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Pepper CG, Mikhaeil JS, Khan JS. Perioperative Regional Anesthesia on Persistent Opioid Use and Chronic Pain after Noncardiac Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Anesth Analg 2024:00000539-990000000-00928. [PMID: 39231035 DOI: 10.1213/ane.0000000000006947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2024]
Abstract
BACKGROUND Whether regional anesthesia impacts the development of chronic postsurgical pain is currently debateable, and few studies have evaluated an effect on prolonged opioid use. We sought to systematically review the effect of regional anesthesia for adults undergoing noncardiac elective surgery on these outcomes. METHODS A systematic search was conducted in MEDLINE, EMBASE, CENTRAL, and CINHAL for randomized controlled trials (from inception to April 2022) of adult patients undergoing elective noncardiac surgeries that evaluated any regional technique and included one of our primary outcomes: (1) prolonged opioid use after surgery (continued opioid use ≥2 months postsurgery) and (2) chronic postsurgical pain (pain ≥3 months postsurgery). We conducted a random-effects meta-analysis on the specified outcomes and used the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach to rate the quality of evidence. RESULTS Thirty-seven studies were included in the review. Pooled estimates indicated that regional anesthesia had a significant effect on reducing prolonged opioid use (relative risk [RR] 0.48, 95% CI, 0.24-0.96, P = .04, I2 0%, 5 trials, n = 348 patients, GRADE low quality). Pooled estimates for chronic pain also indicated a significant effect favoring regional anesthesia at 3 (RR, 0.74, 95% CI, 0.59-0.93, P = .01, I2 77%, 15 trials, n = 1489 patients, GRADE moderate quality) and 6 months (RR, 0.72, 95% CI, 0.61-0.85, P < .001, I2 54%, 19 trials, n = 3457 patients, GRADE moderate quality) after surgery. No effect was found in the pooled analysis at 12 months postsurgery (RR, 0.44, 95% CI, 0.16-1.17, P = .10). CONCLUSIONS The results of this study suggest that regional anesthesia potentially reduces chronic postsurgical pain up to 6 months after surgery. Our findings also suggest a potential decrease in the development of persistent opioid use.
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Affiliation(s)
- Connor G Pepper
- From the Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - John S Mikhaeil
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - James S Khan
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Wasser Pain Management Center, Mount Sinai Hospital, Toronto, ON, Canada
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Baez C, Prieto HA, Tishad A, Vasilopoulos T, Miley EN, Deen JT, Gray CF, Parvataneni HK, Pulido L. Local Infiltration Analgesia Is Superior to Regional Nerve Blocks for Total Hip Arthroplasty: Less Falls, Better Mobility, and Same-Day Discharge. J Clin Med 2024; 13:4645. [PMID: 39200787 PMCID: PMC11355173 DOI: 10.3390/jcm13164645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 08/03/2024] [Accepted: 08/06/2024] [Indexed: 09/02/2024] Open
Abstract
Background: Multimodal analgesia in total hip arthroplasty (THA) provides better pain control, mobility, and reduced side effects compared to monotherapies. Local infiltration analgesia (LIA) and regional nerve blocks (RNBs) are commonly used throughout these protocols. This study aimed to compare these procedures as part of a multimodal analgesia protocol for patients undergoing THA. Materials and Methods: A retrospective review of 1100 consecutive elective primary THAs was performed in 996 patients between June 2018 and December 2021. The RNB consisted of a preoperative continuous femoral nerve catheter and single-shot obturator nerve block, and LIA consisted of the intraoperative infiltration of weight-based bupivacaine. Results: A total of 579 (52.6%) patients received RNB, and 521 (47.4%) received LIA. Mean oral morphine equivalents (OMEs) during the first four hours postoperatively were significantly lower for LIA group (p < 0.001). However, the numeric pain rating scale in the post-anesthesia care unit (PACU) was similar between groups. Patients with LIA had significantly greater first ambulation distance in the PACU (p < 0.001), higher successful same-day discharge rate (p = 0.029), fewer falls (p = 0.041), and less refill OMEs post-discharge (p < 0.001) than RNB. Conclusions: In the setting of similar pain management between groups and better functional outcomes for LIA, the use of minimally invasive procedures like LIA for pain control following THA is favorable.
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Affiliation(s)
- Catalina Baez
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL 32607, USA; (H.A.P.); (E.N.M.)
| | - Hernan A. Prieto
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL 32607, USA; (H.A.P.); (E.N.M.)
| | - Abtahi Tishad
- College of Medicine, University of Florida, Gainesville, FL 32607, USA; (A.T.); (T.V.)
| | - Terrie Vasilopoulos
- College of Medicine, University of Florida, Gainesville, FL 32607, USA; (A.T.); (T.V.)
| | - Emilie N. Miley
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL 32607, USA; (H.A.P.); (E.N.M.)
| | - Justin T. Deen
- Florida Orthopaedic Institute, Gainesville, FL 32607, USA; (J.T.D.); (C.F.G.); (H.K.P.)
| | - Chancellor F. Gray
- Florida Orthopaedic Institute, Gainesville, FL 32607, USA; (J.T.D.); (C.F.G.); (H.K.P.)
| | - Hari K. Parvataneni
- Florida Orthopaedic Institute, Gainesville, FL 32607, USA; (J.T.D.); (C.F.G.); (H.K.P.)
| | - Luis Pulido
- Florida Orthopaedic Institute, Gainesville, FL 32607, USA; (J.T.D.); (C.F.G.); (H.K.P.)
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Haslam N, Halvey E, Scott C. Perioperative care of patients undergoing total hip arthroplasty. BJA Educ 2024; 24:183-190. [PMID: 38764444 PMCID: PMC11096433 DOI: 10.1016/j.bjae.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2024] [Indexed: 05/21/2024] Open
Affiliation(s)
- N. Haslam
- South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - E. Halvey
- Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - C. Scott
- Royal Infirmary of Edinburgh, Edinburgh, UK
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Lee TS, Kwon HM, Park JY, Park MC, Choi YS, Park KK. Evaluating Pain Management from Peripheral Nerve Block for Geriatric Patients following Bipolar Hemiarthroplasty for Displaced Femoral-Neck Fracture. Gerontology 2024; 70:603-610. [PMID: 38574472 PMCID: PMC11177891 DOI: 10.1159/000538614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 03/26/2024] [Indexed: 04/06/2024] Open
Abstract
INTRODUCTION The purpose of this study was to evaluate peripheral nerve block (PNB) effectiveness in postoperative pain management and surgical outcomes for displaced femoral-neck fracture in geriatric patients (>70 years) who underwent bipolar hemiarthroplasty (BHA). METHODS From January 2017 to December 2021, 231 geriatric patients with displaced femoral-neck fracture who consecutively underwent BHA were retrospectively reviewed. Patients were divided into two groups: the patient-controlled analgesia (PCA) group (n = 132) who received only intravenous (IV) PCA for postoperative pain management, and all others who received PNB with IV PCA (PNB+PCA) such as femoral nerve block or fascia iliaca compartment block after surgery (n = 99). Primary outcomes were postoperative visual analog scale (VAS) at rest and during activity at 6, 24, and 48 h postoperatively. Secondary outcomes were postoperative complications, changes in hemoglobin, length of hospital stay, and total morphine usage after surgery. RESULTS Postoperative resting VAS at 6 h and 48 h was significantly lower in the PNB+PCA group compared with the PCA group (p = 0.075, p = 0.0318, respectively). However, there was no significant difference in either resting VAS at 24 h or active VAS. Complications of pneumonia and delirium until 1 month postoperative were significantly lower in the PNB + PCA group than the PCA group (p = 0.0022, p = 0.0055, respectively). CONCLUSION PNB with IV PCA seems to have a beneficial effect on geriatric femoral-neck patients who underwent BHA with postoperative analgesia for reducing postoperative resting pain and complications, especially pneumonia and delirium.
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Affiliation(s)
- Tae Sung Lee
- Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyuck Min Kwon
- Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jun Young Park
- Department of Orthopedic Surgery, Yong-in Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Min Cheol Park
- Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Yong Seon Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Kwan Kyu Park
- Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
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Andrade PP, Lombardi RA, Marques IR, Braga ACDNAE, Isaias BRS, Heiser NE. Pericapsular Nerve Group (PENG) block versus fascia iliaca compartment (FI) block for hip surgery: a systematic review and meta-analysis of randomized controlled trials. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2023; 73:794-809. [PMID: 37507071 PMCID: PMC10625158 DOI: 10.1016/j.bjane.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 07/10/2023] [Accepted: 07/16/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND This study compares Fascia Iliaca compartment (FI) block and Pericapsular Nerve Group (PENG) block for hip surgery. METHODS Pubmed, Embase and Cochrane were systematically searched in April 2022. Inclusion criteria were: Randomized Controlled Trials (RCTs); comparing PENG block versus FI block for hip surgery; patients over 18 years of age; and reporting outcomes immediately postoperative. We excluded studies with overlapped populations and without a head-to-head comparison of the PENG block vs. FI block. Mean-Difference (MD) with 95% Confidence Intervals (CI) were pooled. Trial Sequential Analyses (TSA) were performed to assess inconsistency. Quality assessment and risk of bias were performed according to Cochrane recommendations. RESULTS Eight RCTs comprising 384 patients were included, of whom 196 (51%) underwent PENG block. After hip surgery, PENG block reduced static pain score at 12h post-surgery (MD = 0.61 mm; 95% CI 1.12 to -0.09; p = 0.02) and cumulative postoperative oral morphine consumption in the first 24h (MD = -6.93 mg; 95% CI -13.60 to -0.25; p = 0.04) compared with the FI group. However, no differences were found between the two techniques regarding dynamic and static pain scores at 6 h or 24 h post-surgery, or in the time to the first analgesic rescue after surgery. CONCLUSION The findings suggest that PENG block reduced opioid consumption in the first 24 h after surgery and reduced pain scores at rest at 12 h post-surgery. Further research is needed to fully understand the effects of the PENG block and its potential benefits compared to FI block. PROSPERO REGISTRATION CRD42022339628 PROSPERO REGISTRATION: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=339628.
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Affiliation(s)
- Priscila P Andrade
- Hospital Regional de Sorocaba Adib Domingos Jatene, Divisão de Anestesiologia, Sorocaba, SP, Brazil
| | - Rafael A Lombardi
- University of Nebraska Medical Center, Department of Anesthesiology, Omaha, United States of America.
| | - Isabela R Marques
- Universitat Internacional de Catalunya, Division of Medicine, Barcelona, Spain
| | | | - Beatrice R S Isaias
- Universidade Federal de Mato Grosso do Sul, Divisão de Medicina, Campo Grande, MS, Brazil
| | - Nicholas E Heiser
- University of Nebraska Medical Center, Department of Anesthesiology, Omaha, United States of America
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Bravo D, Aliste J, Layera S, Fernández D, Erpel H, Aguilera G, Arancibia H, Barrientos C, Wulf R, León S, Brañes J, Finlayson RJ, Tran DQ. Randomized clinical trial comparing pericapsular nerve group (PENG) block and periarticular local anesthetic infiltration for total hip arthroplasty. Reg Anesth Pain Med 2023; 48:489-494. [PMID: 36797036 DOI: 10.1136/rapm-2023-104332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 02/09/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND This randomized trial compared pericapsular nerve group block and periarticular local anesthetic infiltration in patients undergoing primary total hip arthroplasty. We hypothesized that, compared with pericapsular nerve group block, periarticular local anesthetic infiltration would decrease the postoperative incidence of quadriceps weakness at 3 hours fivefold (ie, from 45% to 9%). METHODS Sixty patients undergoing primary total hip arthroplasty under spinal anesthesia were randomly allocated to receive a pericapsular nerve group block (n=30) using 20 mL of adrenalized bupivacaine 0.50%, or periarticular local anesthetic infiltration (n=30) using 60 mL of adrenalized bupivacaine 0.25%. Both groups also received 30 mg of ketorolac, either intravenously (pericapsular nerve group block) or periarticularly (periarticular local anesthetic infiltration), as well as 4 mg of intravenous dexamethasone.Postoperatively, a blinded evaluator carried out sensory assessment and motor assessment (knee extension and hip adduction) at 3, 6 and 24 hours. Furthermore, the blinded observer also recorded static and dynamic pain scores at 3, 6, 12, 18, 24, 36 and 48 hours; time to first opioid request; cumulative breakthrough morphine consumption at 24 hours and 48 hours; opioid-related side effects; ability to perform physiotherapy at 6, 24 and 48 hours; as well as length of stay. RESULTS There were no differences in quadriceps weakness at 3 hours between pericapsular nerve group block and periarticular local anesthetic infiltration (20% vs 33%; p=0.469). Furthermore, no intergroup differences were found in terms of sensory block or motor block at other time intervals; time to first opioid request; cumulative breakthrough morphine consumption; opioid-related side effects; ability to perform physiotherapy; and length of stay. Compared with pericapsular nerve group block, periarticular local anesthetic infiltration resulted in lower static pain scores (at all measurement intervals) and dynamic pain scores (at 3 and 6 hours). CONCLUSION For primary total hip arthroplasty, pericapsular nerve group block and periarticular local anesthetic infiltration result in comparable rates of quadriceps weakness. However, periarticular local anesthetic infiltration is associated with lower static pain scores (especially during the first 24 hours) and dynamic pain scores (first 6 hours). Further investigation is required to determine the optimal technique and local anesthetic admixture for periarticular local anesthetic infiltration. TRIAL REGISTRATION NUMBER NCT05087862.
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Affiliation(s)
- Daniela Bravo
- Anesthesiology and Perioperative Medicine, University of Chile, Santiago de Chile, Chile
| | - Julián Aliste
- Anesthesiology and Perioperative Medicine, University of Chile, Santiago de Chile, Chile
| | - Sebastián Layera
- Anesthesiology and Perioperative Medicine, University of Chile, Santiago de Chile, Chile
| | - Diego Fernández
- Anesthesiology and Perioperative Medicine, University of Chile, Santiago de Chile, Chile
| | - Hans Erpel
- Anesthesiology and Perioperative Medicine, University of Chile, Santiago de Chile, Chile
| | - Germán Aguilera
- Anesthesiology and Perioperative Medicine, University of Chile, Santiago de Chile, Chile
| | - Hernán Arancibia
- Anesthesiology and Perioperative Medicine, University of Chile, Santiago de Chile, Chile
| | | | - Rodrigo Wulf
- Orthopedic Surgery, University of Chile, Santiago de Chile, Chile
| | - Sebastián León
- Orthopedic Surgery, University of Chile, Santiago de Chile, Chile
| | - Julián Brañes
- Orthopedic Surgery, University of Chile, Santiago de Chile, Chile
| | - Roderick J Finlayson
- Pain and Research, The University of British Columbia, Vancouver, British Columbia, Canada
| | - De Q Tran
- Anesthesiology, McGill University, Montreal, Québec, Canada
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7
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Gazendam AM, Zhu M, Rubinger L, Chang Y, Phillips S, Bhandari M. Quadratus lumborum block for postoperative pain management in patients undergoing total hip arthroplasty: a systematic review and meta-analysis. Hip Int 2023; 33:850-857. [PMID: 35848126 PMCID: PMC10486167 DOI: 10.1177/11207000221111309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 06/01/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The use of quadratus lumborum nerve blocks (QLB) for pain control following elective total hip arthroplasty (THA) has increased substantially in recent years. The objective of this systematic review and meta-analysis was to compare outcomes from randomised controlled trials (RCTs) utilising QLBs following elective THA. METHODS MEDLINE, EMBASE, and Cochrane databases were searched for RCTs perioperative QLBs for THA. Quantitative synthesis was conducted for pain scores, opioid consumption and adverse events. RESULTS A total of 7 RCTs with 429 patients undergoing THA were included. No differences in pain scores were demonstrated between QLBs and control interventions. Subgroup analysis demonstrated no differences between QLBs and sham procedures or active comparators. No differences in postoperative opioid consumption between QLB and control interventions was found. In trials reporting adverse events, they were rare and similar between groups. Overall, the certainty of the evidence was graded as low or very low. CONCLUSIONS The current literature suggests that a QLB for THA does not reduce pain or opioid consumption compared to sham or active comparators.
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Affiliation(s)
- Aaron M Gazendam
- OrthoEvidence, Burlington, ON, Canada
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Meng Zhu
- OrthoEvidence, Burlington, ON, Canada
| | - Luc Rubinger
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | | | | | - Mohit Bhandari
- OrthoEvidence, Burlington, ON, Canada
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
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Wadhawan A, Arora S, Krishna A, Mandal M, Bhalotra A, Kumar M. A Comparative Evaluation of Combined Nerve Block Versus Periarticular Infiltration on Postoperative Pain Relief in Total Hip Arthroplasty. Indian J Orthop 2023; 57:1251-1266. [PMID: 37525735 PMCID: PMC10387017 DOI: 10.1007/s43465-023-00924-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 06/02/2023] [Indexed: 08/02/2023]
Abstract
Introduction To minimize the side effects of the central neuraxial blockade to obtain postoperative pain relief, there has been an increasing preference for targeting the peripheral structures in patients undergoing total hip arthroplasty (THA). Patients and Methods This prospective study was performed between September 2019 and September 2021 and involved 30 patients that were randomized to two groups. One group (n = 15) received combined nerve block (CNB) [obturator nerve, nerve to quadratus femoris, superior gluteal nerve, and femoral nerve], while another group (n = 15) received periarticular infiltrative analgesia (PIA). All the patients were given the same volume and composition of the drug cocktail (20 ml 0.5% ropivacaine, 1 ml (100 mcg) dexmedetomidine, and 29 ml normal saline). Results The patients in group CNB had a significantly lower visual analog score (VAS) at 6, 12, 18, 24, 30, 36, 42 and 48 h after surgery (p < 0.05). Patients in group CNB required fewer (p < 0.001) doses of the rescue analgesic (1.67 ± 0.90 doses) as compared to group PIA (3.53 ± 0.64 doses). Time to the first rescue analgesia was significantly longer (p = 0.01) in group CNB (6.71 ± 2.36 h) as compared to group PIA (4.80 ± 1.26 h). However, patients in group PIA had significantly faster sensory (p < 0.001) and motor recovery (p < 0.001) as compared to group CNB. It took significantly longer (p < 0.001) to administer the nerve block (16.87 ± 1.80 min) as compared to periarticular infiltration (6.53 ± 1.18 min). There were no complications in either group. Conclusion CNB registered significant superiority over PIA with respect to postoperative pain relief and time to rescue analgesia. However, the time taken to administer CNB was significantly higher and the patients in the PIA group had early recovery in sensory and motor modalities. Level of Evidence III (therapeutic).
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Affiliation(s)
- Akhil Wadhawan
- Department of Orthopaedic Surgery, Maulana Azad Medical College, Associated Lok Nayak Hospital, New Delhi, Delhi 110002 India
| | - Sumit Arora
- Department of Orthopaedic Surgery, Maulana Azad Medical College, Associated Lok Nayak Hospital, New Delhi, Delhi 110002 India
| | - Anant Krishna
- Department of Orthopaedics, SGT Medical College Hospital, Research Institute, Gurugram, Haryana 122505 India
| | - Mainak Mandal
- Department of Orthopaedic Surgery, Maulana Azad Medical College, Associated Lok Nayak Hospital, New Delhi, Delhi 110002 India
| | - Anju Bhalotra
- Department of Anaesthesiology and Intensive Care, Maulana Azad Medical College, Associated Lok Nayak Hospital, New Delhi, 110002 India
| | - Manoj Kumar
- Department of Orthopaedic Surgery, Maulana Azad Medical College, Associated Lok Nayak Hospital, New Delhi, Delhi 110002 India
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Pergolizzi JV, LeQuang JA, Magnusson P, Varrassi G. Identifying risk factors for chronic postsurgical pain and preventive measures: a comprehensive update. Expert Rev Neurother 2023; 23:1297-1310. [PMID: 37999989 DOI: 10.1080/14737175.2023.2284872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/14/2023] [Indexed: 11/26/2023]
Abstract
INTRODUCTION Chronic postsurgical pain (CPSP) is a prevalent condition that can diminish health-related quality of life, cause functional deficits, and lead to patient distress. Rates of CPSP are higher for certain types of surgeries than others (thoracic, breast, or lower extremity amputations) but can occur after even uncomplicated minimally invasive procedures. CPSP has multiple mechanisms, but always starts as acute postsurgical pain, which involves inflammatory processes and may encompass direct or indirect neural injury. Risk factors for CPSP are largely known but many, such as female sex, younger age, or type of surgery, are not modifiable. The best strategy against CPSP is to quickly and effectively treat acute postoperative pain using a multimodal analgesic regimen that is safe, effective, and spares opioids. AREAS COVERED This is a narrative review of the literature. EXPERT OPINION Every surgical patient is at some risk for CPSP. Control of acute postoperative pain appears to be the most effective approach, but principles of good opioid stewardship should apply. The role of regional anesthetics as analgesics is gaining interest and may be appropriate for certain patients. Finally, patients should be better informed about their relative risk for CPSP.
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Affiliation(s)
| | | | - Peter Magnusson
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Department of Cardiology, Center for Clinical Research, Falun, Sweden
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Zheng J, Du L, Chen G, Zhang L, Deng X, Zhang W. Efficacy of pericapsular nerve group (PENG) block on perioperative pain management in elderly patients undergoing hip surgical procedures: a protocol for a systematic review with meta-analysis and trial sequential analysis. BMJ Open 2023; 13:e065304. [PMID: 36604133 PMCID: PMC9827252 DOI: 10.1136/bmjopen-2022-065304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 11/28/2022] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION An increasing number of elderly patients suffer from hip diseases associated with moderate to severe perioperative pain during the accelerating global ageing process. Optimal analgesia can decrease perioperative complications and facilitate elderly patients' perioperative recovery. Pericapsular nerve group (PENG) block is a relatively new, analgesia adequate and motor-sparing block technique for perioperative pain management of hip diseases. However, the efficacy of PENG block remains unclear as the limited clinical evidence. Then, we will perform a protocol for a systematic review and meta-analysis to identify the efficacy of PENG block for perioperative pain management. METHODS AND ANALYSIS PubMed, Ovid Medline, Cochrane Library, Embase, Web of Science, China National Knowledge Infrastructure, Chinese BioMedical Literature, Wanfang and VIP databases will be searched from inception to August 2022 to identify randomised controlled trials of elderly patients accepting PENG block for hip diseases. The primary outcome will be the pain intensity after pain management. Secondary outcomes will be quadriceps strength, perioperative rescue analgesia information and perioperative complications. Assessment of heterogeneity will be primarily inspected by forest plots. If there is no indication of funnel plot asymmetry, a random-effects meta-analysis will be performed. The Cochrane risk-of-bias tool, Grading of Recommendations Assessment, Development and Evaluation and trial sequential analysis will be conducted to evaluate the evidence quality and control the random errors. Funnel plots and Egger's regression test will be performed to evaluate publication bias. ETHICS AND DISSEMINATION Ethical approval was not required for this systematic review protocol. The results will be disseminated through peer-reviewed publications. PROSPERO REGISTRATION NUMBER CRD42022313895.
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Affiliation(s)
- Jianqiao Zheng
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Li Du
- Department of Anesthesiology, Sichuan Cancer Hospital and Research Institute, Chengdu, Sichuan, China
| | - Guo Chen
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lu Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiaoqian Deng
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Weiyi Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Li G, Yu F, Liu S, Weng J, Qi T, Qin H, Chen Y, Wang F, Xiong A, Wang D, Gao L, Zeng H. Patient characteristics and procedural variables are associated with length of stay and hospital cost among unilateral primary total hip arthroplasty patients: a single-center retrospective cohort study. BMC Musculoskelet Disord 2023; 24:6. [PMID: 36600222 PMCID: PMC9811718 DOI: 10.1186/s12891-022-06107-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 12/20/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Total hip arthroplasty (THA) is a successful treatment for many hip diseases. Length of stay (LOS) and hospital cost are crucial parameters to quantify the medical efficacy and quality of unilateral primary THA patients. Clinical variables associated with LOS and hospital costs haven't been investigated thoroughly. METHODS The present study retrospectively explored the contributors of LOS and hospital costs among a total of 452 unilateral primary THA patients from January 2019 to January 2020. All patients received conventional in-house rehabilitation services within our institute prior to discharge. Outcome parameters included LOS and hospital cost while clinical variables included patient characteristics and procedural variables. Multivariable linear regression analysis was performed to assess the association between outcome parameters and clinical variables by controlling confounding factors. Moreover, we analyzed patients in two groups according to their diagnosis with femur neck fracture (FNF) (confine THA) or non-FNF (elective THA) separately. RESULTS Among all 452 eligible participants (266 females and 186 males; age 57.05 ± 15.99 year-old), 145 (32.08%) patients diagnosed with FNF and 307 (67.92%) diagnosed with non-FNF were analyzed separately. Multivariable linear regression analysis revealed that clinical variables including surgery duration, transfusion, and comorbidity (stroke) among the elective THA patients while the approach and comorbidities (stoke, diabetes mellitus, coronary heart disease) among the confine THA patients were associated with a prolonged LOS (P < 0.05). Variables including the American Society of Anesthesiologists classification (ASA), duration, blood loss, and transfusion among the elective THA while the approach, duration, blood loss, transfusion, catheter, and comorbidities (stoke and coronary heart disease) among the confine THA were associated with higher hospital cost (P < 0.05). The results revealed that variables were associated with LOS and hospital cost at different degrees among both elective and confine THA. CONCLUSIONS Specific clinical variables of the patient characteristics and procedural variables are associated the LOS and hospital cost, which may be different between the elective and confine THA patients. The findings may indicate that evaluation and identification of detailed perioperative factors are beneficial in managing perioperative preparation, adjusting patients' anticipation, decreasing LOS, and reducing hospital cost.
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Affiliation(s)
- Guoqing Li
- grid.440601.70000 0004 1798 0578Department of Bone & Joint Surgery, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036 ,grid.440601.70000 0004 1798 0578National & Local Joint Engineering Research Center of Orthopaedic Biomaterials, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036
| | - Fei Yu
- grid.440601.70000 0004 1798 0578Department of Bone & Joint Surgery, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036 ,grid.440601.70000 0004 1798 0578National & Local Joint Engineering Research Center of Orthopaedic Biomaterials, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036
| | - Su Liu
- grid.440601.70000 0004 1798 0578Department of Bone & Joint Surgery, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036 ,grid.440601.70000 0004 1798 0578National & Local Joint Engineering Research Center of Orthopaedic Biomaterials, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036
| | - Jian Weng
- grid.440601.70000 0004 1798 0578Department of Bone & Joint Surgery, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036 ,grid.440601.70000 0004 1798 0578National & Local Joint Engineering Research Center of Orthopaedic Biomaterials, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036
| | - Tiantian Qi
- grid.440601.70000 0004 1798 0578Department of Bone & Joint Surgery, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036 ,grid.440601.70000 0004 1798 0578National & Local Joint Engineering Research Center of Orthopaedic Biomaterials, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036
| | - Haotian Qin
- grid.440601.70000 0004 1798 0578Department of Bone & Joint Surgery, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036 ,grid.440601.70000 0004 1798 0578National & Local Joint Engineering Research Center of Orthopaedic Biomaterials, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036
| | - Yixiao Chen
- grid.440601.70000 0004 1798 0578Department of Bone & Joint Surgery, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036 ,grid.440601.70000 0004 1798 0578National & Local Joint Engineering Research Center of Orthopaedic Biomaterials, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036
| | - Fangxi Wang
- grid.440601.70000 0004 1798 0578Department of Bone & Joint Surgery, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036 ,grid.440601.70000 0004 1798 0578National & Local Joint Engineering Research Center of Orthopaedic Biomaterials, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036
| | - Ao Xiong
- grid.440601.70000 0004 1798 0578Department of Bone & Joint Surgery, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036 ,grid.440601.70000 0004 1798 0578National & Local Joint Engineering Research Center of Orthopaedic Biomaterials, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036
| | - Deli Wang
- grid.440601.70000 0004 1798 0578Department of Bone & Joint Surgery, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036 ,grid.440601.70000 0004 1798 0578National & Local Joint Engineering Research Center of Orthopaedic Biomaterials, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036
| | - Liang Gao
- Center for Clinical Medicine, Huatuo Institute of Medical Innovation (HTIMI), 10787 Berlin, Germany ,Sino Euro Orthopaedics Network (SEON), Berlin, Germany
| | - Hui Zeng
- grid.440601.70000 0004 1798 0578Department of Bone & Joint Surgery, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036 ,grid.440601.70000 0004 1798 0578National & Local Joint Engineering Research Center of Orthopaedic Biomaterials, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036
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12
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Bernaus M, Novellas M, Bartra A, Núñez JH, Anglès F. Local infiltration analgesia does not have benefits in fast-track hip arthroplasty programmes: a double-blind, randomised, placebo-controlled, clinical trial. Hip Int 2022; 32:711-716. [PMID: 33601948 DOI: 10.1177/1120700021992684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Multimodal analgesia regimes including local infiltration analgesia (LIA) have been successfully applied in fast-track hip arthroplasty programmes. LIA's contribution to the analgesic effect in hip arthroplasty has been questioned. Our study sought to determine the analgesic efficacy of LIA in THA surgery in a fast-track programme. METHODS Patients diagnosed with hip osteoarthritis scheduled for arthroplasty were randomised to receive LIA (120 ml ropivacaine 0.2% plus epinephrine 0.5 µ/ml) or saline as a part of a multimodal analgesia regime. The surgical team, the nursing staff, and patients were all blinded regarding patient allocation throughout the study. The primary outcome was pain assessed as a continuous variable using the visual analogue scale (VAS) at 4, 8, 24 and 48 hours postoperatively. Secondary outcomes included the amount of analgesic rescue consumption, complications and length of hospital stay. RESULTS A total of 63 patients were interviewed and agreed to participate in the study. No statistically significant differences were found between groups for pain measurements at 4, 8, 12, 24 and 48 hours after surgery. There were also no differences in rescue medication consumption, complications, or length of stay. CONCLUSIONS Our results suggest LIA (ropivacaine plus epinephrine, single shot) has no effect in pain management and has not shown benefits for early ambulation in primary THA surgery. Further research is needed to establish the optimal multimodal analgesia regime for THA fast-track programmes. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov (NCT03513276).
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Affiliation(s)
- Marti Bernaus
- Department of Orthopaedic Surgery, University Hospital Mutua Terrassa, Barcelona, Spain
| | - Marga Novellas
- Department of Anaesthesiology, University Hospital Mutua Terrassa, Barcelona, Spain
| | - Agustí Bartra
- Department of Orthopaedic Surgery, University Hospital Mutua Terrassa, Barcelona, Spain
| | - Jorge H Núñez
- Department of Orthopaedic Surgery, University Hospital Mutua Terrassa, Barcelona, Spain
| | - Francesc Anglès
- Department of Orthopaedic Surgery, University Hospital Mutua Terrassa, Barcelona, Spain.,Department of Surgery, University of Barcelona, Spain
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13
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The difficulty of choosing the method of analgesia after total replacement of the lower limb large joints (case report, literature review). ACTA BIOMEDICA SCIENTIFICA 2022. [DOI: 10.29413/abs.2022-7.4.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
A case of successful treatment of a patient with a periprosthetic fracture of the femur is described. The fracture occurred one day after total hip replacement as a result of a fall, possibly associated with postoperative conduction analgesia. Lower limb large joints total replacement may become the most frequently performed type of elective surgery already in the current decade. The increasing prevalence of osteoporosis, osteoarthritis, rheumatic diseases and hip fractures is an objective prerequisite for it. Despite of all efforts, the problem of postoperative pain control during these surgical interventions currently remains unresolved. There is currently no “gold standard” for pain relief after total hip and knee replacement surgeries. An excellent ratio of effectiveness and safety is demonstrated by multimodal pain relief programs based on peripheral nerve blocks. However, while having undeniable advantages, conduction anesthesia/analgesia has a critically important drawback. The cornerstone of postoperative rehabilitation for patients undergoing total hip or knee replacement is their early activation. All methods of conduction anesthesia are associated with motor blockade. In particular, femoral nerve block causes weakness of quadriceps muscle of thigh, inducing patients’ inadvertent falling when attempting to stand or walk. The situation with the choice of the method of anesthesia after total replacement of the lower limb large joints can be described as “a long way to go”.
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14
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Wang CG, Yang Y, Yang MY, Wang XL, Ding YL. Analgesic effect of iliopsoas plane block for hip fracture. Perioper Med (Lond) 2022; 11:15. [PMID: 35418144 PMCID: PMC9008941 DOI: 10.1186/s13741-022-00254-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 02/05/2022] [Indexed: 11/25/2022] Open
Abstract
Background Hip fracture and surgery are associated with moderate to severe pain, which hampers early mobilization and extends the hospital stay. Femoral nerve block and fascia iliaca compartment block could provide effective postoperative pain relief. Unfortunately, they could weaken the strength of the quadriceps muscle and increase the risk of falls. Iliopsoas plane block (IPB) is a novel motor-sparing regional technique, which targets the sensory branches of the hip joint originating from the femoral nerve. However, the analgesic effect of IPB has not been confirmed yet. Case presentation In the present case series, IPB and lateral femoral cutaneous nerve block were implemented under the guidance of ultrasound for eight patients with hip fractures. The median (IQR) visual analog scale (VAS) score (0–10; 0: no pain, 10: worst pain) decreased from 1.5 (0.25–2) before IPB to 0 (0–0) 0.5h after IPB at rest. The median (IQR) VAS score decreased from 8 (7–8) before IPB to 2 (1–2) 0.5h after IPB during flexion of hip 30°. Pain score was no more than one at rest and three during flexion of the hip 30° within 48h after surgery. Furthermore, the MMT grades of quadriceps strength were no less than four after IPB. Conclusions Our case series firstly highlights that IPB might be an effective analgesic technique for hip fracture and surgery, while retaining motor function.
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Affiliation(s)
- Chun-Guang Wang
- Department of Anesthesiology, The First Central Hospital of Baoding, Northern Great wall Street 320#, Baoding, 071000, Hebei, China.
| | - Yang Yang
- Department of Anesthesiology, The First Central Hospital of Baoding, Northern Great wall Street 320#, Baoding, 071000, Hebei, China
| | - Ming-Yu Yang
- Department of Anesthesiology, The First Central Hospital of Baoding, Northern Great wall Street 320#, Baoding, 071000, Hebei, China
| | - Xiu-Li Wang
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, China
| | - Yan-Ling Ding
- Department of Anesthesiology, The First Central Hospital of Baoding, Northern Great wall Street 320#, Baoding, 071000, Hebei, China
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15
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Zheng J, Pan D, Zheng B, Ruan X. Preoperative pericapsular nerve group (PENG) block for total hip arthroplasty: a randomized, placebo-controlled trial. Reg Anesth Pain Med 2021; 47:155-160. [PMID: 34873023 DOI: 10.1136/rapm-2021-103228] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 11/20/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND We hypothesized that the addition of a preoperative pericapsular nerve group (PENG) block to intra-articular local anesthetic injection would improve analgesia after total hip arthroplasty. METHOD In this double-blinded trial, 71 patients scheduled for primary total hip arthroplasty were randomized to receive preoperative PENG block with 20 mL 0.5% ropivacaine (PENG group) or 20 mL saline (placebo group). All the patients received an intra-articular injection of 20 mL 0.5% ropivacaine by surgeon after the completion of the procedure. The primary outcome was the highest pain score reported in the recovery room. The secondary outcomes included quadriceps strength, pain scores, opioid use, and opioid-related side effects up to 48 hours after surgery. RESULTS Seventy patients were included in the final analysis. The highest visual analog scale in the recovery room showed significant intergroup difference (placebo: 5.2±3.1 vs PENG: 3.3±2.7, p<0.01) but the difference did not persist after discharge from the recovery room. The two groups' postoperative pain scores at rest were similar. A lower intraoperative morphine equivalent dose and lower postoperative vomiting were found in the PENG group. There were no differences in the other outcomes. CONCLUSION The addition of a preoperative PENG block to intra-articular injections of local anesthetic provides a limited benefit to postoperative analgesia in the recovery room with no discernible benefits thereafter. TRIAL REGISTRATION NUMBER NCT04480320.
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Affiliation(s)
- Jun Zheng
- The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Danyang Pan
- The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Bin Zheng
- The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Xiangcai Ruan
- Department of Anesthesiology and Pain Medicine, Sun Yat-sen University, Guangzhou, China
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16
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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: 67] [Impact Index Per Article: 22.3] [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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17
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Panzenbeck P, von Keudell A, Joshi GP, Xu CX, Vlassakov K, Schreiber KL, Rathmell JP, Lirk P. Procedure-specific acute pain trajectory after elective total hip arthroplasty: systematic review and data synthesis. Br J Anaesth 2021; 127:110-132. [PMID: 34147158 DOI: 10.1016/j.bja.2021.02.036] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 01/25/2021] [Accepted: 02/23/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND For most procedures, there is insufficient evidence to guide clinicians in the optimal timing of advanced analgesic methods, which should be based on the expected time course of acute postoperative pain severity and aimed at time points where basic analgesia has proven insufficient. METHODS We conducted a systematic search of the literature of analgesic trials for total hip arthroplasty (THA), extracting and pooling pain scores across studies, weighted for study size. Patients were grouped according to basic anaesthetic method used (general, spinal), and adjuvant analgesic interventions such as nerve blocks, local infiltration analgesia, and multimodal analgesia. Special consideration was given to high-risk populations such as chronic pain or opioid-dependent patients. RESULTS We identified and analysed 71 trials with 5973 patients and constructed pain trajectories from the available pain scores. In most patients undergoing THA under general anaesthesia on a basic analgesic regimen, postoperative acute pain recedes to a mild level (<4/10) by 4 h after surgery. We note substantial variability in pain intensity even in patients subjected to similar analgesic regimens. Chronic pain or opioid-dependent patients were most often actively excluded from studies, and never analysed separately. CONCLUSIONS We have demonstrated that it is feasible to construct procedure-specific pain curves to guide clinicians on the timing of advanced analgesic measures. Acute intense postoperative pain after THA should have resolved by 4-6 h after surgery in most patients. However, there is a substantial gap in knowledge on the management of patients with chronic pain and opioid-dependent patients.
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Affiliation(s)
- Paul Panzenbeck
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Arvind von Keudell
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, RX, USA
| | - Claire X Xu
- Department of Anesthesiology, Pain and Critical Care Medicine, Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA, USA
| | - Kamen Vlassakov
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kristin L Schreiber
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - James P Rathmell
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Philipp Lirk
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Hu J, Wang Q, Zeng Y, Xu M, Gong J, Yang J. The impact of ultrasound-guided transmuscular quadratus lumborum block combined with local infiltration analgesia for arthroplasty on postoperative pain relief. J Clin Anesth 2021; 73:110372. [PMID: 34098394 DOI: 10.1016/j.jclinane.2021.110372] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 05/14/2021] [Accepted: 05/22/2021] [Indexed: 02/08/2023]
Abstract
STUDY OBJECTIVE This study aimed to evaluate the efficacy of ultrasound-guided transmuscular quadratus lumborum block (QLB) combined with local infiltration analgesia (LIA) for pain management and recovery in patients who have undergone total hip arthroplasty (THA) via a posterolateral approach. DESIGN This was a prospective, randomized controlled trial. SETTING We collected data in the preoperative area, operating room, and bed ward. PATIENTS A total of 80 patients with American Society of Anesthesiology functional status scores of II-III were included and assigned to two groups, and all 80 patients were included in the final analysis. INTERVENTIONS All included patients were randomly assigned to the nerve block (group N) or the control group (group C). Patients in the group N received transmuscular QLB combined with LIA, while patients in the group C received only LIA. MEASUREMENTS The primary outcome was postoperative pain during the first active motion: it was measured at six hours after surgery and assessed using a visual analog scale (VAS). Secondary outcomes were the resting VAS scores in the post-anesthesia care unit (PACU) and at 2, 6, 12, 24, 48, and 72 h after surgery; VAS scores during motion at 12, 24, 48, and 72 h after surgery; intraoperative consumption of opioids; postoperative consumption of morphine hydrochloride; frequency of sleep interruption due to pain on the night of surgery; time until the first "walk out of the bed" after surgery; muscle strength of the quadriceps femoris; and postoperative adverse effects. MAIN RESULTS Compared to the group C, patients in the group N had significantly lower VAS scores during motion at 6, 12, and 24 h after surgery, as well as lower resting VAS scores in the PACU and at 2, 6, 12, and 24 h after surgery. Patients in the group N also consumed significantly smaller amounts of intraoperative opioids and morphine after surgery. Patients in the group N reported significantly fewer interruptions in sleep due to pain on the night of surgery and were able to "walk out of the bed" significantly earlier than those in the group C. There was no significant difference between the two groups in muscle strength of the quadriceps femoris or incidence of postoperative adverse effects. CONCLUSIONS Compared to treatment with LIA alone, ultrasound-guided transmuscular QLB combined with LIA can provide better postoperative pain relief and enhance the recovery of THA patients, since it does not cause quadriceps femoris muscle weakness and is associated with significantly lower need for intraoperative opioids.
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Affiliation(s)
- Jian Hu
- Department of Anesthesiology, West China Hospital, Sichuan University, No. 37 Wainan Guoxue Road, Chengdu 610041, China
| | - Qiuru Wang
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, No. 37 Wainan Guoxue Road, Chengdu 610041, China
| | - Yan Zeng
- Department of Anesthesiology, West China Hospital, Sichuan University, No. 37 Wainan Guoxue Road, Chengdu 610041, China
| | - Min Xu
- Department of Anesthesiology, West China Hospital, Sichuan University, No. 37 Wainan Guoxue Road, Chengdu 610041, China
| | - Jingxuan Gong
- Department of Biomedical Engineering, Northwestern University, 633 Clark Street, Evanston 60201, IL, USA
| | - Jing Yang
- Department of Anesthesiology, West China Hospital, Sichuan University, No. 37 Wainan Guoxue Road, Chengdu 610041, China.
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19
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Anger M, Valovska T, Beloeil H, Lirk P, Joshi GP, Van de Velde M, Raeder J. PROSPECT guideline for total hip arthroplasty: a systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia 2021; 76:1082-1097. [PMID: 34015859 DOI: 10.1111/anae.15498] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2021] [Indexed: 12/11/2022]
Abstract
The aim of this systematic review was to develop recommendations for the management of postoperative pain after primary elective total hip arthroplasty, updating the previous procedure-specific postoperative pain management (PROSPECT) guidelines published in 2005 and updated in July 2010. Randomised controlled trials and meta-analyses published between July 2010 and December 2019 assessing postoperative pain using analgesic, anaesthetic, surgical or other interventions were identified from MEDLINE, Embase and Cochrane databases. Five hundred and twenty studies were initially identified, of which 108 randomised trials and 21 meta-analyses met the inclusion criteria. Peri-operative interventions that improved postoperative pain include: paracetamol; cyclo-oxygenase-2-selective inhibitors; non-steroidal anti-inflammatory drugs; and intravenous dexamethasone. In addition, peripheral nerve blocks (femoral nerve block; lumbar plexus block; fascia iliaca block), single-shot local infiltration analgesia, intrathecal morphine and epidural analgesia also improved pain. Limited or inconsistent evidence was found for all other approaches evaluated. Surgical and anaesthetic techniques appear to have a minor impact on postoperative pain, and thus their choice should be based on criteria other than pain. In summary, the analgesic regimen for total hip arthroplasty should include pre-operative or intra-operative paracetamol and cyclo-oxygenase-2-selective inhibitors or non-steroidal anti-inflammatory drugs, continued postoperatively with opioids used as rescue analgesics. In addition, intra-operative intravenous dexamethasone 8-10 mg is recommended. Regional analgesic techniques such as fascia iliaca block or local infiltration analgesia are recommended, especially if there are contra-indications to basic analgesics and/or in patients with high expected postoperative pain. Epidural analgesia, femoral nerve block, lumbar plexus block and gabapentinoid administration are not recommended as the adverse effects outweigh the benefits. Although intrathecal morphine 0.1 mg can be used, the PROSPECT group emphasises the risks and side-effects associated with its use and provides evidence that adequate analgesia may be achieved with basic analgesics and regional techniques without intrathecal morphine.
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Affiliation(s)
- M Anger
- Service d'Anesthésie Réanimation et Médecine Péri-opératoire, CHU Rennes, Université Rennes, Rennes, France
| | - T Valovska
- Service d'Anesthésie Réanimation et Médecine Péri-opératoire, CHU Rennes, Université Rennes, Rennes, France
| | - H Beloeil
- Department of Anesthesiology, Henry Ford Health Systems, Wayne State School of Medicine, Detroit, MI, USA
| | - P Lirk
- Department of Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - G P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - M Van de Velde
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Anaesthesiology, UZLeuven, Leuven, Belgium
| | - J Raeder
- Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway.,Division of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
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20
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Fanelli A, Torrano V, Cozowicz C, Mariano ER, Balzani E. The opioid sparing effect of erector spinae plane block for various surgeries: a meta-analysis of randomized-controlled trials. Minerva Anestesiol 2021; 87:903-914. [PMID: 33982985 DOI: 10.23736/s0375-9393.21.15356-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The erector spinae plane block (ESPB) is a newer fascial plane block which has been broadly applied for postoperative analgesia after various surgeries, but the effectiveness in these populations is not well established. EVIDENCE ACQUISITION A systematic database search was conducted in PubMed, PMC, Embase, and Scopus for randomized controlled trials (RCTs) comparing ESPB with control, placebo, or other blocks. The primary outcome was intravenous opioid consumption in milligram morphine equivalents 24 h after surgery. Standardized mean differences (SMDs) with 95% confidence intervals (CI) were calculated using a randomeffects model. EVIDENCE SYNTHESIS A total of 29 RCTs were included. An analysis was conducted by subgroups differentiated by surgery type, 'no block' vs. ESPB, and other blocks vs. ESPB. ESPB was effective in reducing opioid consumption against no block for breast surgery (SMD -1.13; CI 95%), thoracic surgery (SMD -3.00; CI 95%), and vertebral surgery (SMD -1.78; CI 95%). ESPB was effective against alternative blocks for breast surgery (vs. paravertebral, SMD -1.07; CI 95%) and abdominal surgery (SMD -1.77; CI 95%). ESPB showed moderate effect in thoracic surgery against paravertebral (SMD 0.58; CI 95%) and against no block in abdominal surgery (SMD 0.80; CI 95%). In only one case did ESPB perform worse than another block: vs. PECS block for breast surgery (SMD 1.66; CI 95%). CONCLUSIONS ESPB may be a useful addition to the multimodal analgesic regimen for a variety of surgeries especially when the alternative is no block. Unanswered questions include determining of the mechanism of action, refining of the EPSB technique, and establishing recommended local anesthetic dose and volume.
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Affiliation(s)
- Andrea Fanelli
- Anesthesia and Pain Medicine Unit, Department of Emergency and Urgency, Policlinico S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Vito Torrano
- Anesthesia and Intensive Care Unit 1, Department of Emergency and Urgency, ASST Grande Ospedale Metropolitano Niguarda Hospital, Milan, Italy
| | - Crispiana Cozowicz
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Edward R Mariano
- 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
| | - Eleonora Balzani
- Department of Medicine and Surgery, University of Turin, Turin, Italy -
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21
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Chuckpaiwong B, Harnroongroj T, Sirivanasandha B, Tharmviboonsri T. Local Ketorolac Injection vs Popliteal Sciatic Nerve Blockade as an Adjuvant to a Spinal Block in Hindfoot Arthrodesis. Foot Ankle Int 2021; 42:570-574. [PMID: 33334174 DOI: 10.1177/1071100720972666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Popliteal nerve blocks reduce pain and markedly improve postoperative outcomes during foot and ankle surgery; however, several potential complications may arise from nerve block procedures. The purpose of this study was to investigate local infiltration analgesia with ketorolac as a convenient alternative for pain relief. METHODS A total of 80 patients scheduled for hindfoot arthrodesis were randomly allocated to one of 2 anesthetic groups: a spinal block augmented with either a popliteal nerve block (n = 40) or local ketorolac and Marcaine infiltration (n = 40). Clinical assessment included postoperative visual analog scale (VAS) pain scores at 4, 8, 12, 24, and 48 hours, total morphine consumption, time to incision (time in operating room to incision), operative time, length of hospital stay, and complications. RESULTS Despite similar morphine consumption between groups (P = .28), VAS scores were significantly lower at 24 hours (1.6 ± 2.2 cm vs 2.7 ± 3.0 cm, P = .01) and 48 hours (0.2 ± 0.7 cm vs 1.0 ± 1.5 cm, P < .01) after surgery using local ketorolac injection. Although time from entry into the operating room to incision was also reduced after local ketorolac injection (19.0 ± 5.3 minutes vs 31.4 ± 14.6 minutes, P < .001), the length of operative time (P = .38), hospital stay (P = .43), and number of complications (P = .24) were similar between groups. CONCLUSION Ketorolac local injection provided effective pain control in hindfoot arthrodesis and markedly reduced VAS pain scores up to 48 hours after surgery compared with popliteal nerve block. In addition, ketorolac local injection also reduced time in the operating room compared with popliteal nerve blockade. LEVEL OF EVIDENCE Level 1, randomized controlled trial.
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Affiliation(s)
- Bavornrit Chuckpaiwong
- Department of Orthopaedic Surgery and Rehabilitation, Faculty of Medicine, Siririaj Hospital Mahidol University, Bangkok, Thailand.,College of Sports Science and Technology, Mahidol University, Nakornpathom, Thailand
| | - Thos Harnroongroj
- Department of Orthopaedic Surgery and Rehabilitation, Faculty of Medicine, Siririaj Hospital Mahidol University, Bangkok, Thailand
| | - Busara Sirivanasandha
- Department of Anesthesiology, Faculty of Medicine, Siririaj Hospital Mahidol University, Bangkok, Thailand
| | - Theerawoot Tharmviboonsri
- Department of Orthopaedic Surgery and Rehabilitation, Faculty of Medicine, Siririaj Hospital Mahidol University, Bangkok, Thailand
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22
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Li J, Dai F, Ona Ayala KE, Zhou B, Schonberger RB, Sharma A. Transmuscular Quadratus Lumborum and Lateral Femoral Cutaneous Nerve Block in Total Hip Arthroplasty. Clin J Pain 2021; 37:366-371. [PMID: 33577193 PMCID: PMC8035232 DOI: 10.1097/ajp.0000000000000923] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 01/28/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Adequate pain control after total hip arthroplasty is essential for patient satisfaction and surgical outcome. METHODS A retrospective study with before and after design was performed in 210 elective total hip arthroplasty patients. The control group (N=132) received spinal anesthesia with periarticular injection (PAI) and the treatment group (N=78) received transmuscular quadratus lumborum block and lateral femoral cutaneous nerve block in addition to spinal anesthesia and PAI. The primary outcome was visual analog scale (VAS) pain score on postoperative day (POD) 1, and secondary outcomes included VAS and opioid consumption on each POD, hospitalization cost, length of stay, and discharge acuity. RESULTS The mean VAS and opioid consumption (MME) were significantly lower in the treatment group than that in the control group on POD 1, with VAS difference -1.10 (95% confidence interval, -1.64 to -0.55), false discover rate corrected (P<0.001), and MME difference -26.19 (95% confidence interval, -39.16 to -13.23, P<0.001). A significant difference was also found for both VAS (P=0.007) and opioid consumption (P=0.018) on POD 2 and for opioid consumption on POD 3 (P=0.008). Length of stay (days) in the control group versus the treatment group was 2.50±1.38 versus 1.36±0.95 (P=0.002), and the total cost of hospitalization was over 20% higher in the control group than that in the treatment group (P=0.002). DISCUSSION The addition of transmuscular quadratus lumborum and lateral femoral cutaneous nerve block in total hip arthroplasty provides improved analgesia indicated by lower pain scores and opioid reduction and accelerated recovery with shorter hospitalization and decreased hospitalization cost.
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Affiliation(s)
- Jinlei Li
- Department of Anesthesiology, School of Medicine, Yale University, 333 Cedar Street, P.O. Box 208051, New Haven, CT 06520
| | - Feng Dai
- Yale Center for Analytical Sciences Department of Biostatistics, School of Public Health, Yale University, 300 George Street, Suite 511, New Haven, CT 06511
| | - Kimberly E. Ona Ayala
- Department of Anesthesiology, School of Medicine, Yale University, 333 Cedar Street, P.O. Box 208051, New Haven, CT 06520
| | - Bin Zhou
- Yale Center for Analytical Sciences Department of Biostatistics, School of Public Health, Yale University, 300 George Street, Suite 511, New Haven, CT 06511
| | - Robert B. Schonberger
- Department of Anesthesiology, School of Medicine, Yale University, 333 Cedar Street, P.O. Box 208051, New Haven, CT 06520
| | - Avijit Sharma
- Department of Anesthesiology, School of Medicine, Yale University, 333 Cedar Street, P.O. Box 208051, New Haven, CT 06520
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23
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Aguirre J, Bonvini JM, Rupnik B, Camponovo C, Saporito A, Borgeat A. Inflammation reduces osteoblast cytotoxicity induced by diclofenac: An in vitro study. Eur J Anaesthesiol 2021; 38:S24-S32. [PMID: 33122572 DOI: 10.1097/eja.0000000000001363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Diclofenac and other NSAIDs are routinely used in the postoperative period. Their effect on fracture healing remains unclear and controversial. OBJECTIVE The primary outcome was to assess the potential cytotoxicity of clinically relevant concentrations of diclofenac on human osteoblasts. DESIGN Laboratory in vitro study. SETTING Institute of Physiology, Zurich, Center for Integrative Human Physiology, University of Zurich. MATERIALS Monolayers of human osteoblasts. INTERVENTIONS Exposure of human osteoblast monolayers to several concentrations of diclofenac, for different periods of time, with and without an artificially induced inflammatory process. MAIN OUTCOME MEASURES Cell count, cell viability, cell proliferation and apoptosis. RESULTS A concentration-mediated, time and exposure dependent cytotoxic effect of diclofenac-mediated apoptosis was observed. Stimulated inflammatory conditions seemed to reduce toxic effects. CONCLUSION Cytotoxic effects of diclofenac are exposure, time and concentration dependent. Simulating aspects of inflammatory conditions seems to increase resistance to diclofenac cytotoxicity, especially in the presence of higher concentration and longer exposure time.
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Affiliation(s)
- José Aguirre
- From the Department of Anaesthesiology, Intensive Care and Pain Medicine, Balgrist University Hospital Zurich, Zurich (JA, JMB, BR, AB), Department of Anaesthesiology, Clinica Ars Medica, Gravesano (CC), Department of Anaesthesiology, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland (AS) and Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA (AB)
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24
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Yang R, Liu RH, Xu JN, Xu GH, Jin XB, Xiao R, Mei B. Effects of Different Local Analgesic Techniques on Postoperative Quality of Life and Pain in Patients Undergoing Total Hip Arthroplasty Under General Anesthesia: A Randomized Controlled Trial. J Pain Res 2021; 14:527-536. [PMID: 33658840 PMCID: PMC7917318 DOI: 10.2147/jpr.s289018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 12/30/2020] [Indexed: 12/04/2022] Open
Abstract
Background Both lumbosacral plexus block (LSPB) and local infiltration analgesia (LIA) can provide postoperative analgesia for patients undergoing total hip arthroplasty (THA). The current study aimed to compare the differences between LSPB and LIA on postoperative pain and quality of life (QoL) in THA patients. Methods A total of 117 patients aged 40–80 years, ASA I-III, were prospectively randomized into two groups: a general anesthesia plus LSPB (Group LSPB) and a general anesthesia plus LIA (Group LIA). Pain intensity and opioid consumption were recorded Within 72 hours after surgery. QoL was measured by EQ-5D and EQ-VAS questionnaires, and the incidence of postoperative pain was measured as part of the EQ-5D on day 1, day 3, day 7, and month 1, month 3, and month 6 after surgery. Results EQ-5D scores: Mobility, Self-Care, Usual Activities, Pain/Discomfort, and Anxiety/Depression were higher in Group LSPB versus Group LIA throughout six-month follow-ups (p = 0.039). The pain intensity was lower in Group LSPB than in Group LIA 0–12 h after surgery (2.41 vs 2.79, p = 0.01), but was higher in Group LSPB than in Group LIA 12–24 h (2.59 vs 2.05, p = 0.02) and 24–48 h (2.18 vs 1.73, p = 0.02) after surgery. There were no differences in opioid consumption between the groups during the first 72 postoperative hours. In the first month after surgery, more patients in Group LSPB than in Group LIA had no pain (52 vs 40, p = 0.04). Conclusion Both LSPB and LIA can provide satisfactory postoperative analgesia. The LSPB is better than LIA for long-term QoL in THA patients undergoing general anesthesia. Clinical Trial Registration Number The Chinese Clinical Trial Registry (ChiCTR-INR-17012545).
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Affiliation(s)
- Rui Yang
- Department of Anesthesiology, First Affiliated Hospital, Anhui Medical University, Hefei, Anhui, 230022, People's Republic of China
| | - Rui-Hong Liu
- Department of Anesthesiology, First Affiliated Hospital, Anhui Medical University, Hefei, Anhui, 230022, People's Republic of China
| | - Jia-Nan Xu
- Department of Anesthesiology, First Affiliated Hospital, Anhui Medical University, Hefei, Anhui, 230022, People's Republic of China
| | - Guang-Hong Xu
- Department of Anesthesiology, First Affiliated Hospital, Anhui Medical University, Hefei, Anhui, 230022, People's Republic of China.,Department of Neurology, First Affiliated Hospital, Anhui Medical University, Hefei, Anhui, 230022, People's Republic of China
| | - Xiao-Bin Jin
- Department of Anesthesiology, First Affiliated Hospital, Anhui Medical University, Hefei, Anhui, 230022, People's Republic of China
| | - Rui Xiao
- Department of Anesthesiology, First Affiliated Hospital, Anhui Medical University, Hefei, Anhui, 230022, People's Republic of China
| | - Bin Mei
- Department of Anesthesiology, First Affiliated Hospital, Anhui Medical University, Hefei, Anhui, 230022, People's Republic of China
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25
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El-Boghdadly K, Short AJ, Gandhi R, Chan V. Addition of dexamethasone to local infiltration analgesia in elective total knee arthroplasty: double-blind, randomized control trial. Reg Anesth Pain Med 2020; 46:130-136. [PMID: 33199379 DOI: 10.1136/rapm-2020-102079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/21/2020] [Accepted: 10/24/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Total knee arthroplasty is associated with significant pain, and effective analgesia is beneficial to patient satisfaction and functional outcomes. Studies have demonstrated that dexamethasone may have a facilitatory role on the action of local anesthesia, but this effect, when added to a local infiltration analgesia (LIA) mixture for patients having knee arthroplasty, is underexplored. Our hypothesis was that the addition of dexamethasone to local anesthetic infiltration would improve analgesic outcomes following total knee arthroplasty. METHODS We performed a double-blind, randomized controlled trial of 140 patients undergoing elective, unilateral, total knee arthroplasty. Patients were randomly allocated to receive either 2 mL of saline 0.9% or 2 mL of dexamethasone 4 mg/mL added to a LIA mixture. Our primary outcome was 24 hours of oral morphine equivalent consumption. Our secondary outcomes included short-term and long-term analgesic and functional outcomes and adverse events. RESULTS A total of 72 patients were included in the saline group and 68 were included in the dexamethasone group. We found comparable 24 hours of morphine consumption between saline and dexamethasone groups, with a median of 60 (IQR 40-105 (range 16-230)) mg and 56 (IQR 41-75 (range 0-300)) mg, respectively (p=0.096). Dexamethasone was associated with a statistically significant reduction in total inpatient opioid consumption, incidence of requiring rescue patient-controlled analgesia, length of hospital stay, and postoperative nausea, compared with saline. Patients in the dexamethasone group had a greater range of joint movement and distance walked on postoperative day 1 than the saline group. There were no differences in rest or active pain scores, timed up and go or 3-month outcomes. CONCLUSIONS Dexamethasone 8 mg was associated with no improvements in 24 hours of morphine consumption but was associated with modest improvements in short-term analgesia, short-term function, length of stay and postoperative nausea. There were no long-term benefits in the use of dexamethasone in LIA for patients undergoing total knee arthroplasty. TRIAL REGISTRATION NUMBER NCT02760043.
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Affiliation(s)
- Kariem El-Boghdadly
- Department of Theatres, Anaesthesia and Perioperative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK .,King's College London, London, London, UK
| | - Anthony James Short
- Department of Anaesthetics, Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan, UK
| | - Rajiv Gandhi
- Division of Orthopedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Vincent Chan
- Department of Anesthesia and Pain Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
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26
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Pala AA, Urcun YS, Çiçek ÖF, Şahin S. Can Continuous Local Anesthetic Infusion After Median Sternotomy Reduce Opioid Use? Cureus 2020; 12:e10711. [PMID: 33133875 PMCID: PMC7594669 DOI: 10.7759/cureus.10711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Introduction Effective treatment of postoperative pain due to median sternotomy speeds up hemodynamic healing of patients. For this purpose, opioids with a wide range of side effects are widely used at high doses. The aim of this study is to investigate the effect of continuous local anesthetic (bupivacaine) infusion on opioid use on cardiac surgery patients undergoing median sternotomy. Methods A total of 215 patients undergoing isolated coronary artery bypass grafting surgery were included in the study; and 105 patients who underwent parasternal continuous local anesthetic infusion (0.5% bupivacaine at 4 mL/h, for 48h) were determined as local anesthesia group and other patients were as control group. The primary outcomes evaluated between the groups in the postoperative period were pain scores (VAS: Visual Analogic Score, PHHPS: Prince Henry Hospital Pain Score) and the number of opioids used. Secondary outcomes were mechanical ventilation time, intensive care unit and hospital stay duration, development of atrial fibrillation and atelectasis. Results Postoperative pain was found to be significantly lower in the local anesthesia group compared to the control group (VAS: 3 ± 1.9 vs 6.4 ± 1.8, p < 0.001; PHHPS: 0.9 ± 0.8 vs 1.62 ± 0.82, p < 0.001). As a result of this, opioid drug use was significantly lower in the local anesthesia group compared to the control group (0 (0 - 4) vs 1 (0 - 8), p < 0.001). Mechanical ventilation time, intensive care unit and hospital stay duration, and development of atelectasis were significantly lower in the local anesthesia group. In terms of the development of atrial fibrillation, no significant difference was found between the groups. Conclusion Parasternal continuous local anesthetic infusion reduces postoperative opioid use and speeds up hemodynamic healing by preventing possible side effects of opioids. It is a simple and effective method in the treatment of postoperative pain due to median sternotomy.
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Affiliation(s)
- Arda Aybars Pala
- Cardiovascular Surgery, Adıyaman Training and Research Hospital, Adıyaman, TUR
| | - Yusuf Salim Urcun
- Cardiovascular Surgery, Adıyaman Training and Research Hospital, Adıyaman, TUR
| | - Ömer Faruk Çiçek
- Cardiovascular Surgery, Selçuk University Faculty of Medicine, Konya, TUR
| | - Serpil Şahin
- Cardiovascular Surgery, Canakkale Onsekiz Mart University Faculty of Medicine, Canakkale, TUR
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Liang D, Xue C, Liu W, Wang Y. What is the optimal regimen for intravenous dexamethasone administration in primary total hip arthroplasty?: A protocol of randomized controlled trial. Medicine (Baltimore) 2020; 99:e22070. [PMID: 32899074 PMCID: PMC7478557 DOI: 10.1097/md.0000000000022070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND A number of recent studies have investigated the optimal dosage and timing of dexamethasone in total hip arthroplasty (THA) but have inconsistent findings. Therefore, we designed the randomized controlled research to look for the optimal intravenous dexamethasone dose for the treatment of early postoperative pain after the THA. METHODS The Declaration of Helsinki principles was followed and the Consolidated Standards of Reporting Trials guidelines for randomized controlled trials was adhered in this study. The First Medical Center in People's Liberation Army General Hospital approved the study (2020-089). After written informed consent was obtained, patients aged between 18 and 80 years with Physical Status I to III of American Society of Anesthesiologists, scheduled for primary unilateral THA, were included in this present work. Randomization is the use of a computer-formed list via a secretary, at a ratio of 1:1:1. The major end points were pain scores at 24 hours, 48 hours, and 72 hours after surgery, with visual analog scale (VAS) utilized at rest, and at 45 degrees passive hip flexion. The secondary outcomes involved the total consumption of morphine, opioid-related side effects, hip range of motion, inflammation markers, and the length of hospital stay. RESULTS We assumed that the patients who received 3 doses of dexamethasone intravenously possessed the best postoperative results compared to those who received 1 or 2 doses of the dexamethasone. TRIAL REGISTRATION This study protocol was registered in Research Registry (researchregistry5864).
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Li K, Li H, Luo D, Feng H, Ji C, Yang K, Liu J, Zhang H, Xu H. Efficacy of local infiltration analgesia with ropivacaine for postoperative pain management in cervical laminoplasty: a retrospective study. Sci Rep 2020; 10:4217. [PMID: 32144316 PMCID: PMC7060250 DOI: 10.1038/s41598-020-61229-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 02/19/2020] [Indexed: 11/11/2022] Open
Abstract
Poor postoperative pain control impairs patient recovery and lengthens the duration of hospitalization after various surgeries. Local infiltration analgesia(LIA) has become an effective method for managing postoperative pain. This study aimed to investigate the efficacy of LIA with ropivacaine for postoperative pain control after cervical laminoplasty. In total, 68 patients undergoing cervical laminoplasty were included for retrospective review and divided into ropivacaine and control groups. The visual analogue scale (VAS) score, postoperative analgesic consumption, operative duration, intraoperative blood loss volume, incision length, hospitalization duration and incidence of complications were analyzed. In the ropivacaine group, the VAS score was 3.2 ± 1.4 at 4 hours postoperatively, which was lower than that of the control group(4.0 ± 1.4, P = 0.024). At 8, 12 and 24 hours after surgery, a significant difference was detected in the VAS score between the two groups(P ≤ 0.015). Sufentanil consumption was less in the ropivacaine group than in the control group in the first 4 hours postoperatively (25.6 ± 6.3 µg vs 32.2 ± 6.8 µg, P < 0.001), and similar results were observed in the first 8, 12, 24, 48 and 72 hours postoperatively(P < 0.001). Fewer patients required rescue analgesia in the ropivacaine group(8/33 vs 18/35 at 4–8 hours, P = 0.021; 9/33 vs 21/35 at 8–12 hours, P = 0.007). The hospitalization duration and time to ambulation were shorter in the ropivacaine group(8.5 ± 1.4 vs 9.6 ± 1.6 for postoperative duration, P = 0.002; 2.9 ± 0.7 vs 3.5 ± 0.8 for time to ambulation, P = 0.001). The incidence of nausea and vomiting was lower in the ropivacaine group than in the control group(30.3% vs 54.3%, P = 0.046). In conclusion, LIA with ropivacaine could effectively reduce postoperative pain, and postoperative analgesic consumption, and promote recovery after cervical laminoplasty.
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Affiliation(s)
- Kunpeng Li
- Department of Orthopaedics, Liaocheng People's Hospital, Liaocheng, China
| | - Hao Li
- Department of Orthopaedics, Liaocheng People's Hospital, Liaocheng, China
| | - Dawei Luo
- Department of Orthopaedics, Liaocheng People's Hospital, Liaocheng, China
| | - Hongyong Feng
- Department of Orthopaedics, Liaocheng People's Hospital, Liaocheng, China
| | - Changbin Ji
- Department of Orthopaedics, Liaocheng People's Hospital, Liaocheng, China
| | - Keshi Yang
- Department of Orthopaedics, Liaocheng People's Hospital, Liaocheng, China
| | - Jinlong Liu
- Department of Orthopaedics, Liaocheng People's Hospital, Liaocheng, China
| | - Honglei Zhang
- Department of Orthopaedics, Liaocheng People's Hospital, Liaocheng, China
| | - Hui Xu
- Department of Orthopaedics, Liaocheng People's Hospital, Liaocheng, China.
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El-Boghdadly K, Short AJ, Gandhi R, Chan VWS. Addition of dexamethasone to local infiltration analgesia in elective total hip arthroplasty: a double-blind, randomized control trial. Reg Anesth Pain Med 2019; 44:rapm-2019-100873. [PMID: 31563881 DOI: 10.1136/rapm-2019-100873] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 08/24/2019] [Accepted: 09/04/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND OBJECTIVES Pain following total hip arthroplasty is significant, and effective analgesia is associated with an improvement in functional outcomes. Dexamethasone may facilitate the action of local anesthesia, but its role as an additive to a local infiltration analgesia (LIA) mixture in hip arthroplasty settings has not been investigated. We hypothesized that the addition of dexamethasone to local anesthetic infiltration improves analgesic outcomes following total hip arthroplasty. METHODS We performed a double-blind, randomized control trial of 170 patients undergoing total hip arthroplasty. Patients were randomized to receive LIA mixed with either 2 mL of saline 0.9% or 2 mL of dexamethasone 4 mg/mL. The primary outcome was 24 hours oral morphine consumption. Secondary outcomes included short-term and long-term analgesic and functional outcomes and adverse events. RESULTS 85 patients were included in each arm. 24 hours morphine consumption was similar between saline and dexamethasone groups, with a median (IQR (range)) of 75 (45-105 (0-240)) and 62.5 (37.5-102.5 (0-210)) mg, respectively (p=0.145). However, patients receiving dexamethasone had significantly reduced opioid consumption for their total in-hospital stay, but not at any other time points examined. Functional outcomes were similar between groups. The incidence of postoperative nausea and vomiting was reduced in patients receiving dexamethasone. CONCLUSIONS The addition of 8 mg dexamethasone to LIA did not reduce 24 hours morphine consumption but was associated with limited improvement in short-term analgesic outcomes and a reduction in postoperative nausea and vomiting. Dexamethasone had no effect on functional outcomes or long-term analgesia. TRIAL REGISTRATION NUMBER NCT02760043.
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Affiliation(s)
- Kariem El-Boghdadly
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Anthony James Short
- Department of Anaesthetics, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Rajiv Gandhi
- Division of Orthopedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Liu P, Wu Y, Liang Z, Deng Y, Meng Q. Comparing the efficacy of pain managements after total hip arthroplasty: A network meta-analysis. J Cell Biochem 2019; 120:4342-4354. [PMID: 30302812 DOI: 10.1002/jcb.27720] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 08/29/2018] [Indexed: 11/09/2022]
Abstract
The aim of our current study is to compare efficiency of various interventions implemented for pain management after total hip arthroplasty (THA). PubMed and EMBASE were searched for randomized clinical trials (RCTs) reporting the pain scales for evaluate the efficacy of pain control after THA including at least one pair of direct control groups. Pain scale values and the associated 95% credible interval (CrI) were used to describe efficacy. Surface under the cumulative ranking curve (SUCRA) of each means of pain control was calculated to compare the relative ranking of different interventions. Thirty-five eligible literatures were involved in data analysis. The interventions for postoperative pain management we examined were psoas compartment block (PCB), posterior nerve block (PNB), fascia iliaca block (FIB), periarticular injection (PAI), femoral nerve block (FNB), lumbar plexus block (LPB), spinal anesthesia (SA), epidural analgesia (EPI), intrathecal morphine (IA), intravenous patient-controlled analgesia (IV-PCA), patient-controlled analgesia (PCA), onsteroidal anti-inflammatory drug (NSAID), local infiltration analgaesia (LIA), and reverse LIA (rLIA). In 0 to 6 hours analysis, patients under SA were found to have significantly lower pain score and SA was ranked the best. In 6 to 12 hours analysis, SA was found to be significantly more effective than other interventions and its SUCRA was the highest. No intervention showed a significant effect on reducing pain score for 12 to 24 hours and 24 to 48 hours after THA. SA is the best intervention to reduce THA postoperative pain in the first 24 hours. LPB is a better choice to reduce pain 12 to 48 hours after THA.
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Affiliation(s)
- Pengcheng Liu
- Second Department of Orthopedics, Affiliated Traditional Chinese Medical of Xinjiang Medical University, Urumqi, Xinjiang, China
- Second Department of Orthopedics, Traditional Chinese Medicine Hospital of Xinjiang Uygur Autonomous region, Urumqi, Xinjiang, China
| | - Yingbo Wu
- Third Department of Orthopedics, Affiliated Traditional Chinese Medical of Xinjiang Medical University, Urumqi, Xinjiang, China
- Third Department of Orthopedics, Traditional Chinese Medicine Hospital of Xinjiang Uygur Autonomous region, Urumqi, Xinjiang, China
| | - Zhiquan Liang
- Second Department of Orthopedics, Affiliated Traditional Chinese Medical of Xinjiang Medical University, Urumqi, Xinjiang, China
- Second Department of Orthopedics, Traditional Chinese Medicine Hospital of Xinjiang Uygur Autonomous region, Urumqi, Xinjiang, China
| | - Yingjie Deng
- Second Department of Orthopedics, Affiliated Traditional Chinese Medical of Xinjiang Medical University, Urumqi, Xinjiang, China
- Second Department of Orthopedics, Traditional Chinese Medicine Hospital of Xinjiang Uygur Autonomous region, Urumqi, Xinjiang, China
| | - Qingcai Meng
- Second Department of Orthopedics, Affiliated Traditional Chinese Medical of Xinjiang Medical University, Urumqi, Xinjiang, China
- Second Department of Orthopedics, Traditional Chinese Medicine Hospital of Xinjiang Uygur Autonomous region, Urumqi, Xinjiang, China
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31
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Lee DK, Bang S, Lee S. Anesthetic considerations for surgical treatment of geriatric hip fracture. Anesth Pain Med (Seoul) 2019. [DOI: 10.17085/apm.2019.14.1.8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Dong Kyu Lee
- Department of Anesthesiology and Pain Medicine, Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Seunguk Bang
- Department of Anesthesiology and Pain Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sangseok Lee
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
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Tran DQ, Salinas FV, Benzon HT, Neal JM. Lower extremity regional anesthesia: essentials of our current understanding. Reg Anesth Pain Med 2019; 44:rapm-2018-000019. [PMID: 30635506 DOI: 10.1136/rapm-2018-000019] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/14/2018] [Accepted: 05/23/2018] [Indexed: 12/16/2022]
Abstract
The advent of ultrasound guidance has led to a renewed interest in regional anesthesia of the lower limb. In keeping with the American Society of Regional Anesthesia and Pain Medicine's ongoing commitment to provide intensive evidence-based education, this article presents a complete update of the 2005 comprehensive review on lower extremity peripheral nerve blocks. The current review article strives to (1) summarize the pertinent anatomy of the lumbar and sacral plexuses, (2) discuss the optimal approaches and techniques for lower limb regional anesthesia, (3) present evidence to guide the selection of pharmacological agents and adjuvants, (4) describe potential complications associated with lower extremity nerve blocks, and (5) identify informational gaps pertaining to outcomes, which warrant further investigation.
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Affiliation(s)
- De Q Tran
- Department of Anesthesiology, McGill University, Montreal, Quebec, Canada
| | - Francis V Salinas
- Department of Anesthesiology, US Anesthesia Partners-Washington, Swedish Medical Center, Seattle, Washington, USA
| | - Honorio T Benzon
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Joseph M Neal
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington, USA
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Ueshima H, Otake H. Supra-inguinal fascia iliaca block under ultrasound guidance for perioperative analgesia during bipolar hip arthroplasty in a patient with severe cardiovascular compromise: A case report. Medicine (Baltimore) 2018; 97:e12746. [PMID: 30290689 PMCID: PMC6200485 DOI: 10.1097/md.0000000000012746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
RATIONALE The relief of selective hip pain may be difficult to attain. Therefore, a deep nerve block such as epidural anesthesia or lumbar plexus nerve block is required. However, deep nerve blocks may not be possible in patients with complications, including severe cardiovascular disease. PATIENTS CONCERNS The patient in our report had coronary stents inserted previously and required continuous anticoagulant therapy owing to severe heart failure. DIAGNOSIS Bipolar hip arthroplasty was required in our patient because of a fracture of the neck of femur on the left side. INTERVENTIONS We decided to perform the surgery using a fascia iliaca block (block of the femoral and the lateral femoral cutaneous nerves) by the suprainguinal approach. The fascia iliaca nerve block was performed under ultrasound guidance, using 20 mL of levobupivacaine. OUTCOMES The surgery was performed successfully with adequate sensory block around the hip region. LESSONS Ultrasound-guided fascia iliaca nerve block by the supra-inguinal approach may be an effective anesthetic technique for patients undergoing surgery for fracture of the neck of femur.
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Affiliation(s)
- Hironobu Ueshima
- Department of Anesthesiology, Showa University Hospital, Tokyo, Japan
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34
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Bugada D, Bellini V, Lorini LF, Mariano ER. Update on Selective Regional Analgesia for Hip Surgery Patients. Anesthesiol Clin 2018; 36:403-415. [PMID: 30092937 DOI: 10.1016/j.anclin.2018.04.001] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
In hip surgery, regional anesthesia offers benefits in pain management and recovery. There are a wide range of regional analgesic options; none have shown to be superior. Lumbar plexus block, femoral nerve block, and fascia iliaca block are the most supported by published literature. Other techniques, such as selective obturator and/or lateral femoral cutaneous nerve blocks, represent alternatives. Newer approaches, such as quadratus lumborum block and local infiltration analgesia, require rigorous studies. To realize long-term outcome benefits, postoperative regional analgesia must be tailored to the individual patient and last longer.
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Affiliation(s)
- Dario Bugada
- Emergency and Intensive Care Department, ASST Papa Giovanni XXIII, Piazza OMS, 1, Bergamo 24127, Italy.
| | - Valentina Bellini
- Department of Anesthesia and Pain Therapy, Parma University Hospital, Via Gramsci, 14, Parma 43126, Italy
| | - Luca F Lorini
- Emergency and Intensive Care Department, ASST Papa Giovanni XXIII, Piazza OMS, 1, Bergamo 24127, Italy
| | - Edward R Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 3801 Miranda Avenue, MC 112A, Palo Alto, CA 94304, USA; Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue, MC 112A, Palo Alto, CA 94304, USA
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35
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Dupleichs M, Gao Q, Badran Z, Janvier P, Bouler JM, Gauthier O, Tamimi F, Verron E. Delivery systems of local anesthetics in bone surgery: are they efficient and safe? Drug Discov Today 2018; 23:1897-1903. [PMID: 29958991 DOI: 10.1016/j.drudis.2018.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 06/11/2018] [Accepted: 06/22/2018] [Indexed: 01/25/2023]
Abstract
Management of postoperative pain following bone surgery includes administration of local anesthetics (LAs). Smart delivery systems, including triggered systems, have been designed to provide a continuous release of LA in situ. However, these systems can provide a high level of LA locally. This review will examine the state-of-the-art regarding the LA delivery systems optimized for management of postoperative pain in bone surgery and will discuss the potential adverse effects of LAs on the overall pathways of bone healing, including the inflammation response phase, hemostasis phase, tissue repair phase and remodeling phase. There is a clinical need to document these effects and the potential impacts on the clinical outcome of the patient.
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Affiliation(s)
- Manon Dupleichs
- CEISAM, CNRS UMR 6230, University of Nantes, Nantes, France; RMeS-lab, INSERM UMR 1229, University of Nantes, Nantes, France
| | - Qiman Gao
- Faculty of Dentistry, McGill University, Montreal, Canada
| | - Zahi Badran
- RMeS-lab, INSERM UMR 1229, University of Nantes, Nantes, France; Faculty of Dentistry, McGill University, Montreal, Canada
| | - Pascal Janvier
- CEISAM, CNRS UMR 6230, University of Nantes, Nantes, France
| | | | - Olivier Gauthier
- RMeS-lab, INSERM UMR 1229, University of Nantes, Nantes, France; ONIRIS, Nantes Atlantic College of Veterinary Medicine, Food Science and Engineering, France
| | - Faleh Tamimi
- Faculty of Dentistry, McGill University, Montreal, Canada
| | - Elise Verron
- CEISAM, CNRS UMR 6230, University of Nantes, Nantes, France; Faculty of Pharmaceutical Sciences, University of Nantes, Nantes, France.
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Guay J, Johnson RL, Kopp S. Nerve blocks or no nerve blocks for pain control after elective hip replacement (arthroplasty) surgery in adults. Cochrane Database Syst Rev 2017; 10:CD011608. [PMID: 29087547 PMCID: PMC6485776 DOI: 10.1002/14651858.cd011608.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND It is estimated that over 300,000 total hip replacements are performed each year in the USA. For European countries, the number of hip replacement procedures per 100,000 people performed in 2007 varied from less than 50 to over 250. To facilitate postoperative rehabilitation, pain must be adequately treated. Peripheral nerve blocks and neuraxial blocks have been proposed to replace or supplement systemic analgesia. OBJECTIVES We aimed to compare the relative effects (benefits and harms) of the different nerve blocks that may be used to relieve pain after elective hip replacement in adults. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 12, 2016), MEDLINE (Ovid SP) (1946 to December Week 49, 2016), Embase (Ovid SP) (1980 to December week 49, 2016), CINAHL (EBSCO host) (1982 to 6 December 2016), ISI Web of Science (1973 to 6 December 2016), Scopus (from inception to December 2016), trials registers, and relevant web sites. SELECTION CRITERIA We included all randomized controlled trials (RCTs) performed in adults undergoing elective primary hip replacement and comparing peripheral nerve blocks to any other pain treatment modality. We applied no language or publication status restrictions. DATA COLLECTION AND ANALYSIS Data were extracted independently by two review authors. We contacted study authors. MAIN RESULTS We included 51 RCTs with 2793 participants; of these 45 RCTs (2491 participants: peripheral nerve block = 1288; comparators = 1203) were included in meta-analyses. There are 11 ongoing studies and three awaiting classification.Compared to systemic analgesia alone, peripheral nerve blocks reduced: pain at rest on arrival in the postoperative care unit (SMD -1.12, 95% CI -1.67 to -0.56; 9 trials, 429 participants; equivalent to 3.2 on 0 to 10 scale; moderate-quality evidence); risk of acute confusional status: risk ratio (RR) 0.10 95% CI 0.02 to 0.54; 1 trial, 225 participants; number needed to treat for additional benefit (NNTB) 12, 95% CI 11 to 22; very low-quality evidence); pruritus (RR 0.16, 95% CI 0.04 to 0.70; 2 trials, 259 participants for continuous peripheral nerve blocks; NNTB 4 (95% CI 4 to 8); very low-quality evidence); hospital length of stay (SMD -0.75, 95% CI -1.02 to -0.48; very low-quality evidence; 2 trials, 249 participants; equivalent to 0.75 day). Participant satisfaction increased (SMD 0.67, 95% CI 0.45 to 0.89; low-quality evidence; 5 trials, 363 participants; equivalent to 2.4 on 0 to 10 scale). We did not find a difference for the number of participants walking on postoperative day one (very low-quality evidence). Two nerve block-related complications were reported: one local haematoma and one delayed persistent paresis.Compared to neuraxial blocks, peripheral nerve blocks reduced the risk of pruritus (RR 0.33, 95% CI 0.19 to 0.58; 6 trials, 299 participants; moderate-quality evidence; NNTB 6 (95% CI 5 to 9). We did not find a difference for pain at rest on arrival in the postoperative care unit (moderate-quality evidence); number of nerve block-related complications (low-quality evidence); acute confusional status (very low-quality evidence); hospital length of stay (low quality-evidence); time to first walk (low-quality evidence); or participant satisfaction (high-quality evidence).We found that peripheral nerve blocks provide better pain control compared to systemic analgesia with no major differences between peripheral nerve blocks and neuraxial blocks. We also found that peripheral nerve blocks may be associated with reduced risk of postoperative acute confusional state and a modest reduction in hospital length of stay that could be meaningful in terms of cost reduction considering the increasing numbers of procedures performed annually. AUTHORS' CONCLUSIONS Compared to systemic analgesia alone, there is moderate-quality evidence that peripheral nerve blocks reduce postoperative pain, low-quality evidence that patient satisfaction is increased and very low-quality evidence for reductions in acute confusional status, pruritus and hospital length of stay .We found moderate-quality evidence that peripheral nerve blocks reduce pruritus compared with neuraxial blocks.The 11 ongoing studies, once completed, and the three studies awaiting classification may alter the conclusions of the review once assessed.
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Affiliation(s)
- Joanne Guay
- University of SherbrookeDepartment of Anesthesiology, Faculty of MedicineSherbrookeQuebecCanada
| | - Rebecca L Johnson
- Mayo Clinic College of MedicineDepartment of Anesthesiology and Perioperative Medicine200 First Street SWRochesterMNUSA55905
| | - Sandra Kopp
- Mayo Clinic College of MedicineDepartment of Anesthesiology and Perioperative Medicine200 First Street SWRochesterMNUSA55905
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Ræder J. Local anaesthesia methods for analgesia after total hip replacement: Problems of anatomy, methodology and interpretation? Scand J Pain 2017; 16:221-222. [PMID: 28850407 DOI: 10.1016/j.sjpain.2017.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Johan Ræder
- University of Oslo, Faculty of Medicine, Oslo, Norway; Oslo University Hospital, Section for Emergency Medicine, Oslo, Norway; Department of Anaesthesiology, Oslo, Norway.
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