Continuous peripheral nerve blocks in hospital wards after orthopedic surgery: a multicenter prospective analysis of the quality of postoperative analgesia and complications in 1,416 patients

ACL injury and surgical treatment options

The anterior cruciate ligament (ACL) has been the focus of a substantial amount of research. Thousands of studies have evaluated the structure and function of the intact ACL, as well as the best reconstruction techniques. Despite the amount of literature, many controversies remain regarding the ACL and its surgical reconstruction. This article reviews the anatomy and function of the native ACL, the nature of injury, and aspects of ACL reconstruction, including surgical approach, tunnel positioning, graft choice, and graft fixation.

Continuous peripheral nerve blocks in acute pain management

The indications for continuous nerve blocks for the perioperative pain management in hospitalized and ambulatory patients have extended well beyond orthopaedics. These techniques are not only used to control pain in patients undergoing major upper and lower extremity surgery, but also to provide perioperative analgesia in patients undergoing abdominal, plastic, urological, gynaecological, thoracic, and trauma surgeries. Infusion regimens of local anaesthetics and supplements must take into consideration the condition of the patient before and after surgery, the nature and intensity of the surgical stress associated with the surgery, and the possible need for immediate functional recovery. Continuous nerve blocks have proved safe and effective in reducing opioid consumption and related side-effects, accelerating recovery, and in many patients reducing the length of hospital stay. Continuous nerve blocks provide a safer alternative to epidural analgesia in patients receiving thromboprophylaxis, especially with low molecular-weight heparin.

Complications of peripheral nerve blocks

Complications of peripheral nerve blocks are fortunately rare, but can be devastating for both the patient and the anaesthesiologist. This review will concentrate on current knowledge about peripheral nerve injury secondary to nerve blocks, complications from continuous peripheral nerve catheter techniques, and local anaesthetic systemic toxicity.

Continuous central and perineural infusions for postoperative pain control in children

PURPOSE OF REVIEW

Continuous infusion remains the technique of choice when there is a prolonged operation or intense postoperative pain is anticipated. Supplementing a general anesthesia with a nerve block can result in a pain-free awakening and postoperative analgesia without the potentially deleterious effects associated with parenteral opioids. The literature confirms the very low rate of complications and adverse effects of regional anesthesia in children.

RECENT FINDINGS

Clinicians need to be aware of the key points for performing a block and placing a catheter in children: good knowledge of anatomic and physiologic differences between adults and children is necessary; the use of newer local anesthetics, such as ropivacaine and levobupivacaine, increases the therapeutic window; and moreover it is mandatory to work with dedicated pediatric equipment.

SUMMARY

The introduction of high-resolution portable ultrasound brought a great advance for the pediatric anesthesiologists; ultrasound-guided visualization of anatomic structures, in fact, allows greater precision of needle and catheter placement, and confirmation that the drug is deposited in the site of choice. This article reviews the safety and efficacy of central and perineural continuous infusions for postoperative pain control in children.

Regional anaesthesia practice for total knee arthroplasty: French national survey - 2008

BACKGROUND AND OBJECTIVE

Improved pain management techniques and rehabilitation programs have significantly modified outcome for total knee arthroplasty (TKA).

OBJECTIVE

The aim of the survey was to describe the French practice patterns in regional anaesthesia for TKA.

METHODS

Twenty-item questionnaires were distributed to units with significant orthopaedic activity across France. The content referred to the type of orthopaedic activity; anaesthetic and analgesic management; preoperative patient information; technical aspects describing regional anaesthesia and postoperative analgesia.

RESULTS

Response rate was 54%. Combined general anaesthesia and perineural catheter was the most frequently used anaesthetic technique. Most of respondents used multimodal analgesia (including femoral nerve catheter by 80%). Written hygiene protocols were rarely available. Sterile gowns were seldom worn. Among antiseptic agents, povidone iodine was most often used. Sedative agents were systematically used by 36% of respondents. Ropivacaine was the preferred local anaesthetic agent. Finally, adjuvants were rarely used. In most cases (58%) the femoral block was performed before induction of general anaesthesia. The catheter was commonly threaded to a length between 5 and 8 cm. The correct position of the catheter tip was verified clinically by majority of respondents. Local anaesthetics were administered by continuous infusion, continuous infusion plus boluses and boluses alone in 44, 36 and 8% of cases. Catheter duration was 48 and 72 h in 45 and 33% of the units and was independent of pain scores.

CONCLUSION

This national survey showed practices in accordance with recent guidelines as well as persistent challenges in regional anaesthesia for TKA.

In vitro exposure of human fibroblasts to local anaesthetics impairs cell growth

Lidocaine, bupivacaine or ropivacaine are used routinely to manage perioperative pain. Sparse data exist evaluating the effects of local anaesthetics (LA) on fibroblasts, which are involved actively in wound healing. Therefore, we investigated the effects of the three LA to assess the survival, viability and proliferation rate of fibroblasts. Human fibroblasts were exposed to 0·3 mg/ml and 0·6 mg/ml of each LA for 2 days, followed by incubation with normal medium for another 1, 4 or 7 days (group 1). Alternatively, cells were incubated permanently with LA for 3, 6 or 9 days (group 2). Live cell count was assessed using trypan blue staining. Viability was measured by the tetrazolium bromide assay. Proliferation tests were performed with the help of the colorimetric bromodeoxyuridine assay. Production of reactive oxygen species (ROS) was determined, measuring the oxidation of non-fluorescent-2,7'-dichlorofluorescin. Treatment of cells with the three LA showed a concentration-dependent decrease of live cells, mitochondrial activity and proliferation rate. Group arrangement played a significant role for cell count and proliferation, while exposure time influenced viability. Among the analysed LA, bupivacaine showed the most severe cytotoxic effects. Increased production of ROS correlated with decreased viability of fibroblasts in lidocaine- and bupivacaine-exposed cells, but not upon stimulation with ropivacaine. This study shows a concentration-dependent cytotoxic effect of lidocaine, bupivacaine and ropivacaine on fibroblasts in vitro, with more pronounced effects after continuous incubation. A possible mechanism of cell impairment could be triggered by production of ROS upon stimulation with lidocaine and bupivacaine.

Colonização e infecção em pacientes com cateter peridural não tunelizado para analgesia

OBJETIVO: Correlacionar a colonização e a infecção no paciente em uso do cateter peridural não tunelizado para analgesia. MÉTODOS: Estudo prospectivo realizado com 109 pacientes clínicos ou cirúrgicos e com tempo de permanência do cateter >72 horas em um hospital privado do Município de São Paulo. A cultura de vigilância foi realizada com base na coleta da ponta do cateter peridural, swab pericateter e hemocultura periférica. RESULTADOS: Dentre os 109 acompanhados 109 pacientes, 106 (97,2%) foram cirúrgicos e 3 (2,8%) clínicos. O tempo de permanência do cateter variou de 3 a 18 dias e a taxa de colonização foi de 11%. Doze pacientes apresentaram colonização do cateter peridural e o principal micro-organismo isolado foi o Staphylococcus coagulase-negativa. CONCLUSÕES: A cultura positiva do cateter peridural constituiu um fator preditor para a colonização, porém nenhum paciente com positividade evoluiu com infecção.

Adding regional analgesia to general anaesthesia: increase of risk or improved outcome?

Although it is clear that regional analgesia in association with general anaesthesia substantially reduces postoperative pain, the benefits in terms of overall perioperative outcome are less evident. The aim of this nonsystematic review was to evaluate the effect on middle and long-term postoperative outcomes of adding regional perioperative analgesia to general anaesthesia. This study is based mostly on systematic reviews, large epidemiological studies and large or high-quality randomized controlled trials that were selected and evaluated by the author. The endpoints that are discussed are perioperative morbidity, cancer recurrence, chronic postoperative pain, postoperative rehabilitation and risk of neurologic damage. Epidural analgesia may have a favourable but very small effect on perioperative morbidity. The influence of other regional anaesthetic techniques on perioperative morbidity is unclear. Preliminary data suggest that regional analgesia might reduce the incidence of cancer recurrence. However, adequately powered randomized controlled trials are lacking. The sparse literature available suggests that regional analgesia may prevent the development of chronic postoperative pain. Rehabilitation in the immediate postoperative period is possibly improved, but the advantages in the long term remain unclear. Permanent neurological damage is extremely rare. In conclusion, while the risk of permanent neurologic damage remains extremely low, evidence suggests that regional analgesia may improve relevant outcomes in the long term. The effect size is mostly small or the number-needed-to-treat is high. However, considering the importance of the outcomes of interest, even minor improvement probably has substantial clinical relevance.

Pain management in total joint arthroplasty: a historical review

Patients undergoing total hip and knee arthroplasty experience substantial and sustained postoperative pain. Inadequate analgesia may impede recovery and delay hospital discharge. Traditionally, postoperative analgesia following arthroplasty was provided by intravenous patient-controlled analgesia or epidural analgesia, but each technique has distinct advantages and disadvantages. Recently, peripheral nerve blockade of the lumbosacral plexus has emerged as an alternative analgesic approach. An increasing number of studies have reported multimodal analgesia featuring unilateral peripheral block provide pain relief and functional outcomes similar to that of continuous epidural and superior to systemic analgesia but with fewer side effects. This review discusses the indications, benefits, and side effects associated with conventional and innovative analgesic approaches to facilitate rehabilitation and improve outcome following total joint arthroplasty.

Use of catheters in the postoperative patient

Continuous peripheral nerve block has been shown to be superior to traditional opioid-based analgesia in terms of improved analgesia with reduced sedation, nausea, pruritis, and hospital stay. Because of its safety and efficacy, continuous peripheral nerve block has broad application in ambulatory and pediatric patients. Techniques for continuous peripheral nerve block have advanced significantly in the past decade, particularly as a result of affordable, high-resolution ultrasound equipment that permits rapid and successful administration and results in reduced procedure-related pain, lower dose requirements, and fewer vascular punctures. Continuous peripheral nerve block is associated with some limitations, including infection, neurologic injury, local anesthetic toxicity, and patient falls. The benefits of continuous peripheral nerve block are becoming increasingly relevant in the ambulatory surgery setting where more complex procedures are being performed on an outpatient basis.

Implementation of a standardized pain management in a pediatric surgery unit

Postoperative pain is still a major complication causing discomfort and significant suffering, especially for children. Therefore, every effort should be made to prevent pain and treat it effectively once it arises. Under-treatment of pediatric pain is often due to a lack of both knowledge about age-specific aspects of physiology and pharmacology and routine pain assessment. Factors for long term success require regularly assessing pain, as routinely as the other vital signs together with documentation of side effects. The fear of side effects mostly prevents the adequate usage of analgesics. Essential is selecting and establishing a simple concept for clinical routine involving a combination of non-pharmacological treatment strategies, non-opioid drugs, opioids and regional anesthesia.

Time course of mitochondrial metabolism alterations to repeated injections of bupivacaine in rat muscle

PURPOSE

Bupivacaine-induced myotoxicity is associated with mitochondrial bioenergetic alterations. The impact of the duration of bupivacaine treatment on mitochondrial energy production remains undetermined. Here, we assessed, in vivo, the alteration of mitochondrial metabolism following different durations of bupivacaine exposure (40, 56, or 112 hr) that correspond to 5, 7, or 14 repeated injections of 0.25% bupivacaine, respectively.

METHODS

Rats were divided randomly into seven different groups: one control group (no catheter); three groups with normal saline injections (1 mL x kg(-1)) every eight hours via a femoral nerve catheter for 40, 56, and 112 hr, respectively; and three groups with 0.25% bupivacaine injections (1 mL x kg(-1)) every eight hours via a femoral nerve catheter for 40, 56, and 112 hr. Psoas and gracilis muscle samples located within the bupivacaine infusion-diffusion space were investigated. To estimate mitochondrial respiratory capacity, the protein content of the mitochondrial respiratory chain apparatus was evaluated by measuring citrate synthase activity. To measure mitochondrial respiratory function, adenosine diphosphate-stimulated oxygen consumption was measured by polarography in saponin-skinned muscle fibres using glutamate-malate or succinate as energy substrates.

RESULTS

In psoas and gracilis muscles, saline solution had no effect on the two mitochondrial parameters. Bupivacaine induced a significant decrease in the citrate synthase activity in psoas (r(2) = 0.74; P < 0.001) and gracilis muscle (r(2) = 0.52; P < 0.001), and there was a significant decrease in the adenosine diphosphate-stimulated oxygen consumption using glutamate or succinate as substrates in both muscles (P < 0.001).

CONCLUSIONS

The severity of bupivacaine-induced myotoxicity is closely linked to the duration of bupivacaine exposure in the muscle fibres located close to the catheter tip.

Complications in shoulder arthroscopy

Shoulder arthroscopy is generally a safe and effective method for treating a wide variety of shoulder pathology. Fortunately, complications following shoulder arthroscopy are rare, with reported rates between 4.6% and 10.6%.¹⁻⁷ These rates may be underestimated, as underreporting of complications and varying definitions of the term complication are likely. During shoulder arthroscopy, complications may occur at numerous points. The surgeon must be aware of potential problems and take necessary measures to prevent them. This article describes common complications after arthroscopic shoulder surgery. Although failure of treatment and postoperative stiffness are undesirable outcomes, they are not described.

Ambulatory anesthesia and regional catheters: when and how

Several clinical trials have demonstrated the superiority of continuous peripheral nerve block compared with traditional opioid-based analgesia. The ability to provide safe and effective continuous peripheral nerve block at home is an attractive alternative to opioid-based analgesia with its related side effects. In this article, the practical issues related to catheter use in the ambulatory setting are discussed. Techniques for catheter placement, infusion regimens, patient education, and complications are subject to many institutional preferences. In this review, special emphasis is placed on evidence-based techniques.

Continuous tunnelled femoral nerve block for palliative care of a patient with metastatic osteosarcoma

An 18-year-old man with metastatic femoral osteosarcoma had inadequate pain control with gabapentin, naproxen and intravenous fentanyl. A tunnelled femoral nerve catheter was used to administer a continuous infusion of 0.2% ropivacaine and 4 microg/ml clonidine (10 ml/hour) until his death 88 days later During discharge from hospital, catheter disconnection resulted in severe pain and readmission. Tunnelling, aseptic insertion technique, antibiotics and sterile infusate prepared by the pharmacy may have reduced the chance of infection. We propose that this is a suitable and effective technique in the long-term management of patients with terminal cancer and should be considered on a case-by-case basis.

Safety of amide local anesthetics: new trends

IMPORTANCE OF THE FIELD

Local anesthetics have become one of the most common drugs used in daily practice worldwide. Neurologic and cardiovascular events are the most frequent adverse reactions related to local anesthetics use. Recently, new trends have been developed on this topic.

AREAS COVERED IN THIS REVIEW

We performed an overview of the data available so far on local anesthetics adverse reactions. Relevant literature was identified using PubMed search of articles published up to November 2009, including experimental studies, case reports or clinical studies when available. Search terms included: 'local anaesthetics', 'adverse drug reaction', 'pharmacovigilance' and 'complication'.

WHAT THE READER WILL GAIN

Neurologic, cardiovascular and allergic reactions remain the most frequent adverse drug reactions related to local anesthetics in the literature. Studies based on pharmacovigilance systems have highlighted the frequency of adverse reactions little known until now, such as failure of block. Lipid emulsions are included into algorithm for cardiac resuscitation. Recent studies have demonstrated the myotoxicity and chondrotoxic effects of long-acting local anesthetics.

TAKE HOME MESSAGE

Physicians must keep in mind all these adverse reactions to better prevent their occurrence and give the most appropriate treatment.

Interscalene brachial plexus block for open-shoulder surgery: a randomized, double-blind, placebo-controlled trial between single-shot anesthesia and patient-controlled catheter system

INTRODUCTION

Interscalene brachial plexus block (ISB) is widely used as an adjuvant regional pain therapy in patients undergoing major shoulder surgery and has proved its effectiveness on postoperative pain reduction and opioid-sparing effect.

METHOD

This single-center, prospective, double-blind, randomized and placebo-controlled study was to compare the effectiveness of a single-shot and a patient-controlled catheter insertion ISB system after major open-shoulder surgeries. Seventy patients were entered to receive an ISB and a patient-controlled interscalene catheter. The catheter was inserted under ultrasound guidance. Patients were then assigned to receive one of two different postoperative infusions, either 0.2% ropivacaine (catheter group) or normal saline solution (single-shot group) via a disposable patient-controlled infusion pump.

RESULTS

The study variables were amount of rescue medication, pain at rest and during physiotherapy, patient satisfaction and incidence of unwanted side effects. The ropivacaine group revealed significantly less consumption of rescue medication within the first 24 h after surgery. Incidence of side effects did not differ between the two groups.

CONCLUSION

Based on our results, we recommend the use of interscalene plexus block in combination with a patient-controlled catheter system under ultrasound guidance only for the first 24 h after major open-shoulder surgery.

Case report: continuous interscalene block associated with neck hematoma and postoperative sepsis

Continuous peripheral nerve blockade is often used for the management of postoperative pain, even in ambulatory patients. The reported incidence of infectious complications after continuous nerve blockade is low. We report a case of Staphylococcus aureus sepsis after total shoulder arthroplasty in a patient who presented to her surgeon 8 days postoperatively with lethargy and labored breathing. Preoperatively, the patient had received a continuous interscalene block for analgesia that was associated with a neck hematoma. After readmission, exploratory laparotomy, and extensive hospital stay, the patient was discharged to an extended care facility in good condition.

[Concepts for perioperative pain therapy. A critical stocktaking]

Despite numerous publications, new guidelines for the treatment of acute pain and efforts from a number of initiatives, there is still a tremendous need for improvement in postoperative pain therapy. One of the reasons for the shortcomings in the care of patients with postoperative pain is the lack of applicability of guidelines in daily clinical practice. Therefore, simple but effective and easy to implement concepts need to be developed. In the following review, different concepts that have been developed over recent years are presented and evaluated for their effectiveness. One of these is the notion of balanced analgesia, currently probably one of the most widely used perioperative therapy concepts. The idea of this concept is to reduce the doses of analgesics, e.g. opioids, through combinations of different classes of analgesics, thereby reducing their side effects. However, recent studies and essential meta-analyses indicate pitfalls using this concept. The pros and cons will be discussed and ideas on how to deal with balanced analgesia in daily practice will be given. Another pain concept of "procedure-specific postoperative pain therapy", is an appealing idea of an international initiative from surgeons and anaesthesiologists and an essential part of the German S3 guidelines for acute pain released last year. Critical evaluation of the available recommendations for procedure-specific analgesia together with the presentation of relatively simple but evidence-based algorithms for specific procedures may help to implement this concept in clinical routine.

[Postoperative analgesia following trapeziectomy with continuous intra-articular infusion of ropivacaïne versus continuous perineural infusion. A prospective randomised study]

A prospective randomised study on 46 patients was performed to evaluate postoperative analgesia after trapezectomy. We compare the efficacy of an in situ catheter 777 (ISC) positioned by the surgeon in the space of the trapezectomy (26 patients) with an axilliary perineural catheter (APC) positioned preoperatively by the anaesthetist (20 patients). The patients were followed-up postoperatively for 48 hours and assessed at 3, 7, 24 and 48 hours, recording pain (VAS), consumption of intravenous rescue analgesia and recovery of sensory and motor function.

RESULTS

The mean time to site the ISC was 1 min 30 versus 16 min the APC group. The mean pain scores were: in the ISC group consistently below 2 for the entire postoperative 48 hours. Seven patients (29%) required supplemental analgesia (16 doses). Two patients failed (7.7%) to achieve adequate postoperative analgesia; they were the only patients in whom the surgeon had sited a drain, probably implying a siphoning off of the local anaesthetic solution. In the APC group also less than 2, and rescue analgesia was required by seven patients (35%) (40 doses). In four patients (20%) the pain score remained greater than 4 throughout the study period implying failure of the perineural catheter. There was a more rapid and complete recovery of both sensory and motor function in the group treated with in situ catheters during the study period. There were no haematomata or infections in the tow groups.

CONCLUSION

The in situ catheter provided at least as good postoperative analgesia while requiring considerably less time and expertise to site. There was also more rapid recovery of motor and sensory function in patients treated with in situ catheters.

[Peripheral nerve blocks of the lower extremities. Clinical and practical aspects]

Peripheral nerve blocks (PNBs) of the lower extremities are effective techniques for anesthesia and postoperative pain control. So far, these techniques have been used less frequently than PNBs of the upper limb. Nevertheless, growing awareness of complications of neuroaxial techniques, improved equipment and modern techniques for nerve localization have led to an increased use of PNBs of the lower limb. Anesthesiologists should be familiar with the anatomical basics and procedural details of these PNBs. They should also know the typical complications and side-effects and thoroughly inform patients about such potential problems. Continuous PNBs (perineural catheters) allow the benefits of PNBs to be prolonged into the postoperative period. Compared to continuous neuroaxial techniques continuous PNBs are equally effective for pain control but seem to be associated with fewer complications and side-effects.

Outpatient continuous interscalene brachial plexus block in cancer-related pain

This case outlines the use of a continuous interscalene brachial plexus block to treat cancer-related pain. Using an elastomeric device, the patient's previously intractable pain was controlled and he was able to return home. Furthermore, the patient developed a pragmatic and effective method of balancing loss of power and sensation against pain control using the flow restrictor. This case illustrates the potential of an integrated approach to cancer pain management to obtain rapid pain relief in the acute hospital setting.

Major complications associated with femoral nerve catheters for knee arthroplasty: a word of caution

One thousand one hundred ninety patients underwent knee arthroplasty between January 2004 and July 1, 2007, and received an indwelling continuous infusion femoral catheter for postoperative ropivicaine pump infusion. Catheters were placed using electrical stimulation guidance. For the initial 469 patients (group 1), the continuous infusion ran for 2 to 3 days. In 721 patients, the infusion was discontinued 12 hours after surgery. There were 9 femoral nerve palsies (2 in group 1, 7 in group 2) and 8 major falls (0.7%). The overall complication rate was 1.5%, and the risk of permanent nerve injury was 0.2%. Patients should be made aware of these complications as part of the usual informed consent process before using this technique for postoperative pain control after knee arthroplasty. We did not observe fewer falls when the continuous infusion was stopped 12 hours after surgery.

Continuous peripheral nerve blocks for postoperative analgesia in children: feasibility and side effects in a cohort study of 339 catheters

INTRODUCTION

Perioperative continuous peripheral nerve blocks (CPNB) are increasingly being used in children. Only one previous study has reported adverse events of CPNB in a high number of pediatric cases. We evaluated the indications, block efficacy, and adverse events related to CPNB in children.

METHODS

All CPNBs that were performed in children for postoperative analgesia over a 5-year period at the Montpellier University Hospital in France were included in this study. The first bolus dose and the continuous doses of local anesthetic were not standardized. In the postoperative period, demographic data, quality of analgesia, amount of rescue analgesic medication, child/parent satisfaction, and adverse events were recorded in our Departmental Regional Anesthesia registry.

RESULTS

A total of 339 catheters were evaluated in 292 children ASA physical status I to III. The median age was 8 yr (0.6-17 yr) and the median weight was 28 kg (7-116 kg). The main surgical indications were hip, femoral, or tibial osteotomies (44.5%) and club foot repair (27.4%). The local anesthetics used were either bupivacaine or ropivacaine. The mean volume of the local anesthetic bolus dose was 0.49 +/- 0.16 mL . kg(-1), and the mean regimen of local anesthetic continuous infusion was 0.11 +/- 0.04 mL . kg(-1) . hr(-1). The median duration of CPNB was 61.6 hr (range 0-264 hr). Pain relief, which was evaluated with the children at rest, was considered optimal in the majority of patients throughout the study period. The Children and Infants Postoperative Pain Scale (CHIPPS) was used in children age 0-6 yr and the Visual Analog Pain Scale (VAS) was used in children 7 yr and older. There were no major adverse events. There were 211 minor adverse events recorded in 153 CPNBs (45.1%). The most frequently reported complication (20.1%) involved mechanical problems with the catheter, followed by nausea and vomiting (14.7%).

CONCLUSION

CPNBs are indicated after orthopedic surgery in children. Our results demonstrate that CPNBs are feasible in the pediatric setting, and in skilled hands, they promote prolonged analgesia in the majority of patients without major adverse events. The most common minor adverse events are catheter-related mechanical problems and postoperative nausea and vomiting.

Neurological complication analysis of 1000 ultrasound guided peripheral nerve blocks for elective orthopaedic surgery: a prospective study

Little data exists regarding the frequency of neurological complications following ultrasound guided peripheral nerve blockade. Therefore, we studied single injection and continuous ultrasound guided interscalene, supraclavicular, infraclavicular, femoral and sciatic nerve blocks in patients undergoing orthopaedic extremity surgery. All patients were contacted during postoperative weeks 2-4 and questioned for numbness or altered sensation anywhere in the involved extremity, and pain or weakness unrelated to surgery. The presumed aetiology of symptoms was based on the collective agreement of principal investigator, primary surgeon and a neurologist. Multivariate analysis was performed for characteristics potentially important in the causation of neurological complications. Of 1010 consecutive blocks, successful follow up between weeks 2 and 4 occurred in 98.6%. New, all-cause, neurological symptoms were present in 56/690 blocks (8.2%) at day 10, 37/1010 (3.7%) at 1 month and 6/1010 (0.6%) at 6 months. Most symptoms were due to causes unrelated to the block. Of 452 patients directly questioned at the time of the block, new neurological symptoms were more common in patients who experienced procedure-induced paraesthesia (odds ratio = 1.7, p = 0.029). The postoperative neurological symptom rate in this series is very similar to those previously reported following traditional techniques.

Quality of reporting of regional anesthesia outcomes in the literature

OBJECTIVE

Consistent and reliable standards for reporting of regional anesthetic adverse events are lacking. The quality of reporting of regional anesthetic morbidity has not been assessed critically.

AIM

To evaluate quality of regional anesthesia outcomes reporting. Methods. Published retrospective or prospective observational cohort or randomized controlled trials in peer-reviewed journals were reviewed, and judged according to seven criteria related to quality of reporting of regional anesthesia complications: method of accrual, duration of data collection, definition of complication, morbidity and mortality rates, grade of complication severity, exclusion criteria, and study follow up. Differences in reporting outcomes according to study design, sample size and time period were compared.

RESULTS

Ninety-one articles published from 1996-2006 involving 8,833 patients were analyzed. The majority of studies (75%) met < or =4 reporting criteria. Recently published, prospective studies with >200 patients were associated with significantly higher-quality reporting (P < 0.05). Fewer than 50% of studies reported at least one recognized, accepted complication with defined criteria or indicated duration of follow up. Reporting compliance was worse (29%) for reporting of actual morbidity rates, and complications leading to death. Complication severity grading related to regional anesthesia was reported in 2% of studies.

CONCLUSION

Consistent and comparative regional anesthesia outcome data are lacking in peer-reviewed journals. A graded regional anesthetic morbidity and mortality system according to the intensity of therapy required for the treatment of the defined complication is proposed, along with a structured format for the reporting of regional anesthesia complications according to defined reporting standards.

Using the patient global assessment of the method of pain control to assess new analgesic modalities in clinical trials

OBJECTIVE

To assess the validity of the patient global assessment (PGA) of the method of pain control, a single-item patient-reported outcome measure of a method of pain control for patients experiencing postoperative pain.

RESEARCH DESIGN AND METHODS

Content validity of the PGA of the method of pain control was assessed using cognitive debriefing interviews. Construct validity was evaluated using data from six clinical trials that compared the efficacy of the fentanyl HCl iontophoretic transdermal system (fentanyl ITS) with morphine intravenous patient-controlled analgesia or placebo fentanyl ITS for acute postoperative pain management.

MAIN OUTCOME MEASURES

To assess the construct validity of the PGA rating scale, four hypotheses were developed that related positive PGA ratings ('good' or 'excellent') to (1) lower pain intensity scores, (2) higher satisfaction ratings, (3) a greater propensity to select the assigned pain control method in the future, and (4) favorable ratings of ease of use/convenience on the Patient Ease-of-Care Questionnaire. Descriptive statistics were used to evaluate the association of pain intensity and Overall Ease-of-Care scores with PGA ratings. An exact linear-by-linear association test was conducted to evaluate the association of satisfaction ratings and propensity to select the pain control method in the future with PGA ratings.

RESULTS

Results of cognitive debriefing interviews indicated that the PGA incorporates patient perceptions of several aspects of treatment with an analgesic modality, including level of pain, ease of use, and control of administration. PGA ratings were associated in the expected direction with other patient-reported outcomes used in several clinical studies.

CONCLUSIONS

Findings suggest that both the content and construct validity of the PGA of the method of pain control in clinical trial settings are supported. However, this conclusion is potentially limited by the use of a narrow range of therapeutic interventions and, in some cases, small sample sizes in the clinical trials used to assess construct validity. The PGA of the method of pain control is an informative and useful measure for assessing pain control provided by different drug delivery systems for patients experiencing postoperative pain.

Effect of pre-incisional continuous regional block on early and late postoperative conditions in tibial osteotomy and total knee arthroplasty

Background:

Postoperative regional anesthesia hastens recovery and reduces the length of hospital stay of orthopedic surgical patients. This study was designed to assess the impact of pre-incisional continuous femoral block on postoperative conditions (POC) of tibial osteotomy and total knee arthroplasty patients.

Methods:

After insertion of a femoral catheter under peripheral nerve stimulation control, 111 patients scheduled for total knee arthroplasty or tibial osteotomy were randomized to receive either pre-incisionnal (treatment) or postoperative (control) continuous femoral block. Anesthesia and postoperative management was standardized. An assessor blinded to the randomization process recorded early and late postoperative conditions (POC) which included pain scores, opioid demands, length of stay in Postoperative care unit and patients’ satisfaction.

Results:

Eleven patients were excluded from the final analysis because of catheter disconnection or malfunction. Thus 100 patients (50 in each group) were analyzed for POC. Treatment failed to influence patients overall satisfaction but significantly improved early POC. Subgroup analysis demonstrated that late POC were significantly improved in tibial osteotomy as compared to total knee arthroplasty patients. No complication occurred during the study period.

Conclusion:

Continuous femoral nerve block before surgery significantly improved early postoperative conditions in both surgery while late postoperative conditions were improved only in tibial osteotomy.

Femoral nerve blocks

Femoral nerve blocks and indeed all peripheral nerve blocks have become a popular, safe and effective method of providing postoperative analgesia. The advantages of a femoral nerve block for lower limb surgery include good postoperative analgesia, a reduction in the need for opioids (thus reducing the associated complications of opioids such as nausea, vomiting, itching and confusion (Allen et al 1998, Wang et al 2002)) and the potential for earlier mobilisation and discharge from the hospital (Wang et al 2002, Ilfeld et al 2008).