regarding the incidence of nausea (P = 0.030), vomiting (P = 0.005), and pruritus (P = 0.000) between two groups. There was no significant difference between groups in terms of morphine equivalent consumption at postoperative 24 or 48 h. CONCLUSIONS Local infiltration analgesia (LIA) provided superior analgesic effects within the first 24 h compared to intrathecal morphine (ITM) following total knee and hip arthroplasty. There were fewer adverse effects in LIA. Doses of morphine consumption were similar in the two groups.
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DeSousa K, Chandran R. Intrathecal morphine vs femoral nerve block for postoperative-analgesia after total knee arthroplasty: A two-year retrospective analysis. World J Anesthesiol 2016; 5:67-72. [DOI: 10.5313/wja.v5.i3.67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 07/17/2016] [Accepted: 09/18/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To compare the efficacy of intrathecal morphine and single shot femoral nerve block for patients undergoing primary total knee arthroplasty.
METHODS Data was extracted from electronic medical records and case-paper record files of patients who underwent unilateral primary total knee arthroplasty under spinal anesthesia using bupivacaine 12.5 mg with intrathecal morphine (ITM) 0.2 mg and under general anesthesia (GA) with single shot femoral nerve block (FNB) using 20 mL 0.5% bupivacaine at our hospital in 2013 and 2014. All patients had received peri-articular infiltration as per the hospital protocol. Data for gender, age, weight, American Society of Anesthesiologists status, total surgical time, postoperative pain score using visual analogue scale (VAS) from 1 to 10 at 6 h, 12 h and 24 h postoperatively, 24 h opioid consumption, use of oral multimodal analgesia, postoperative high dependency unit (HDU) admission and the time to discharge from the hospital was collected. The data was analyzed using Mann-Whitney U test for continuous variables and Fischer’s exact-t-test for categorical variables.
RESULTS Twenty-two patients in ITM group and 32 patients in FNB group were analyzed. Median pain scores using VAS in ITM group were significantly lower at 6 h (0.0 vs 2.0, P < 0.001), 12 h (0.0 vs 2.0, P < 0.001) and 24 h (0.0 vs 2.0, P < 0.001) postoperatively. Also, postoperative morphine consumption in ITM group was significantly lower (P < 0.001). However, median of non-steroid anti-inflammatory drug unit requirement in 24 h postoperatively was statistically significant higher in ITM compared to FNB group (2.0 vs 1.0, P = 0.025). The difference in postoperative paracetamol consumption in 24 h was not statistically significant (P = 0.147). There was no significant difference in the postoperative HDU admission or time to discharge from the hospital. No respiratory depression in either group was noticed.
CONCLUSION The ITM group patients had much lower pain scores and morphine requirement in the first 24 hour postoperatively compared to FNB group.
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Li XM, Huang CM, Zhong CF. Intrathecal morphine verse femoral nerve block for pain control in total knee arthroplasty: A meta-analysis from randomized control trials. Int J Surg 2016; 32:89-98. [PMID: 27370542 DOI: 10.1016/j.ijsu.2016.06.043] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 06/22/2016] [Accepted: 06/25/2016] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Total knee arthroplasty (TKA) is usually associated with postoperative pain. The objective of this systematic review and meta-analysis was to evaluate the effectiveness and safety of femoral nerve block compared with intrathecal morphine for pain management after TKA. METHODS Potentially relevant literature was identified from electronic databases including Medline, PubMed, Embase, ScienceDirect and the Cochrane Library. Gray academic studies were also identified from the reference of included literature. There was no language restriction. Pooling of data was carried out using Stata 11.0. RESULTS Four randomized controlled trials (RCTs) involving 185 patients met the inclusion criteria. The meta-analysis indicated that there were no significant differences in terms of Visual Analog Scale (VAS) score at 6 h (standard mean difference (SMD) = -0.09, 95% CI: -1.62 to 1.43, P = 0.903), 12 h (weighted mean difference (WMD) = 1.84, 95% CI: -8.01 to 11.69, P = 0.714) or 24 h (WMD = 1.56, 95% CI: -14.31 to 17.42, P = 0.8474). No significant difference were found regarding morphine consumption at 6 h (WMD = -0.84, 95% CI: -2.52 to 0.85, P = 0.332), 12 h (WMD = 0.031, 95% CI: -3.304 to 0.3366, P = 0.985), 24 h (WMD = 0.21, 95% CI: -7.32 to 7.75, P = 0.956) or incidence of postoperative vomit and nausea (risk difference (RD) = -0.01, 95% CI: -0.15 to 0.12, P = 0.847). There was a significant difference between the groups in terms of the risk of itching postoperatively (RD = 0.41, 95% CI: 0.29 to 0.54, P < 0.001). CONCLUSIONS Femoral nerve block provides equal postoperative pain control compared with intrathecal morphine following total knee arthroplasty, although there were fewer side effects in the FNB groups. In contrast, FNB was performed with an additional procedure and required a special apparatus. Both methods are effective at pain control following TKA.
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Affiliation(s)
- Xian-Min Li
- Orthopedics Department, Gaozhou People's Hospital, No 89, Xi-Guan Road, Guangdong, 525200, PR China.
| | - Chun-Ming Huang
- Orthopedics Department, Gaozhou People's Hospital, No 89, Xi-Guan Road, Guangdong, 525200, PR China
| | - Cheng-Fan Zhong
- Orthopedics Department, Gaozhou People's Hospital, No 89, Xi-Guan Road, Guangdong, 525200, PR China
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Atchabahian A, Schwartz G, Hall CB, Lajam CM, Andreae MH. Regional analgesia for improvement of long-term functional outcome after elective large joint replacement. Cochrane Database Syst Rev 2015; 2015:CD010278. [PMID: 26269416 PMCID: PMC4566967 DOI: 10.1002/14651858.cd010278.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Regional analgesia is more effective than conventional analgesia for controlling pain and may facilitate rehabilitation after large joint replacement in the short term. It remains unclear if regional anaesthesia improves functional outcomes after joint replacement beyond three months after surgery. OBJECTIVES To assess the effects of regional anaesthesia and analgesia on long-term functional outcomes 3, 6 and 12 months after elective major joint (knee, shoulder and hip) replacement surgery. SEARCH METHODS We performed an electronic search of several databases (CENTRAL, MEDLINE, EMBASE, CINAHL), and handsearched reference lists and conference abstracts. We updated our search in June 2015. SELECTION CRITERIA We included randomized controlled trials (RCTs) comparing regional analgesia versus conventional analgesia in patients undergoing total shoulder, hip or knee replacement. We included studies that reported a functional outcome with a follow-up of at least three months after surgery. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We contacted study authors for additional information. MAIN RESULTS We included six studies with 350 participants followed for at least three months. All of these studies enrolled participants undergoing total knee replacement. Studies were at least partially blinded. Three studies had a high risk of performance bias and one a high risk of attrition bias, but the risk of bias was otherwise unclear or low.Only one study assessed joint function using a global score. Due to heterogeneity in outcome and reporting, we could only pool three out of six RCTs, with range of motion assessed at three months after surgery used as a surrogate for joint function. All studies had a high risk of detection bias. Using the random-effects model, there was no statistically significant difference between the experimental and control groups (mean difference 3.99 degrees, 95% confidence interval (CI) - 2.23 to 10.21; P value = 0.21, 3 studies, 140 participants, very low quality evidence).We did not perform further analyses because immediate adverse effects were not part of the explicit outcomes of any of these typically small studies, and long-term adverse events after regional anaesthesia are rare.None of the included studies elicited or reported long-term adverse effects like persistent nerve damage. AUTHORS' CONCLUSIONS More high-quality studies are needed to establish the effects of regional analgesia on function after major joint replacement, as well as on the risk of adverse events (falls).
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Affiliation(s)
- Arthur Atchabahian
- NYU School of MedicineDepartment of Anesthesiology, Perioperative Care, and Pain MedicineNew YorkNYUSA
| | - Gary Schwartz
- Maimonides Medical CenterDepartment of Anesthesiology4802 10th AvenueBrooklynNew YorkUSA11219
| | - Charles B Hall
- Albert Einstein College of Medicine, Mazer 220ADivision of Biostatistics, Department of Epidemiology and Population Health, Saul
B Korey Department of Neurology1300 Morris Park AvenueBronxNYUSA10461
| | - Claudette M Lajam
- NYU Langone Medical CenterDepartment of Orthopedic SurgeryNew YorkNYUSA
| | - Michael H Andreae
- Montefiore Medical Center, Albert Einstein College of MedicineDepartment of Anesthesiology111E 210th Street,#N4‐005New YorkNYUSA10467‐2401
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Olive DJ, Barrington MJ, Said SA, Kluger R. A Randomised Controlled Trial Comparing Three Analgesia Regimens following Total Knee Joint Replacement: Continuous Femoral Nerve Block, Intrathecal Morphine or Both. Anaesth Intensive Care 2015; 43:454-60. [DOI: 10.1177/0310057x1504300406] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This randomised controlled trial compared three analgesia regimens following primary unilateral total knee joint replacement: continuous femoral nerve block (CFNB), intrathecal morphine (ITM), and both. The primary outcome was pain ratings over the first 24 hours. Secondary outcomes included morphine consumption, nausea, pruritus and sedation ratings, oxygen saturation (SpO2) ratings, and ability to mobilise postoperatively. All patients received a spinal anaesthetic and a postoperative patient-controlled morphine pump. Patients were randomised to receive CFNB, ITM, or both. In patients with no CFNB, the use of ITM was blinded. Eighty-one patients were randomised and there were no withdrawals. At 24 hours, the ITM-only group had higher pain ratings than either of the other groups ( P=0.04 versus CFNB, P=0.01 versus combination). In the 18 to 24-hour period, the ITM group used more morphine than either of the other groups. There were no statistically significant differences in pain ratings or morphine consumption at earlier time intervals. The ITM group were less likely to be able to sit out of bed on day one. Patients who received ITM were more likely to have pruritus. There were no statistically significant differences in nausea, SpO2 or sedation ratings. This study showed that a CFNB resulted in reduced pain and was also associated with less morphine consumption and improved mobilisation at 24 hours compared to ITM. This study did not show any statistically significant differences between CFNB alone and CFNB+ITM.
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Affiliation(s)
- D. J. Olive
- Department of Anaesthesia, St Vincent's Hospital, Melbourne, Victoria
| | - M. J. Barrington
- Department of Anaesthesia, St Vincent's Hospital, Melbourne, Victoria
| | - S. A. Said
- Department of Anaesthesia, St Vincent's Hospital, Melbourne, Victoria
| | - R. Kluger
- Department of Anaesthesia, St Vincent's Hospital, Melbourne, Victoria
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Forrest P. Antibiotic prophylaxis for surgery: time to get our house in order. Anaesth Intensive Care 2015; 43:445-6. [PMID: 26099754 DOI: 10.1177/0310057x1504300403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Kessler J, Marhofer P, Hopkins P, Hollmann M. Peripheral regional anaesthesia and outcome: lessons learned from the last 10 years. Br J Anaesth 2015; 114:728-45. [DOI: 10.1093/bja/aeu559] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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McCartney CJL, Nelligan K. Postoperative pain management after total knee arthroplasty in elderly patients: treatment options. Drugs Aging 2014; 31:83-91. [PMID: 24399578 DOI: 10.1007/s40266-013-0148-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Total knee arthroplasty (TKA) is a common surgical procedure in the elderly and is associated with severe pain after surgery and a high incidence of chronic pain. Several factors are associated with severe acute pain after surgery, including psychological factors and severe preoperative pain. Good acute pain control can be provided with multimodal analgesia, including regional anesthesia techniques. Studies have demonstrated that poor acute pain control after TKA is strongly associated with development of chronic pain, and this emphasizes the importance of attention to good acute pain control after TKA. Pain after discharge from hospital after TKA is currently poorly managed, and this is an area where increased resources need to be focused to improve early pain control. This is particularly as patients are often discharged home within 4-5 days after surgery. Chronic pain after TKA in the elderly can be managed with both pharmacological and non-pharmacological techniques. After excluding treatable causes of pain, the simplest approach is with the use of acetaminophen combined with a short course of non-steroidal anti-inflammatory drugs (NSAIDs). Careful titration of opioid analgesics can also be helpful with other adjuvants such as the antidepressants or antiepileptic medications used especially for patients with neuropathic pain. Topical agents may provide benefit and are associated with fewer systemic side effects than oral administration. Complementary or psychological therapies may be beneficial for those patients who have failed other options or have depression associated with chronic pain.
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Affiliation(s)
- Colin J L McCartney
- Department of Anaesthesia, Holland Orthopaedic and Arthritic Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada,
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Comparison of three techniques for ultrasound-guided femoral nerve catheter insertion: a randomized, blinded trial. Anesthesiology 2014; 121:239-48. [PMID: 24758775 DOI: 10.1097/aln.0000000000000262] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Ultrasound guidance for continuous femoral perineural catheters may be supplemented by electrical stimulation through a needle or through a stimulating catheter. The authors tested the primary hypothesis that ultrasound guidance alone is noninferior on both postoperative pain scores and opioid requirement and superior on at least one of the two. Second, the authors compared all interventions on insertion time and incremental cost. METHODS Patients having knee arthroplasty with femoral nerve catheters were randomly assigned to catheter insertion guided by: (1) ultrasound alone (n = 147); (2) ultrasound and electrical stimulation through the needle (n = 152); or (3) ultrasound and electrical stimulation through both the needle and catheter (n = 138). Noninferiority between any two interventions was defined for pain as not more than 0.5 points worse on a 0 to 10 verbal response scale and for opioid consumption as not more than 25% greater than the mean. RESULTS The stimulating needle group was significantly noninferior to the stimulating catheter group (difference [95% CI] in mean verbal response scale pain score [stimulating needle vs. stimulating catheter] of -0.16 [-0.61 to 0.29], P < 0.001; percentage difference in mean IV morphine equivalent dose of -5% [-25 to 21%], P = 0.002) and to ultrasound-only group (difference in mean verbal response scale pain score of -0.28 [-0.72 to 0.16], P < 0.001; percentage difference in mean IV morphine equivalent dose of -2% [-22 to 25%], P = 0.006). In addition, the use of ultrasound alone for femoral nerve catheter insertion was faster and cheaper than the other two methods. CONCLUSION Ultrasound guidance alone without adding either stimulating needle or needle/catheter combination thus seems to be the best approach to femoral perineural catheters.
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Manage pain before, during and after total knee arthroplasty using a multimodal approach to analgesia. DRUGS & THERAPY PERSPECTIVES 2014. [DOI: 10.1007/s40267-014-0138-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Uesugi K, Kitano N, Kikuchi T, Sekiguchi M, Konno SI. Comparison of peripheral nerve block with periarticular injection analgesia after total knee arthroplasty: a randomized, controlled study. Knee 2014; 21:848-52. [PMID: 24827696 DOI: 10.1016/j.knee.2014.04.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2013] [Revised: 04/03/2014] [Accepted: 04/09/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Pain after total knee arthroplasty (TKA) is usually severe. Recently, the usefulness of local periarticular injection analgesia (PAI) and peripheral nerve block (PNB) has been reported. We report a prospective blinded randomized trial of PAI versus PNB in patients undergoing primary TKA, in accordance with the CONSORT statement 2010. METHODS A total of 210 patients undergoing TKA under spinal anesthesia were randomized to receive PNB group or PAI group. In the PNB group, femoral nerve block and sciatic nerve block were performed. In the PAI group, a special mixture containing ropivacaine, saline, epinephrine, morphine hydrochloride, and dexamethasone was injected into the periarticular soft tissue. Pain intensity at rest was assessed using a numerical rating scale (NRS: 0-10) after surgery. Use of a diclofenac sodium suppository (25mg) was allowed for all patients at any time after surgery, and the diclofenac sodium suppository usage was assessed. The NRS for patient satisfaction at 48 hours after surgery was examined. RESULTS The average NRS for pain at rest up to 48 hours after surgery was low in both groups. Within 48 hours after surgery, the diclofenac sodium suppository usage was similar in both groups. There were no significant differences in the NRS for patient satisfaction in both groups. CONCLUSIONS The analgesic effects of PAI and PNB are similar. PAI may be considered superior to PNB because it is easier to perform. LEVEL OF EVIDENCE Therapeutic Level 1.
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Affiliation(s)
- Kazuhide Uesugi
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan.
| | - Naoko Kitano
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Tadashi Kikuchi
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Miho Sekiguchi
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Shin-Ichi Konno
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
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Chan E, Fransen M, Parker DA, Assam PN, Chua N. Femoral nerve blocks for acute postoperative pain after knee replacement surgery. Cochrane Database Syst Rev 2014; 2014:CD009941. [PMID: 24825360 PMCID: PMC7173746 DOI: 10.1002/14651858.cd009941.pub2] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Total knee replacement (TKR) is a common and often painful operation. Femoral nerve block (FNB) is frequently used for postoperative analgesia. OBJECTIVES To evaluate the benefits and risks of FNB used as a postoperative analgesic technique relative to other analgesic techniques among adults undergoing TKR. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2013, Issue 1, MEDLINE, EMBASE, CINAHL, Web of Science, dissertation abstracts and reference lists of included studies. The date of the last search was 31 January 2013. SELECTION CRITERIA We included randomized controlled trials (RCTs) comparing FNB with no FNB (intravenous patient-controlled analgesia (PCA) opioid, epidural analgesia, local infiltration analgesia, and oral analgesia) in adults after TKR. We also included RCTs that compared continuous versus single-shot FNB. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection and data extraction. We undertook meta-analysis (random-effects model) and used relative risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) or standardized mean differences (SMDs) for continuous outcomes. We interpreted SMDs according to rule of thumb where 0.2 or smaller represents a small effect, 0.5 a moderate effect and 0.8 or larger, a large effect. MAIN RESULTS We included 45 eligible RCTs (2710 participants) from 47 publications; 20 RCTs had more than two allocation groups. A total of 29 RCTs compared FNB (with or without concurrent treatments including PCA opioid) versus PCA opioid, 10 RCTs compared FNB versus epidural, five RCTs compared FNB versus local infiltration analgesia, one RCT compared FNB versus oral analgesia and four RCTs compared continuous versus single-shot FNB. Most included RCTs were rated as low or unclear risk of bias for the aspects rated in the risk of bias assessment tool, except for the aspect of blinding. We rated 14 (31%) RCTs at high risk for both participant and assessor blinding and rated eight (18%) RCTs at high risk for one blinding aspect.Pain at rest and pain on movement were less for FNB (of any type) with or without a concurrent PCA opioid compared with PCA opioid alone during the first 72 hours post operation. Pooled results demonstrated a moderate effect of FNB for pain at rest at 24 hours (19 RCTs, 1066 participants, SMD -0.72, 95% CI -0.93 to -0.51, moderate-quality evidence) and a moderate to large effect for pain on movement at 24 hours (17 RCTs, 1017 participants, SMD -0.94, 95% CI -1.32 to -0.55, moderate-quality evidence). Pain was also less in each FNB subgroup: single-shot FNB, continuous FNB and continuous FNB + sciatic block, compared with PCA. FNB also was associated with lower opioid consumption (IV morphine equivalent) at 24 hours (20 RCTs, 1156 participants, MD -14.74 mg, 95% CI -18.68 to -10.81 mg, high-quality evidence) and at 48 hours (MD -14.53 mg, 95% CI -20.03 to -9.02 mg), lower risk of nausea and/or vomiting (RR 0.47, 95% CI 0.33 to 0.68, number needed to treat for an additional harmful outcome (NNTH) four, high-quality evidence), greater knee flexion (11 RCTs, 596 participants, MD 6.48 degrees, 95% CI 4.27 to 8.69 degrees, moderate-quality evidence) and greater patient satisfaction (four RCTs, 180 participants, SMD 1.06, 95% CI 0.74 to 1.38, low-quality evidence) compared with PCA.We could not demonstrate a difference in pain between FNB (any type) and epidural analgesia in the first 72 hours post operation, including pain at 24 hours at rest (six RCTs, 328 participants, SMD -0.05, 95% CI -0.43 to 0.32, moderate-quality evidence) and on movement (six RCTs, 317 participants, SMD 0.01, 95% CI -0.21 to 0.24, high-quality evidence). No difference was noted at 24 hours for opioid consumption (five RCTs, 341 participants, MD -4.35 mg, 95% CI -9.95 to 1.26 mg, high-quality evidence) or knee flexion (six RCTs, 328 participants, MD -1.65, 95% CI -5.14 to 1.84, high-quality evidence). However, FNB demonstrated lower risk of nausea/vomiting (four RCTs, 183 participants, RR 0.63, 95% CI 0.41 to 0.97, NNTH 8, moderate-quality evidence) and higher patient satisfaction (two RCTs, 120 participants, SMD 0.60, 95% CI 0.23 to 0.97, low-quality evidence), compared with epidural analgesia.Pooled results of four studies (216 participants) comparing FNB with local infiltration analgesia detected no difference in analgesic effects between the groups at 24 hours for pain at rest (SMD 0.06, 95% CI -0.61 to 0.72, moderate-quality evidence) or pain on movement (SMD 0.38, 95% CI -0.10 to 0.86, low-quality evidence). Only one included RCT compared FNB with oral analgesia. We considered this evidence insufficient to allow judgement of the effects of FNB compared with oral analgesia.Continuous FNB provided less pain compared with single-shot FNB (four RCTs, 272 participants) at 24 hours at rest (SMD -0.62, 95% CI -1.17 to -0.07, moderate-quality evidence) and on movement (SMD -0.42, 95% CI -0.67 to -0.17, high-quality evidence). Continuous FNB also demonstrated lower opioid consumption compared with single-shot FNB at 24 hours (three RCTs, 236 participants, MD -13.81 mg, 95% CI -23.27 to -4.35 mg, moderate-quality evidence).Generally, the meta-analyses demonstrated considerable statistical heterogeneity, with type of FNB, allocation concealment and blinding of participants, personnel and outcome assessors reducing heterogeneity in the analyses. Available evidence was insufficient to allow determination of the comparative safety of the various analgesic techniques. Few RCTs reported on serious adverse effects such as neurological injury, postoperative falls or thrombotic events. AUTHORS' CONCLUSIONS Following TKR, FNB (with or without concurrent treatments including PCA opioid) provided more effective analgesia than PCA opioid alone, similar analgesia to epidural analgesia and less nausea/vomiting compared with PCA alone or epidural analgesia. The review also found that continuous FNB provided better analgesia compared with single-shot FNB. RCTs were insufficient to allow definitive conclusions on the comparison between FNB and local infiltration analgesia or oral analgesia.
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Affiliation(s)
- Ee‐Yuee Chan
- University of SydneyFaculty of Health SciencesCumberland Campus C42, Room 205, O Block,75 East StreetSydneyNSWAustralia1825
- Tan Tock Seng HospitalNursing ServiceSingaporeSingapore
| | - Marlene Fransen
- University of SydneyFaculty of Health SciencesCumberland Campus C42, Room 205, O Block,75 East StreetSydneyNSWAustralia1825
| | - David A Parker
- Sydney Orthopaedic Research InstituteLevel 1, The Gallery445 Victoria Avenue, ChatswoodSydneyNSWAustralia2050
| | - Pryseley N Assam
- Duke‐NUS Graduate Medical SchoolCentre for Quantitative Medicine, Office of Clinical SciencesSingaporeSingapore138669
- Singapore Clinical Research Institute Pte LtdDepartment of BiostatisticsSingaporeSingapore
| | - Nelson Chua
- Tan Tock Seng HospitalDepartment of Anaesthesiology11 Jalan Tan Tock SengSingaporeSingapore308433
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Dold AP, Murnaghan L, Xing J, Abdallah FW, Brull R, Whelan DB. Preoperative femoral nerve block in hip arthroscopic surgery: a retrospective review of 108 consecutive cases. Am J Sports Med 2014; 42:144-9. [PMID: 24284048 DOI: 10.1177/0363546513510392] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The utility of a femoral nerve block as an adjunct for pain management has been recognized for various surgical techniques but has yet to be examined in the preoperative setting as an adjunct to general anesthesia for improved postoperative pain control in hip arthroscopic surgery. PURPOSE To evaluate the safety and efficacy of a preoperative femoral nerve block for postoperative pain control in patients undergoing hip arthroscopic surgery. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A retrospective chart review of 108 consecutive hip arthroscopic surgery cases (in 103 patients) was carried out. All patients underwent arthroscopic surgery under a general anesthetic with or without a preoperative femoral nerve block. Groups were compared with respect to patient sex, age, and body mass index (BMI); physical status classification according to the American Society of Anesthesiologists (ASA); procedure performed; operative time; total intraoperative morphine-equivalent dose; pain scores (0-10 scale) recorded at 0, 15, 30, 45, and 60 minutes postoperatively in the post-anesthesia care unit (PACU); total morphine-equivalent dose in the PACU; presence of nausea or vomiting in the PACU; time to discharge from the PACU; oxycodone consumption in the surgical day care unit (SDCU); and maximal patient-reported pain score in the SDCU. RESULTS Twelve cases were excluded from the analysis for a total of 96 cases (in 92 patients). Forty patients had general anesthesia alone (group A), and 56 patients had a preoperative femoral nerve block before the induction of general anesthesia (group B). There was no significant difference between the groups with regard to sex, age, weight, height, BMI, ASA classification, or type of procedure performed. Patients who received a femoral nerve block also received a significantly lower total intraoperative morphine-equivalent dose than did those patients who did not receive a block. Postoperative patient-reported pain scores were lower at all time points for the femoral nerve block group; however, a statistical significance was seen only at the 60-minute postoperative time point. Patients who did not receive a block had significantly higher morphine-equivalent doses in the PACU. There was no difference in the rates of nausea and vomiting and time to discharge from the PACU between the 2 groups. Oxycodone consumption in the SDCU was similar between the groups, but the femoral nerve block group had significantly lower maximal patient-reported pain scores in the SDCU. Two patients in the general anesthesia group were admitted to the hospital postoperatively because of inadequate postoperative pain control. No complications were noted in any patient with regard to the femoral nerve block. CONCLUSION A preoperative femoral nerve block is a relatively safe procedure that may decrease the requirement for intraoperative morphine while providing effective postoperative pain control in patients undergoing hip arthroscopic surgery.
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Affiliation(s)
- Andrew P Dold
- Andrew P. Dold, University of Toronto, Division of Orthopaedic Surgery, 100 College Street, Room 302, Toronto, ON M5G 1L5, Canada.
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Chan MH, Chen WH, Tung YW, Liu K, Tan PH, Chia YY. Single-injection femoral nerve block lacks preemptive effect on postoperative pain and morphine consumption in total knee arthroplasty. ACTA ACUST UNITED AC 2012; 50:54-8. [DOI: 10.1016/j.aat.2012.05.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Revised: 01/07/2012] [Accepted: 01/12/2012] [Indexed: 11/17/2022]
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Two continuous femoral nerve block strategies after TKA. Knee Surg Sports Traumatol Arthrosc 2011; 19:1901-8. [PMID: 21484386 DOI: 10.1007/s00167-011-1510-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Accepted: 04/04/2011] [Indexed: 01/06/2023]
Abstract
PURPOSE The purposes of this study were to compare the pain score, systemic opioid consumption, and range of motion (ROM) between the group where the use of continuous femoral nerve block (CFNB) was discontinued on postoperative day 3 (POD 3) and the group where it was discontinued on POD 7 within an established clinical pathway for postoperative recovery after total knee arthroplasty (TKA) and to assess the treatment-related side effects and complications, as well as the functional status of these two groups of patients at 2 years after surgery. METHODS This prospective, randomized, double-blinded trial compared the analgesic efficacy and the functional outcomes between group A (n = 30) where continuous femoral nerve block was performed until POD 3 (discontinued prior to the initiation of range of motion (ROM) exercises) and group B (n = 33), where the continuous femoral nerve block was performed until POD 7 (discontinued during the ROM exercise) after TKA. RESULTS The resting pain scores of group B were lower than those of group A but there was no significant difference between the two groups (n.s., P = 0.387). However, the peak pain scores during ROM exercise, beginning on POD3 through to POD14, were significantly lower in group B than in group A (P = 0.001). The cumulative morphine IV-PCA requirements through the POD 2 were similar in the two groups (n.s., P = 0.811). However, the cumulative oral oxycodone consumption during hospitalization was significantly lower in group B than in group A, P < 0.0001. Group B showed significantly greater satisfaction with their method of analgesia than group A (P = 0.001). Group A scored 2.0 (2.0-3.0), whereas group B scored 1.0 (1.0-2.0). At 2 years, there was no significant difference in the functional outcomes (the knee flexion and extension angle, the Knee Society Score, and WOMAC pain, stiffness, and function scale). CONCLUSION The study group who received 7-day continuous femoral nerve block after TKA showed superior analgesia and higher patient satisfaction during the hospital stay than those given 3-day continuous femoral nerve block. Despite the additional time, effort and cost to place and manage continuous femoral nerve catheters, the 7-day continuous femoral nerve block can be recommended as an effective and safe regional component of a multimodal analgesia strategy after TKA.
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Raeder JC. Local Infiltration Analgesia for Pain After Total Knee Replacement Surgery. Anesth Analg 2011; 113:684-6. [DOI: 10.1213/ane.0b013e3182288e14] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Value of Single-Injection or Continuous Sciatic Nerve Block in Addition to a Continuous Femoral Nerve Block in Patients Undergoing Total Knee Arthroplasty. Reg Anesth Pain Med 2011; 36:481-8. [DOI: 10.1097/aap.0b013e318228c33a] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Park CK, Cho CK, Lee GG, Lee JH. Optimizing dose infusion of 0.125% bupivacaine for continuous femoral nerve block after total knee replacement. Korean J Anesthesiol 2010; 58:468-76. [PMID: 20532056 PMCID: PMC2881523 DOI: 10.4097/kjae.2010.58.5.468] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2009] [Revised: 01/06/2010] [Accepted: 03/19/2010] [Indexed: 11/10/2022] Open
Abstract
Background The optimal dose infusion of 0.125% bupivacaine via a femoral catheter after total knee replacement (TKR) has not been defined. This study examined various dose infusions of bupivacaine to determine the analgesic quality in patients receiving a continuous femoral nerve block (CFNB). Methods Patients were randomized to receive a single-injection femoral nerve block (SFNB) or CFNB performed with 20 ml of 0.125% bupivacaine, followed by a continuous infusion of 0.125% bupivacaine in four groups (n = 20 per group): 1) 0 ml/h (SFNB), 2) 2 ml/h, 3) 4 ml/h, and 4) 6 ml/h. The pain intensity at rest and on knee movement was assessed using a visual analog scale (VAS) for the first 2 postoperative days. The cumulative bolus use of IV patientcontrolled analgesia (PCA) with a morphine-ketorolac combination was evaluated. Results A lower cumulative bolus of IV PCA was noted in all CFNB groups compared to SFNB on postoperative days (PODs) 1 and 2, respectively (P < 0.05). Lower VAS scores at rest were observed in the 4 ml/h and 6 ml/h groups than in the SFNB group on PODs 1 and 2, respectively, but only on POD 2 in the 2 ml/h group (P < 0.05). Lower VAS scores on movement were noted in the 4 ml/h than the SFNB group on PODs 1 and 2, but only on POD 1 in 6 ml/h (P < 0.05). Conclusions The minimum effective infusion rate of 0.125% bupivacaine for CFNB after TKR appears to be 4 ml/h according to the VAS pain scores.
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Affiliation(s)
- Chang Kil Park
- Department of Anesthesiology and Pain Medicine, College of Medicine, Eulji University, Daejeon, Korea
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Fredrickson MJ, Danesh-Clough TK. Ambulatory continuous femoral analgesia for major knee surgery: a randomised study of ultrasound-guided femoral catheter placement. Anaesth Intensive Care 2010; 37:758-66. [PMID: 19775040 DOI: 10.1177/0310057x0903700514] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Needle-nerve stimulation has a false negative motor response rate, which may increase needle passes. This prospective, randomised study tested the hypothesis that femoral nerve catheters placed with ultrasound-only guidance could provide comparable postoperative analgesia to those placed using a conventional nerve stimulation endpoint. Patients presenting for major knee surgery to the lead investigator were recruited. Needles introduced for femoral nerve catheter placement were initially guided with 'oblique' out-of-plane ultrasound imaging but were then prospectively randomised to either an ultrasound (n = 21) or nerve stimulation (n = 24) endpoint. An elastomeric infusion of ropivacaine 0.2% 2 ml/hour with as required hourly 5 ml boluses was continued for > 48 hours in hospital and/or in the home. Needle time under the skin and numerical rating pain score during insertion were recorded. Patients were questioned for worst numerical rating pain score, the need for supplementary ropivacaine boluses and tramadol on postoperative days one and two. There was no difference in the worst numerical rating pain score at rest and on movement and the requirement for supplementary ropivacaine boluses or tramadol during the first 48 postoperative hours. The median (quartiles) needle time under the skin was 58 seconds (51 to 76) in the ultrasound group and 120 seconds (95 to 178) in the nerve stimulation group (P = 0.001). The median (quartiles) insertion numerical rating pain score was 2 (0 to 2) in the ultrasound group and 4 (2 to 6) in the nerve stimulation group (P = 0.014). Femoral nerve catheters placed for major knee surgery using an ultrasound endpoint provided postoperative analgesia comparable to that obtained when using a nerve stimulation endpoint and were associated with a reduction in both needle manipulations and procedure-related pain.
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Affiliation(s)
- M J Fredrickson
- Department of Anaesthesiology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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A Comparison of Sensory and Motor Loss After a Femoral Nerve Block Conducted With Ultrasound Versus Ultrasound and Nerve Stimulation. Reg Anesth Pain Med 2009; 34:508-13. [DOI: 10.1097/aap.0b013e3181ae7306] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Shum CF, Lo NN, Yeo SJ, Yang KY, Chong HC, Yeo SN. Continuous femoral nerve block in total knee arthroplasty: immediate and two-year outcomes. J Arthroplasty 2009; 24:204-9. [PMID: 18534496 DOI: 10.1016/j.arth.2007.09.014] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2007] [Accepted: 09/09/2007] [Indexed: 02/01/2023] Open
Abstract
We conducted a prospective study to investigate the immediate and 2-year outcomes of total knee arthroplasty patients who received continuous femoral nerve block (FNB) for analgesia. Sixty patients undergoing unilateral total knee arthroplasty were randomized into 3 groups and received high-dose continuous FNB, low-dose continuous FNB, or no FNB. In the immediate postoperative period, we studied their pain scores, cumulative morphine use, any FNB-related complications, time of first ambulation, and patient satisfaction. At 2 years, we assessed their functional outcomes with Oxford knee questionnaire and Knee Society clinical rating system. Immediately after surgery, there was less pain, higher satisfaction, and lower morphine use among patients on continuous FNB regardless of ropivacaine dosage used. At 2 years, there were no significant differences in functional outcomes.
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Affiliation(s)
- Cheuk Fan Shum
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
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Matava MJ, Prickett WD, Khodamoradi S, Abe S, Garbutt J. Femoral nerve blockade as a preemptive anesthetic in patients undergoing anterior cruciate ligament reconstruction: a prospective, randomized, double-blinded, placebo-controlled study. Am J Sports Med 2009; 37:78-86. [PMID: 18936277 DOI: 10.1177/0363546508324311] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Femoral nerve blockade has been purported to be an effective regional anesthetic in patients undergoing various procedures to lower extremities. HYPOTHESIS Femoral nerve blockade will provide improved postoperative pain control over a local anesthetic in the knee joint alone in patients undergoing endoscopic patellar tendon anterior cruciate ligament reconstruction. STUDY DESIGN Randomized, controlled trial; Level of evidence, 1. METHODS Fifty-six adult patients undergoing an endoscopic patellar tendon anterior cruciate ligament reconstruction under general anesthesia were prospectively randomized to receive either a bupivacaine femoral nerve blockade (block) or a saline placebo injection (control). Both groups received local bupivacaine injection and intravenous ketorolac at wound closure. Outcomes included postoperative pain measured on a validated visual analog scale at postoperative intervals for 72 hours, intraoperative and postoperative narcotic consumption, admission rates, hospital charges, patient satisfaction, and complications related to the femoral nerve block. RESULTS There were 31 block patients and 25 control patients. No significant differences between groups for postoperative pain scores, intraoperative or postoperative narcotic consumption, readiness for discharge, duration of hospitalization, admission rates, hospital charges, or patient satisfaction were observed. There were no complications related to the femoral nerve block. CONCLUSION A preemptive femoral nerve blockade, although safe, does not provide significant clinical benefit in this patient population to justify its routine use.
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Affiliation(s)
- Matthew J Matava
- Department of Orthopaedic Surgery, Washington University School of Medicine, St Louis, MO 63110, USA.
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Fischer HBJ, Simanski CJP, Sharp C, Bonnet F, Camu F, Neugebauer EAM, Rawal N, Joshi GP, Schug SA, Kehlet H. A procedure-specific systematic review and consensus recommendations for postoperative analgesia following total knee arthroplasty. Anaesthesia 2008; 63:1105-23. [PMID: 18627367 DOI: 10.1111/j.1365-2044.2008.05565.x] [Citation(s) in RCA: 230] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The PROSPECT Working Group, a collaboration of anaesthetists and surgeons, conducts systematic reviews of postoperative pain management for different surgical procedures (http://www.postoppain.org). Evidence-based consensus recommendations for the effective management of postoperative pain are then developed from these systematic reviews, incorporating clinical practice observations, and transferable evidence from other relevant procedures. We present the results of a systematic review of pain and other outcomes following analgesic, anaesthetic and surgical interventions for total knee arthroplasty (TKA). The evidence from this review supports the use of general anaesthesia combined with a femoral nerve block for surgery and postoperative analgesia, or alternatively spinal anaesthesia with local anaesthetic plus spinal morphine. The primary technique, together with cooling and compression techniques, should be supplemented with paracetamol and conventional non-steroidal anti-inflammatory drugs or COX-2-selective inhibitors, plus intravenous strong opioids (high-intensity pain) or weak opioids (moderate- to low-intensity pain).
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Affiliation(s)
- H B J Fischer
- Department of Anaesthesia, Alexandra Hospital, Redditch, UK.
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Abstract
BACKGROUND Use of ultrasound by anaesthesiologists performing regional blocks is rapidly gaining popularity. The aims of this review were to summarize and update accumulating evidence on ultrasound-guided nerve blocks, with an emphasis on the clinical relevance of the results and to critically appraise changing standards in regional anaesthesia. METHODS A search of MEDLINE and EMBASE (1966 to 31 December 2007) was conducted using the following free terms: 'ultrasound and regional anesthesia', 'ultrasound and peripheral block' and 'ultrasound and nerve and block'. These were combined with the MESH terms 'nerve block' and 'ultrasonography'. The following limits were applied: studies with abstracts, only in humans, published in core clinical journals. Trial type: meta-analysis, randomized-controlled trial and clinical trial. RESULTS When peripheral nerves are adequately imaged by ultrasound, the concomitant use of nerve stimulation offers no further advantage. However, several studies reported problems with obtaining satisfactory images in some patients. Ultrasound guidance significantly shortened the block performance time and/or reduced the number of needle passes to reach the target in all comparative studies. The occurrence of paraesthesia during block performance was also reduced, but not the incidence of short-lasting post-operative neuropraxia. The frequency of accidental vascular punctures may be lower, but the data are contradictory. Block onset time was significantly shortened. Block duration was longer in children, but not in adults. Ultrasound also allowed dose reduction of the local anaesthetic (LA). CONCLUSIONS Ultrasound guidance shortens the block performance time, reduces the number of needle passes and shortens the block onset time. Blocks may be performed using lower LA doses.
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Affiliation(s)
- Z J Koscielniak-Nielsen
- Department of Anaesthesia 4231, HOC, Rigshospital, University of Copenhagen, Copenhagen, Denmark.
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Grant CR, Checketts MR. Analgesia for primary hip and knee arthroplasty: the role of regional anaesthesia. ACTA ACUST UNITED AC 2008. [DOI: 10.1093/bjaceaccp/mkn007] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Hsu HT, Lu IC, Chang YL, Wang FY, Kuo YW, Chiu SL, Chu KS. Lateral Rotation of the Lower Extremity Increases the Distance Between the Femoral Nerve and Femoral Artery: An Ultrasonographic Study. Kaohsiung J Med Sci 2007; 23:618-23. [DOI: 10.1016/s1607-551x(08)70060-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Huang YS, Lin LC, Huh BK, Sheen MJ, Yeh CC, Wong CS, Wu CT. Epidural Clonidine for Postoperative Pain After Total Knee Arthroplasty: A Dose–Response Study. Anesth Analg 2007; 104:1230-5, tables of contents. [PMID: 17456679 DOI: 10.1213/01.ane.0000263284.34950.f4] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Combinations of epidural clonidine, local anesthetics, and opioids have improved postoperative analgesia after total knee arthroplasty. In this study we sought to determine the optimal epidural bolus dose of clonidine, which provides the best analgesia and fewest side effects. METHODS Eighty ASA I-III patients, who underwent total knee arthroplasty were randomly assigned to one of four groups of 20 patients each. Identical epidural anesthesia procedures were used for all groups. After surgery, groups C0, C1, C2, and C4 received patient-controlled epidural analgesia (PCEA) with clonidine (0, 1.0, 2.0, or 4.0 mug/mL, respectively) and morphine (0.1 mg/mL) in 0.2% ropivacaine. The analgesia effect was estimated by PCEA consumption volume and visual analog pain scale at rest and with movement at 1, 2, 4, 12, 24, 48, and 72 h after surgery. Systolic blood pressure, heart rate, sedation, and sensory and motor blockade were also recorded for 72 h after surgery. RESULTS The PCEA consumption volume for groups C0, C1, C2, and C4 were 71.8 +/- 19.5 mL, 49.6 +/- 12.3 mL, 48.1 +/- 9.3 mL, and 39.4 +/- 9.0 mL, respectively. The clonidine groups experienced less postoperative pain (P = 0.002). In the C4 group, four patients had prolonged sensory blockade and one patient had both severe sedation and prolonged sensory motor blockade. No significant statistical difference in analgesic consumption (P = 0.78) and pain intensity (P = 0.66) between groups C1 and C2 were noted. CONCLUSIONS The optimal amount of epidural clonidine in a solution of morphine and ropivacaine for postoperative pain management is 1.0 microg/mL.
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Affiliation(s)
- Yuan-Shiou Huang
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China
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Peters CL, Shirley B, Erickson J. The effect of a new multimodal perioperative anesthetic regimen on postoperative pain, side effects, rehabilitation, and length of hospital stay after total joint arthroplasty. J Arthroplasty 2006; 21:132-8. [PMID: 16950075 DOI: 10.1016/j.arth.2006.04.017] [Citation(s) in RCA: 166] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2006] [Accepted: 04/17/2006] [Indexed: 02/01/2023] Open
Abstract
This study evaluated the effect of a new multimodal perioperative anesthetic and pain management strategy for primary total hip (THA) and total knee arthroplasty (TKA). Two cohorts of 50 consecutive THA and 50 TKA patients from before and after initiation of the new protocol were compared. The protocol involved scheduled oral narcotics, cyclooxygenase-2 inhibitors, no intrathecal narcotics, femoral nerve catheters for TKAs, and local anesthetic wound infiltration. Use of patient-controlled analgesia was discouraged. Physical therapy was attempted on the day of surgery. The demographic data, surgical procedure, and implants were similar. There were statistically significant improvements after the protocol regarding rest-pain scores post-operative day (POD) 1 and 2, total narcotic consumption, distance walked POD 1 and 2, and length of stay. There were no significant differences in complications. Implementation of this new multimodal perioperative protocol combined with early mobilization for TKA and THA patients has shortened length of stay, improved pain control, and accomplished therapy goals sooner with less narcotic consumption.
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MESH Headings
- Anesthesia, Epidural/adverse effects
- Anesthesia, Epidural/methods
- Anesthesia, General/adverse effects
- Anesthesia, General/methods
- Arthroplasty, Replacement, Hip/methods
- Arthroplasty, Replacement, Hip/rehabilitation
- Arthroplasty, Replacement, Knee/methods
- Arthroplasty, Replacement, Knee/rehabilitation
- Combined Modality Therapy
- Cyclooxygenase 2 Inhibitors/administration & dosage
- Cyclooxygenase 2 Inhibitors/adverse effects
- Humans
- Length of Stay
- Middle Aged
- Narcotics/administration & dosage
- Narcotics/adverse effects
- Pain, Postoperative/drug therapy
- Retrospective Studies
- Treatment Outcome
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Montenegro A, Pourtalés MC, Greib N, End E, Gaertner E, Tulasne PA, Pottecher T. [Assessment of patient satisfaction after regional anaesthesia in two institutions]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2006; 25:687-95. [PMID: 16698225 DOI: 10.1016/j.annfar.2006.02.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2005] [Accepted: 02/25/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVES This study was designed to assess patient satisfaction after regional anaesthesia for limb surgery. METHODS An anaesthesia satisfaction questionnaire was developed, validated (Kappa coefficient) and submitted to 314 patients operated in two institutions (one university hospital with anaesthesiology residents and one specialised in orthopaedics with experienced anaesthesiologists). Items explored were information modalities, pain and anxiety during procedure and global satisfaction rated with four levels (very satisfied [VS], satisfied [S], partially satisfied [PS], non-satisfied [NS]). Patients were interviewed by telephone at postoperative D1 and D8 by a pharmacist student not involved in the patient's care. RESULTS Inspite of a high level of patient satisfaction at D8 (VS: 50%, S: 44%), some interesting aspects should be emphasised: a) sedation given before nerve block was not efficient to reduce anxiety and pain during procedure; b) VS levels decreased from D1 (56%) to D8 (50%) mainly because of late postoperative pain (after discharge) and discomforts; c) willingness to undergo the same nerve block again (294/314) was not correlated with patient's satisfaction since among PS and NS patients, a majority (9/15) wished for a block in case of renewed limb surgery; d) multivariate analysis showed that VS level was highly correlated with the quality of communication by the anaesthesiologist mainly for informations about pre and postoperative periods. No correlation was found with pain level during procedure; e) satisfaction levels were not different in the two institutions. CONCLUSION This study has emphasised some important factors of patient satisfaction which were not sufficiently taken into account in our daily practice.
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Affiliation(s)
- A Montenegro
- Service d'anesthésie-réanimation chirurgicale, hôpital de Hautepierre, 67098 Strasbourg cedex, France
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