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Özbaş N, Ersoy E, Korkmaz M, Olçar HA. Effect of Transcutaneous Electrical Nerve Stimulation on Patients with Total Knee Replacement: A Randomized Controlled Trial. Pain Manag Nurs 2024:S1524-9042(24)00215-7. [PMID: 39153958 DOI: 10.1016/j.pmn.2024.07.003] [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: 08/19/2023] [Revised: 07/02/2024] [Accepted: 07/10/2024] [Indexed: 08/19/2024]
Abstract
PURPOSE The aim of this study was to determine the effect of transcutaneous electrical nerve stimulation (TENS) on pain, functionality, quality of life, and analgesic consumption in patients undergoing TKR. DESIGN A single center, randomized controlled trial. METHODS A total of 52 participants were randomly assigned to the intervention (n = 26) and control (n = 26) groups. The intervention group was exposed to conventional TENS. Data were collected with a Patient Identification Form, the Visual Analogue Scale (VAS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Quality of Life Scale (SF-36), and the Analgesic Tracking Form. RESULTS VAS and WOMAC scores significantly decreased in the intervention group, over time, while they increased in the control group. SF-36 scores significantly increased in the intervention group over time. It was determined that analgesic consumption was significantly lower in the intervention group than in the control group. CONCLUSIONS TENS significantly reduced pain and increased functionality and quality of life. Our findings suggest that TENS may be an effective adjunctive analgesic therapy in patients receiving TKR; however, more testing is needed in larger and more heterogeneous populations. CLINICAL IMPLICATIONS Nurses can provide effective postoperative pain control in patients undergoing TKR, increase functionality, accelerate the healing process, and improve their quality of life by using TENS, a non-pharmacological treatment method, in the perioperative period.
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Affiliation(s)
- Nilgün Özbaş
- Akdağmadeni Health College Nursing Department, Surgical Diseases Nursing, Yozgat Bozok University, Yozgat, Turkey.
| | - Emre Ersoy
- Sarıkaya School of Physiotherapy and Rehabilitation, Yozgat Bozok University, Yozgat, Turkey
| | - Murat Korkmaz
- Faculty of Medicine, Department of Orthopedics and Traumatology, Yozgat Bozok University, Yozgat, Turkey
| | - Hacı Ali Olçar
- Faculty of Medicine, Department of Orthopedics and Traumatology, Yozgat Bozok University, Yozgat, Turkey
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Hussain N, Brull R, Gilron I, Weaver TE, Shahzad H, D'Souza RS, Abdel-Rasoul M, Clarke H, McCartney CJL, Abdallah FW. Association of peri-operative prescription of non-steroidal anti-inflammatory drugs with continued prescription of opioids after total knee arthroplasty: a retrospective claims-based cohort study. Anaesthesia 2024; 79:725-734. [PMID: 38385772 DOI: 10.1111/anae.16259] [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] [Accepted: 01/06/2024] [Indexed: 02/23/2024]
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the mainstays of multimodal pain management. While effective for acute pain control, recent pre-clinical evidence has raised concerns regarding an association between NSAIDs and chronic pain and potential opioid use. Our objective was to explore the association between peri-operative use of prescription NSAIDs and the need for continued opioid prescriptions lasting 90-180 days in previously opioid-naïve patients undergoing total knee arthroplasty. A database of health claims in the USA was used to identify all opioid-naïve adult patients who underwent primary knee arthroplasty between January 2010 and October 2021. We evaluated the magnitude of association between peri-operative prescription NSAID claims and claims for opioids at 90 days postoperatively using multivariable logistic regression models. Secondary outcomes included: the magnitude of association between peri-operative NSAID prescription and claims for opioids at 180 days postoperatively; and identifying other potential factors associated with opioid claims at 90 days postoperatively. After risk adjustment using multivariable logistic regression models in the 789,736-patient cohort, the adjusted odds ratio (95%CI) for a continuous claim of opioids at 90 and 180 days postoperatively among patients with a peri-operative NSAID prescription within 30 days was 1.32 (1.30-1.35), p < 0.001; and 1.12 (1.10-1.15), p < 0.001, respectively. This estimate of effect remained robust at 90 days after accounting for known potential confounders, including pre-existing knee pain and acute postoperative pain severity. Similar analysis of other pain medications (e.g. paracetamol) did not detect such an association. This population-based cohort study suggests that peri-operative prescription NSAID use may be associated with continued opioid prescription claims at 90 and 180 days after knee arthroplasty, even after adjusting for other observed covariates for continuous opioid claims. These novel findings can inform clinical decision-making for post-surgical pain management, risk-benefit discussions with patients and future research.
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Affiliation(s)
- N Hussain
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - R Brull
- Department of Anesthesiology and Pain Management, Women's College Hospital and Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - I Gilron
- Departments of Anesthesia and Perioperative Medicine and Biomedical and Molecular Science, Centre for Neuroscience Studies, School of Policy Studies, Queen's University, Kingston, ON, Canada
| | - T E Weaver
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - H Shahzad
- Department of Orthopedics, UC Davis Health, Sacramento, CA, USA
| | - R S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - M Abdel-Rasoul
- Department of Biomedical Informatics, College of Medicine, Center for Biostatistics, The Ohio State University, Columbus, OH, USA
| | - H Clarke
- Department of Anesthesia and Pain Management, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - C J L McCartney
- Department of Anesthesiology and Pain Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - F W Abdallah
- Department of Anesthesiology and Pain Medicine and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
- Department of Anesthesia, and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
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Hughey S, Cole J, Drew B, Brust A, Stedjelarsen E. Regional anesthesia in resource-limited and disaster environments: a daring discourse. Reg Anesth Pain Med 2024:rapm-2024-105680. [PMID: 38942425 DOI: 10.1136/rapm-2024-105680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 06/12/2024] [Indexed: 06/30/2024]
Abstract
Regional anesthesia (RA) is commonly used in perioperative settings of developed and well-resourced environments. RA has significant potential benefits when used in resource-limited environments, including disaster, mass casualty, and wartime environments. RA offers benefits over general anesthesia and opioid-based analgesia, including decreased risk of complications, decreased reliance on mechanical ventilation, improved cost efficiency, and others. The decreasing cost of ultrasound matched with its smaller size and portability increases the availability of ultrasound in these environments, making ultrasound-guided RA more feasible. This daring discourse discusses some historical examples of RA in ultralow resource environments, both man-made disasters and natural disasters. Future investigations should increase the usefulness and availability of RA in resource-limited environments.
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Affiliation(s)
- Scott Hughey
- Anesthesiology and Pain Medicine, US Naval Hospital Okinawa, Okinawa, Japan
- Naval Biotechnology Group, Portsmouth, Virginia, USA
| | - Jacob Cole
- Anesthesiology and Pain Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
- Naval Biotechnology Group, Portsmouth, Virginia, USA
| | - Benjamin Drew
- Naval Medical Center San Diego, San Diego, California, USA
- Naval Biotechnology Group, Portsmouth, Virginia, USA
| | - Adam Brust
- Anesthesiology, US Naval Hospital Pensacola, Pensacola, Florida, USA
- Naval Biotechnology Group, Portsmouth, Virginia, USA
| | - Eric Stedjelarsen
- Anesthesiology and Pain Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
- Naval Biotechnology Group, Portsmouth, Virginia, USA
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Sowa H, Patzkowski J, Ismawan J, Velosky AG, Highland KB. Racialized Inequities in Knee Arthroplasty Receipt After Osteoarthritis Diagnosis in the US Military Health System. Arthritis Care Res (Hoboken) 2024; 76:664-672. [PMID: 38185854 DOI: 10.1002/acr.25290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 12/11/2023] [Accepted: 12/28/2023] [Indexed: 01/09/2024]
Abstract
OBJECTIVE The goal was to evaluate institutional inequities in the US Military Health System in knee arthroplasty receipt within three years of knee osteoarthritis diagnosis when accounting for other treatments received (eg, physical therapy, medications). METHODS In this retrospective observational cohort study, medical record data of patients (n = 29,734) who received a primary osteoarthritis diagnosis in the US Military Health System between January 2016 and January 2020 were analyzed. Data included receipt of physical therapy one year before diagnosis and up to three years after diagnosis, prediagnosis opioid and nonopioid prescription receipt, health-related factors associated with levels of racism, and the primary outcome, knee arthroplasty receipt within three years after diagnosis. RESULTS In a generalized additive model with time-varying covariates, Asian and Pacific Islander (incidence rate ratio [IRR] 0.58, 95% confidence interval [CI] 0.45-0.74), Black (IRR 0.52, 95%CI 0.46-0.59), and Latine (IRR 0.66, 95%CI 0.52-0.85) patients experienced racialized inequities in knee arthroplasty receipt, relative to white patients (all P < 0.001). CONCLUSIONS In the present sample, Asian and Pacific Islander, Black, and Latine patients were significantly less likely to receive a knee arthroplasty, relative to white patients. Taken together, system-level resources are needed to identify and address mechanisms underlying institutional inequities in knee arthroplasty receipt, such as factors related to systemic and structural, institutional, and personally mediated racism.
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Affiliation(s)
| | - Jeanne Patzkowski
- Brooke Army Medical Center, San Antonio, Texas, and Uniformed Services University, Bethesda, Maryland
| | - Johanes Ismawan
- Naval Medical Center, San Diego, California, and Uniformed Services University, Bethesda, Maryland
| | - Alexander G Velosky
- Uniformed Services University and Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
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Macheras GA, Tzefronis D, Argyrou C, Nikolakopoulou E, Gálvez Miravete A, Karachalios TS. Pain management after total hip arthroplasty: comparative study of analgesic efficacy and tolerability between oral tramadol/dexketoprofen and injectable paracetamol + tramadol. Hip Int 2024; 34:304-310. [PMID: 38204364 DOI: 10.1177/11207000231219797] [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] [Indexed: 01/12/2024]
Abstract
BACKGROUND Multimodal analgesia for total hip arthroplasty (THA) is increasingly employed to reduce early postoperative pain and promote fast patient discharge. The aim of this study was to compare the efficacy and tolerability of tramadol/dexketoprofen (TRAM/DKP, Group A) versus paracetamol + tramadol (PARA+TRAM, Group B) in patients undergoing THA using minimally invasive direct anterior approach (DAA). METHODS A single-centre, randomised, single-blind, parallel, interventional study conducted in 323 patients undergoing primary THA with DAA was performed. Group A consisted of 188 patients and Group B of 135. The primary endpoints were the change from baseline (measured 2 hours postoperatively) in pain intensity (PI) during the treatment period (48 hours), assessed by visual analogue scale (VAS) at pre-specified postoperative time-points (2, 8, 24, 48 hours) and the total rescue medication (RM) use during the first 24 hours postoperatively. RESULTS As early as 2 hours after baseline, Group A showed a greater PI reduction from baseline compared to Group B (-26.24% vs. -6.87%; p < 0.001). A lower mean PI (VAS) score was consistently found over the entire observation period following treatment with TRAM/DKP than with PARA+TRAM as well as more than 2-fold higher proportion of responders at the end of treatment period. More patients in Group B required RM in comparison to those in Group A (15.6% vs. 3.7%, p < 0.001). Both treatments were well tolerated. CONCLUSIONS After THA, oral TRAM/DKP provides faster and greater pain relief when compared to intravenous PARA+TRAM with limited consumption of RM and favourable tolerability profile. Our study expands the use of TRAM/DKP in the setting of major orthopaedic surgeries. CLINICAL TRIAL REGISTRATION clinicaltrials.gov (NCT04178109).
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MESH Headings
- Humans
- Pain, Postoperative/drug therapy
- Pain, Postoperative/diagnosis
- Arthroplasty, Replacement, Hip
- Male
- Female
- Tramadol/administration & dosage
- Tramadol/therapeutic use
- Acetaminophen/administration & dosage
- Acetaminophen/therapeutic use
- Middle Aged
- Ketoprofen/administration & dosage
- Ketoprofen/analogs & derivatives
- Ketoprofen/therapeutic use
- Single-Blind Method
- Aged
- Administration, Oral
- Pain Measurement
- Tromethamine/administration & dosage
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/therapeutic use
- Treatment Outcome
- Anti-Inflammatory Agents, Non-Steroidal/administration & dosage
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Drug Therapy, Combination
- Analgesics, Non-Narcotic/administration & dosage
- Analgesics, Non-Narcotic/therapeutic use
- Adult
- Pain Management/methods
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Affiliation(s)
- George A Macheras
- 7th Department of Orthopaedic Surgery, Henry Dunant Hospital Centre, Athens, Attica, Greece
| | - Dimitrios Tzefronis
- 7th Department of Orthopaedic Surgery, Henry Dunant Hospital Centre, Athens, Attica, Greece
| | - Chrysoula Argyrou
- 4th Department of Trauma and Orthopaedics, KAT Hospital, Athens, Attica, Greece
| | - Elena Nikolakopoulou
- 7th Department of Orthopaedic Surgery, Henry Dunant Hospital Centre, Athens, Attica, Greece
| | | | - Thefilos S Karachalios
- Department of Orthopaedic Surgery and Musculoskeletal Trauma, University General Hospital of Larissa, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Thessalia Sterea Ellada, Greece
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Nag DS, Swain A, Sahu S, Sahoo A, Wadhwa G. Multidisciplinary approach toward enhanced recovery after surgery for total knee arthroplasty improves outcomes. World J Clin Cases 2024; 12:1549-1554. [PMID: 38576736 PMCID: PMC10989428 DOI: 10.12998/wjcc.v12.i9.1549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/26/2024] [Accepted: 02/28/2024] [Indexed: 03/25/2024] Open
Abstract
Knee osteoarthritis is a degenerative disorder of the knee, which leads to joint pain, stiffness, and inactivity and significantly affects the quality of life. With an increased prevalence of obesity and greater life expectancies, total knee arthroplasty (TKA) is now one of the major arthroplasty surgeries performed for knee osteoarthritis. When enhanced recovery after surgery (ERAS) was introduced in TKA, clinical outcomes were enhanced and the economic burden on the healthcare system was reduced. ERAS is an evidence-based scientific protocol aimed at ameliorating the surgical stress response. ERAS aims to enhance the recovery phase, which encompasses multidisciplinary strategies at every step of perioperative care, including the rehabilitation phase. Implementation of ERAS in TKA aids in reducing the length of hospital stay, improving pain management, reducing perioperative complications, and enhancing patient satisfaction. Multidisciplinary collaboration, integrating the expertise of anesthesiologists, orthopedic surgeons, nursing personnel, and other healthcare professionals, is the cornerstone of ERAS in patients undergoing TKA.
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Affiliation(s)
- Deb Sanjay Nag
- Department of Anaesthesiology, Tata Main Hospital, Jamshedpur 831001, India
| | - Amlan Swain
- Department of Anaesthesiology, Tata Main Hospital, Jamshedpur 831001, India
| | - Seelora Sahu
- Department of Anaesthesiology, Tata Main Hospital, Jamshedpur 831001, India
| | - Ayaskant Sahoo
- Department of Anaesthesiology, Manipal Tata Medical College, Jamshedpur 831001, India
| | - Gunjan Wadhwa
- Department of Anaesthesiology, Tata Main Hospital, Jamshedpur 831001, India
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Eshag MME, Hasan LOM, Elshenawy S, Ahmed MS, Emad Mostafa AEM, Abdelghafar YA, Althawadi YJ, Ibraheem NM, Badr H, AbdelQadir YH. Fascia iliaca compartment block for postoperative pain after total hip arthroplasty: a systematic review and meta-analysis of randomized controlled trials. BMC Anesthesiol 2024; 24:95. [PMID: 38459449 PMCID: PMC10924383 DOI: 10.1186/s12871-024-02476-y] [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: 10/13/2023] [Accepted: 02/27/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Fascia iliaca compartment block (FICB) is one of the regional nerve blocks used to reduce pain after total hip arthroplasty (THA). We aim to assess the efficacy of FICB in reducing post-operative pain and opioid consumption. METHODS We searched PubMed, Web of Science, Cochrane Library, Embase, and Scopus on February 19, 2023, and we updated our search in august 2023 using relevant search strategy. Studies were extensively screened for eligibility by title and abstract screening, followed by full-text screening. We extracted the data from the included studies, and then pooled the data as mean difference (MD) or odds ratio (OR) with a 95% confidence interval (CI), using Review Manager Software (ver. 3.5). RESULTS FIBC significantly reduced analgesic consumption at 24 h (MD = -8.75, 95% CI [-9.62, -7.88] P < 0.00001), and at 48 h post-operatively. (MD = -15.51, 95% CI [-26.45, -4.57], P = 0.005), with a significant sensory block of the femoral nerve (P = 0.0004), obturator nerve (P = 0.0009), and lateral femoral cutaneous nerve (P = 0.002). However, FICB was not associated with a significant pain relief at 6, 24, and 48 h postoperatively, except at 12 h where it significantly reduced pain intensity (MD = -0.49, 95% CI [-0.85, -0.12], P = 0.008). FICB was also not effective in reducing post-operative nausea and vomiting (MD = 0.55, 95% CI [0.21, 1.45], P = 0.23), and was associated with high rates of quadriceps muscle weakness (OR = 9.09, % CI [3.70, 22.30], P = < 0.00001). CONCLUSIONS FICB significantly reduces the total analgesic consumption up to 48 h; however, it is not effective in reducing post-operative pain, nausea and vomiting and it induced postoperative muscle weakness.
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Affiliation(s)
| | | | - Salem Elshenawy
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | | | | | | | | | | | - Helmy Badr
- Faculty of Medicine, Tanta University, Tanta, Egypt
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Alturki AA, Aljaafri ZA, Alshabraqi H, Hassan I, Alturki A, Alhandi AA. Regional Anesthesia for High-Risk Patients Undergoing Total Knee Arthroplasty: A Case Report. Cureus 2024; 16:e55269. [PMID: 38558733 PMCID: PMC10981540 DOI: 10.7759/cureus.55269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/29/2024] [Indexed: 04/04/2024] Open
Abstract
Total knee arthroplasty (TKA) is a commonly performed surgery for individuals experiencing advanced knee osteoarthritis. Patients undergoing TKA can present with a variety of comorbidities, ranging from the absence of chronic illnesses to the presence of multiple health conditions. The complexity of these comorbidities can pose challenges in carrying out the desired procedure due to the elevated risk profile; this limits the anesthesia modalities that the physician can utilize. Careful consideration of patients' overall health status and personalized anesthesia approaches are crucial to ensure optimal outcomes in this diverse patient population. This case involves an eighty-year-old male with a history of multiple comorbidities who underwent a left TKA. The patient presented a high-risk profile during evaluation, classified as American Society of Anesthesiology (ASA) class IV, which made general and neuraxial anesthesia unfavorable due to high risks. Regional anesthesia was utilized as the sole modality of anesthesia and was successful. This demonstrates that regional anesthesia is a viable option when attending to patients with high risks associated with other anesthesia modalities.
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Affiliation(s)
- Abdullah A Alturki
- Department of Orthopedics, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, SAU
| | - Ziad A Aljaafri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Halah Alshabraqi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Ibrahim Hassan
- Department of Anesthesia, Dr. Sulaiman Al-Habib Hospital, Riyadh, SAU
| | - Ahmad Alturki
- College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
| | - Ali A Alhandi
- Department of Orthopedics, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, SAU
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Hao C, Qian H, Li H, Zhu P, Zhang X, Zhao Z, Luan H. Effect of ultrasound-guided femoral nerve block with dexmedetomidine and ropivacaine on postoperative analgesia in patients undergoing total knee arthroplasty: a randomized controlled trial. Ann Med Surg (Lond) 2023; 85:5977-5982. [PMID: 38098568 PMCID: PMC10718317 DOI: 10.1097/ms9.0000000000001427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 10/11/2023] [Indexed: 12/17/2023] Open
Abstract
Background Dexmedetomidine, a potent and highly selective α2-adrenoreceptor agonist, has become a popular adjuvant to local anesthetics. This study was designed to investigate the effect of dexmedetomidine with ropivacaine for femoral nerve block on postoperative analgesia after total knee arthroplasty. Methods Forty-six patients after total knee arthroplasty received ultrasound-guided femoral nerve block with either 0.3% ropivacaine alone (group R) or 0.3% ropivacaine with 0.5 μg/kg dexmedetomidine (group RD). Total 24-h sufentanil consumption, visual analogue scale (VAS) pain scores, frequency of patient-controlled analgesia (PCA) pressed, Ramsay sedation score, the incidence of bradycardia and hypotension, and incidence of postoperative nausea and vomiting (PONV) were recorded. Results Compared to group R, the total 24-h sufentanil consumption was significantly reduced (110.76 ± 11.56 vs. 99.09 ± 13.31; P<0.05), the VAS scores were lower at 10 and 12 h postoperatively [3(2-3) vs. 2(1-2) and 3(2-3) vs. 2(1-3), respectively; P<0.05], the frequency of PCA pressed was lower at 8-12 and 12-16-h time intervals [(5(3-6) vs. 2(1-3) and 4(3-4) vs. 2(1-3), respectively; P<0.05]. However, there were no differences in Ramsay's sedation score and the incidence of PONV. Also, no patient experienced bradycardia and hypotension. Conclusions 0.5 μg/kg dexmedetomidine with 0.3% ropivacaine for femoral nerve block significantly decreased the total 24-h sufentanil consumption, prolonged and enhanced the analgesic efficacy of ropivacaine, without clinically relevant cardiovascular depression or over-sedation in patients undergoing total knee arthroplasty.
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Affiliation(s)
- Conghui Hao
- Department of Anesthesiology, Jinzhou Medical University, Jinzhou
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, The First People’s Hospital of Lianyungang, Lianyungang
| | - Haitao Qian
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, People’s Republic of China
| | - Han Li
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, The First People’s Hospital of Lianyungang, Lianyungang
| | - Pin Zhu
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, The First People’s Hospital of Lianyungang, Lianyungang
| | - Xiaobao Zhang
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, The First People’s Hospital of Lianyungang, Lianyungang
| | - Zhibin Zhao
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, The First People’s Hospital of Lianyungang, Lianyungang
| | - Hengfei Luan
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, The First People’s Hospital of Lianyungang, Lianyungang
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10
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Yun HJ, Kim JB, Chung HS. Predictive Ability of Perfusion Index for Determining the Success of Adductor Canal Nerve Block for Postoperative Analgesia in Patients Undergoing Unilateral Total Knee Arthroplasty. Life (Basel) 2023; 13:1865. [PMID: 37763269 PMCID: PMC10532524 DOI: 10.3390/life13091865] [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: 08/06/2023] [Revised: 08/30/2023] [Accepted: 09/02/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND The perfusion index (PI) is an objective method used to determine a successful nerve block. This study aimed to investigate the prognostic ability of the PI for a successful adductor canal nerve block (ACB) and suggest the optimal PI cut-off value for predicting a block. METHODS This study was a prospective observational study and enrolled a total of 39 patients. The patients were dichotomized into successful and inappropriate ACB groups according to the results of the sensation tests. The PI value, Pleth variability index (PVi) value, and heart rate were recorded one minute before the block, at the time of the block, and one to 30 min after the block at one-minute intervals. Delta (dPI), which was defined as the difference in PI value from the baseline (the value one minute before the block), was the primary outcome. The area under the receiver operating characteristic curve (AUROC) was calculated to determine the dPI prognostic accuracy and optimal cut-off value. RESULTS Successful ACB was achieved in 33 patients, while ACB was inappropriate in six patients. The dPI showed significant differences between the two groups under the time interval measured (p = 0.001). The dPI at 5 and 20 min showed good prognostic ability for a successful block, with optimal cut-off values of 0.33 (AUROC: 0.725, 95% CI 0.499-0.951) and 0.64 (AUROC: 0.813, 95% CI 0.599-1.000), respectively. CONCLUSIONS The dPI is an effective predictor of successful ACB. The suggested dPI cut-off values at 5 and 20 min were below 0.33 and 0.64, respectively.
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Affiliation(s)
| | | | - Hyun Sik Chung
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 03312, Republic of Korea
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11
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Baratta JL, Deiling B, Hassan YR, Schwenk ES. Total joint replacement in ambulatory surgery. Best Pract Res Clin Anaesthesiol 2023; 37:269-284. [PMID: 37929822 DOI: 10.1016/j.bpa.2023.03.005] [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: 11/14/2022] [Revised: 03/08/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023]
Abstract
Total joint arthroplasty is one of the most commonly performed surgical procedures in the United States, and projected numbers are expected to double in the next ten years. From 2018 to 2020, total hip and knee arthroplasty were removed from the United States' Center for Medicare and Medicaid Services "inpatient-only" list, accelerating this migration to the ambulatory setting. Appropriate patient selection, including age, body mass index, comorbidities, and adequate social support, is critical for successful ambulatory total joint arthroplasty. General anesthesia and neuraxial anesthesia are both safe and effective anesthetic choices, and recent studies in this population have found no difference in outcomes. Multimodal analgesia, including acetaminophen, nonsteroidal anti-inflammatory drugs, local infiltration analgesia, and peripheral nerve blocks, is the foundation for adequate pain control. Common reasons for "failure to launch" include postoperative urinary retention, postoperative nausea and vomiting, inadequate analgesia, and hypotension.
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Affiliation(s)
- Jaime L Baratta
- Department of Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Gibbon Building, Suite 8290, Philadelphia, PA 19107, USA.
| | - Brittany Deiling
- Department of Anesthesiology, University of Virginia Health System, 1215 Lee Street, Charlottesville, VA 22908, USA.
| | - Yasser R Hassan
- Department of Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Gibbon Building, Suite 8290, Philadelphia, PA 19107, USA.
| | - Eric S Schwenk
- Department of Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Gibbon Building, Suite 8290, Philadelphia, PA 19107, USA.
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Osman BM, Tieu TG, Caceres YG, Hernandez VH. Current Trends and Future Directions for Outpatient Total Joint Arthroplasty: A Review of the Anesthesia Choices and Analgesic Options. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202309000-00001. [PMID: 37669101 PMCID: PMC10481314 DOI: 10.5435/jaaosglobal-d-22-00259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 07/11/2023] [Indexed: 09/06/2023]
Abstract
The aging population and the obesity epidemic have led to an increased rate of joint arthroplasty procedures, specifically total knee arthroplasty and total hip arthroplasty. These surgeries are associated with increased hospital length of stay and, consequently, higher costs. Despite the benefits of outpatient surgery, only a small percentage of total joint arthroplasties (TJAs) are done in this manner. We reviewed the most up-to-date trends for outpatient TJA and discussed essential factors for a successful outpatient program, including the proper patient selection process and best available anesthetic and analgesic options, along with their risks and benefits. Risk stratification tools, such as the Outpatient Arthroplasty Risk Assessment, are helpful for predicting outcomes regarding outpatient TJA, and neuraxial anesthesia should be considered to minimize complications and facilitate early discharge. A multimodal analgesia regimen could be effective for pain management in outpatient TJA, and the currently recommended peripheral nerve blocks for total hip arthroplasty and total knee arthroplasty are the fascia iliaca compartment block and adductor canal block, respectively. However, blocks should be carefully considered for outpatient procedures. Enhanced recovery after surgery (ERAS) protocols help to guide perioperative care teams and allow for improved patient recovery, decreased length of stay, and increased patient satisfaction.
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Affiliation(s)
- Brian M. Osman
- From the Perioperative Medicine and Pain Management, University of Miami Health System, University of Miami Miller School of Medicine, Miami, FL (Dr. Osman, Dr. Caceres, and Dr. Hernandez); Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL (Dr. Tieu)
| | - Tuan G. Tieu
- From the Perioperative Medicine and Pain Management, University of Miami Health System, University of Miami Miller School of Medicine, Miami, FL (Dr. Osman, Dr. Caceres, and Dr. Hernandez); Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL (Dr. Tieu)
| | - Yosira Guevara Caceres
- From the Perioperative Medicine and Pain Management, University of Miami Health System, University of Miami Miller School of Medicine, Miami, FL (Dr. Osman, Dr. Caceres, and Dr. Hernandez); Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL (Dr. Tieu)
| | - Victor H. Hernandez
- From the Perioperative Medicine and Pain Management, University of Miami Health System, University of Miami Miller School of Medicine, Miami, FL (Dr. Osman, Dr. Caceres, and Dr. Hernandez); Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL (Dr. Tieu)
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Highland KB, Sowa HA, Herrera GF, Bell AG, Cyr KL, Velosky AG, Patzkowski JC, Kanter T, Patzkowski MS. Post-total joint arthroplasty opioid prescribing practices vary widely and are not associated with opioid refill: an observational cohort study. Arch Orthop Trauma Surg 2023; 143:5539-5548. [PMID: 37004553 DOI: 10.1007/s00402-023-04853-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 03/18/2023] [Indexed: 04/04/2023]
Abstract
INTRODUCTION Optimized health system approaches to improving guideline-congruent care require evaluation of multilevel factors associated with prescribing practices and outcomes after total knee and hip arthroplasty. MATERIALS AND METHODS Electronic health data from patients who underwent a total knee or hip arthroplasty between January 2016-January 2020 in the Military Health System Data were retrospectively analyzed. A generalized linear mixed-effects model (GLMM) examined the relationship between fixed covariates, random effects, and the primary outcome (30-day opioid prescription refill). RESULTS In the sample (N = 9151, 65% knee, 35% hip), the median discharge morphine equivalent dose was 660 mg [450, 892] and varied across hospitals and several factors (e.g., joint, race and ethnicity, mental and chronic pain conditions, etc.). Probability of an opioid refill was higher in patients who underwent total knee arthroplasty, were white, had a chronic pain or mental health condition, had a lower age, and received a presurgical opioid prescription (all p < 0.01). Sex assigned in the medical record, hospital duration, discharge non-opioid prescription receipt, discharge morphine equivalent dose, and receipt of an opioid-only discharge prescription were not significantly associated with opioid refill. CONCLUSION In the present study, several patient-, care-, and hospital-level factors were associated with an increased probability of an opioid prescription refill within 30 days after arthroplasty. Future work is needed to identify optimal approaches to reduce unwarranted and inequitable healthcare variation within a patient-centered framework.
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Affiliation(s)
- Krista B Highland
- Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA.
| | - Hillary A Sowa
- School of Medicine, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
| | - Germaine F Herrera
- Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, 6720A Rockledge Dr., #100, Bethesda, MD, 20817, USA
| | - Austin G Bell
- Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
- Department of Anesthesia, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20910, USA
- Department of Anesthesiology, Dwight D. Eisenhower Army Medical Center, 300, E Hospital Rd, Fort Gordon, GA, 30905, USA
| | - Kyle L Cyr
- Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
- Department of Anesthesia, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20910, USA
| | - Alexander G Velosky
- Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, 6720A Rockledge Dr., #100, Bethesda, MD, 20817, USA
| | - Jeanne C Patzkowski
- Department of Orthopaedic Surgery, Brooke Army Medical Center, 3551 Roger Brooke Drive, TX, 78234-6200, Fort Sam Houston, USA
- Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
| | - Trevor Kanter
- Emory University, 201 Dowman Drive, Atlanta, GA, 30322, USA
| | - Michael S Patzkowski
- Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
- Department of Anesthesiology, Brooke Army Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX, 78234-6200, USA
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Li Y, Gu Z, Ning R, Yin H. Study on the effect of internet plus continuous nursing on functional recovery and medication compliance of patients with knee joint replacement. J Orthop Surg Res 2023; 18:424. [PMID: 37303038 DOI: 10.1186/s13018-023-03907-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/04/2023] [Indexed: 06/13/2023] Open
Abstract
OBJECTIVE To evaluate the effect of "Internet + " continuity of care on postoperative functional recovery and medication compliance in patients with knee arthroplasty. METHODS In this retrospective study, 100 patients who underwent knee replacement in our hospital between January 2021 and December 2022 were recruited and assigned to receive routine care (routine group) or "Internet + " continuity of care (continuity group), with 50 patients in each group. Outcome measures included knee function, sleep quality, emotional state, medication compliance, and self-care ability. RESULTS Patients in the continuity group showed better knee function after discharge and during follow-up versus those in the routine group (P < 0.05). Continuity care resulted in significantly lower Pittsburgh Sleep Quality Index (PSQI), Self-Rating Anxiety Scale (SAS), and Self-Rating Depression Scale (SDS) scores versus routine care (P < 0.05). Patients in the continuity group showed higher treatment compliance, ability of daily living (ADL) scores, and nursing satisfaction than those in the routine group (P < 0.05). CONCLUSION The "Internet + " continuity of care is highly feasible and can effectively promote the postoperative functional recovery of knee replacement patients, improve patients' medication compliance, sleep quality, and self-care ability, mitigate negative emotions, and provide enhanced home care.
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Affiliation(s)
- Yan Li
- Department of Joint Surgery, Hefei First People's Hospital, Hefei, Anhui, China
| | - Zongyun Gu
- Department of Joint Surgery, Hefei First People's Hospital, Hefei, Anhui, China
| | - Rende Ning
- Department of Joint Surgery, Hefei First People's Hospital, Hefei, Anhui, China
| | - Hao Yin
- Department of Joint Surgery, Hefei First People's Hospital, Hefei, Anhui, China.
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Zhao C, Wang L, Chen L, Wang Q, Kang P. Effects of magnesium sulfate on periarticular infiltration analgesia in total knee arthroplasty: a prospective, double-blind, randomized controlled trial. J Orthop Surg Res 2023; 18:301. [PMID: 37060089 PMCID: PMC10105472 DOI: 10.1186/s13018-023-03790-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 04/10/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND To investigate whether adding magnesium sulfate to a periarticular infiltration analgesia (PIA) cocktail could improve pain control and functional outcomes in patients undergoing total knee arthroplasty (TKA). METHODS Ninety patients were randomly assigned to the magnesium sulfate and control groups, with 45 patients in each group. In the magnesium sulfate group, patients were given a periarticular infusion of a cocktail of analgesics consisting of epinephrine, ropivacaine, magnesium sulfate, and dexamethasone. The control group received no magnesium sulfate. The primary outcomes consisted of visual analogue scale (VAS) pain scores, postoperative morphine hydrochloride consumption for rescue analgesia, and time to first rescue analgesia. Secondary outcomes were postoperative inflammatory biomarkers (IL-6 and CRP), postoperative length of stay, and knee functional recovery (assessed by knee range of motion, quadriceps strength, daily mobilization distance, and time to first straight-leg raising). Tertiary outcomes included the postoperative swelling ratio and complication rates. RESULTS Within 24 h of surgery, patients in the magnesium sulfate group had markedly lower VAS pain scores during motion and at rest. After the addition of magnesium sulfate, the analgesic effect was dramatically prolonged, leading to a reduction in morphine dosage within 24 h and the total morphine dosage postoperatively. Postoperative inflammatory biomarker levels were significantly reduced in the magnesium sulfate group compared with the control. There were no considerable differences between the groups in terms of the postoperative length of stay and knee functional recovery. Both groups had similar postoperative swelling ratios and incidences of complications. CONCLUSIONS The addition of magnesium sulfate to the analgesic cocktail for PIA can prolong postoperative analgesia, decrease the consumption of opioids, and effectively alleviate early postoperative pain after TKA. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR2200056549. Registered on 7 February 2022, https://www.chictr.org.cn/showproj.aspx?proj=151489 .
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Affiliation(s)
- Chengcheng Zhao
- Department of Orthopaedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, Sichuan, China
| | - Liying Wang
- Department of Operating Room, West China Hospital, Sichuan University, Chengdu, China
- West China School of Nursing, Sichuan University, Chengdu, China
| | - Liyile Chen
- Department of Orthopaedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, Sichuan, China
| | - Qiuru Wang
- Department of Orthopaedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, Sichuan, China
| | - Pengde Kang
- Department of Orthopaedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, Sichuan, China.
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Wang Q, Zhao C, Hu J, Ma T, Yang J, Kang P. Efficacy of a Modified Cocktail for Periarticular Local Infiltration Analgesia in Total Knee Arthroplasty: A Prospective, Double-Blinded, Randomized Controlled Trial. J Bone Joint Surg Am 2023; 105:354-362. [PMID: 36856693 DOI: 10.2106/jbjs.22.00614] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Periarticular local infiltration analgesia (LIA) is largely utilized for controlling pain after total knee arthroplasty (TKA). The present work aimed to assess the efficacy of a modified LIA cocktail for patients undergoing TKA. METHODS Magnesium sulfate (MgSO4) and sodium bicarbonate (NaHCO3) were added to a conventional LIA cocktail comprising ropivacaine, epinephrine, and dexamethasone. After the safety of this modified cocktail was tested in rats, its efficacy and safety were evaluated in a prospective, double-blinded study including 100 individuals randomized to receive periarticular infiltration of the modified cocktail or a conventional cocktail. The primary outcome was postsurgical use of morphine hydrochloride for rescue analgesia. Secondary outcomes were the time until the first rescue analgesia, postsurgical pain (on a visual analog scale [VAS]), functional recovery (assessed by range of knee motion and ambulation distance), time to discharge, and complication rates. RESULTS Adding NaHCO3 to the local anesthetics caused some instantaneous precipitation in all cases. Administering the modified cocktail to rats did not obviously damage the injected area of the nerve or surrounding tissues. Administration of the modified cocktail to patients was associated with markedly reduced postsurgical morphine use in the initial 24 hours (4.2 ± 5.0 versus 14.6 ± 8.9 mg, p < 0.001), reduced total morphine use (9.8 ± 8.4 versus 19.6 ± 11.4 mg, p < 0.001), prolonged time to the first rescue analgesia, lower VAS pain scores at rest and during motion at 12 and 24 hours following the operation, better functional recovery on postoperative days 1 and 2, and a shorter hospital stay. The modified and conventional cocktail groups had similar rates of complications. CONCLUSIONS The present modification of a conventional cocktail significantly prolonged analgesia and reduced opioid consumption, which may substantially improve pain control in arthroplasty. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Qiuru Wang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Chengcheng Zhao
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Jian Hu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Ting Ma
- Anesthesia and Surgery Center, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Jing Yang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Pengde Kang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
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Pic C, Macabeo C, Waissi E, Lasselin P, Raffin M, Pradat P, Lalande L, Lustig S, Aubrun F, Dziadzko M. No Benefit of Adductor Canal Block Compared with Anterior Local Infiltration Analgesia in Primary Total Knee Arthroplasty: A Single-Blinded Randomized Controlled Clinical Trial. J Bone Joint Surg Am 2023; 105:231-238. [PMID: 36723467 DOI: 10.2106/jbjs.22.00745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND An adductor canal block (ACB) performed by an anesthesiologist is an established component of analgesia after total knee arthroplasty. Alternatively, surgeons may perform periarticular local infiltration analgesia (LIA) intraoperatively. We hypothesized that ACB would be superior to anterior LIA in terms of morphine consumption in the first 48 hours after primary total knee arthroplasty under spinal anesthesia. METHODS This prospective controlled and blinded trial included 98 patients; 48 received an ACB plus sham (saline solution) anterior LIA, and 50 received a sham (saline solution) ACB plus anterior LIA. Both groups received posterior LIA with local anesthetic. The primary outcome was cumulative morphine consumption at 48 hours after surgery. Secondary outcomes were pain while resting, standing, and walking, rehabilitation scores, opioid-related side effects, and patient satisfaction. RESULTS No difference in the primary outcome was found, and the 48-hour morphine consumption was low in both arms (28.8 ± 17.6 mg with ACB, 26.8 ± 19.2 mg with anterior LIA; p = 0.443). Pain scores were significantly better in the anterior LIA arm, but the differences were not clinically relevant. There were no differences in any other secondary outcome measures. CONCLUSIONS LIA may be used as the primary option for multimodal postoperative pain management in patients undergoing primary total knee arthroplasty with spinal anesthesia. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Caroline Pic
- Département d'Anesthésie-Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard, Lyon, France
| | - Caroline Macabeo
- Département d'Anesthésie-Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard, Lyon, France
| | - Emran Waissi
- Département d'Anesthésie-Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard, Lyon, France
| | - Philippe Lasselin
- Département d'Anesthésie-Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard, Lyon, France
| | - Mahé Raffin
- Centre de Recherche Clinique, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard, Lyon, France
| | - Pierre Pradat
- Centre de Recherche Clinique, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard, Lyon, France
| | - Laure Lalande
- Service de Pharmacie, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard, Lyon, France
| | - Sebastien Lustig
- Département de Chirurgie Orthopédique et Médecine de Sport, Centre d'Excellence FIFA Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard, Lyon, France.,IFSTTAR, LBMC UMR_T9406, Université Claude Bernard, Lyon, France
| | - Frederic Aubrun
- Département d'Anesthésie-Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard, Lyon, France.,Research on Healthcare Performance Lab (RESHAPE INSERM U1290), Université Claude Bernard, Lyon, France
| | - Mikhail Dziadzko
- Département d'Anesthésie-Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard, Lyon, France.,Research on Healthcare Performance Lab (RESHAPE INSERM U1290), Université Claude Bernard, Lyon, France
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Hussain N, Brull R, Zhou S, Schroell R, McCartney C, Sawyer T, Abdallah FW. Analgesic benefits of single-shot versus continuous adductor canal block for total knee arthroplasty: a systemic review and meta-analysis of randomized trials. Reg Anesth Pain Med 2023; 48:49-60. [PMID: 36351742 DOI: 10.1136/rapm-2022-103756] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 10/21/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Adductor canal block (ACB) can provide important analgesic benefits following total knee arthroplasty (TKA), however, the extent to which these benefits can be enhanced or prolonged by a continuous catheter-based infusion compared with a single-shot injection of local anesthetic is unclear. OBJECTIVES This systematic review and meta-analysis (PROSPERO: CRD42021292738) review sought to compare the analgesic effectiveness of single shot to continuous ACB following TKA. EVIDENCE REVIEW We sought randomized trials from the US National Library of Medicine database (MEDLINE), Excerpta Medica database (EMBASE), and Cochrane Database of Systematic Reviews from inception to November 1, 2021, that compared single-shot to continuous ACB in adult patients undergoing TKA. The primary outcomes were (1) area under the curve (AUC) pain severity at rest and (2) cumulative opioid (oral morphine equivalent) consumption during the first 48 hours postoperatively. Secondary outcomes included postoperative pain severity scores up to 48 hours, cumulative opioid consumption at 24 hours, functional recovery, opioid-related side effects, and block-related complications. Risk of bias of included studies was assessed using the Cochrane risk of bias tool. Statistical pooling was conducted using the Hartung-Knapp-Sidik-Jonkman method for random effects. No funding was obtained for this review. FINDINGS Eleven trials (1185 patients) were included. No differences were observed in rest pain severity (AUC) or cumulative opioid consumption up to 48 hours postoperatively. In addition, no differences were observed in individual postoperative rest pain scores in the recovery room and at 12 and 24 hours, or in cumulative opioid consumption at 24 hours, functional recovery, and opioid-related side effects. Finally, fewer block-related complications were observed with single-shot ACB, with an OR (95% CI) of 0.24 (0.14 to 0.41) (p=0.002). CONCLUSIONS Our results suggest that continuous catheter-based ACB does not enhance or prolong the analgesic benefits when compared with single-shot ACB for TKA over the first 48 hours postoperatively. Overall, the results of our meta-analysis do not support the routine use of continuous ACB for postoperative analgesia after TKA.
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Affiliation(s)
- Nasir Hussain
- Anesthesiology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Richard Brull
- Department of Anesthesiology and Pain Medicine, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Steven Zhou
- Anesthesiology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Robert Schroell
- Anesthesiology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Colin McCartney
- Department of Anesthesia and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Tamara Sawyer
- Central Michigan University College of Medicine, Mount Pleasant, Michigan, USA
| | - Faraj W Abdallah
- Department of Anesthesia and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Jørgensen CC, Petersen PB, Daugberg LO, Jakobsen T, Gromov K, Varnum C, Andersen MR, Palm H, Kehlet H. Peripheral nerve-blocks and associations with length of stay and readmissions in fast-track total hip and knee arthroplasty. Acta Anaesthesiol Scand 2023; 67:169-176. [PMID: 36354132 PMCID: PMC10098538 DOI: 10.1111/aas.14169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/05/2022] [Accepted: 11/04/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Peripheral nerve blocks (PNB) have recently been recommended in total hip (THA) and knee (TKA) arthroplasty as they may reduce pain, morphine consumption, length of stay (LOS) and complications. However, whether PNBs are associated with early discharge within an enhanced recovery protocol including multimodal analgesia is uncertain. METHODS An observational multicenter study from January to August 2017 in six Danish Arthroplasty Centers with established fast-track protocols. Prospective recording of preoperative characteristics and information on PNB, LOS and readmissions through the Danish National Patient Registry and medical records. Multiple logistic regression was used to investigate associations between PNB and a LOS >1 day, LOS >4 days, and 30-days readmissions. We also reported on mobilization, pain, opioid and fall-related complications leading to LOS >4 days or readmissions. RESULTS A total of 2027 (58.6%) THA and 1432 (41.4%) TKAs with a median LOS of 1 day (IQR 1-2) and 5.3% (CI:4.6-6.1) 30-days readmission rate were identified. PNB was used in 40.7% (CI:38.2-43.3) of TKA and 2.7% (CI:2.0-3.5) of THA, but with considerable interdepartmental variation (0.0-89.0% for TKA). There was no association between PNB and LOS >1 day (OR:1.19 CI:0.82-1.72; p = .354), LOS >4 days (OR:1.4 CI:0.68-2.89; p = .359) or 30-days readmissions (OR:1.02 CI:0.63-1.65; p = .935) in TKA. Logistic regression in THA was not possible due to limited use of PNB. In TKA there were 12 (2.1% CI:1.2-3.6) with and 1 (0.1% CI:0.02-0.7) without a PNB, who had mobilization, pain or opioid-related complications, and 5 (0.9% CI:0.4-2.0) versus 4 (0.5% CI:0.2-1.2) who fell. Correspondingly, 2 (3.7% CI:1.0-12.6) and 11 (0.6% CI:0.3-1.0) of THA patients had these complications, while 0 (0.0% CI:0.0-6.6) and 17 (0.8% CI:0.5-1.3) fell. CONCLUSION Routine use of peripheral nerve blocks was not associated with early discharge or 30-days readmissions in fast-track THA and TKA. Future studies should focus on benefits of PNB in high-risk patients.
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Affiliation(s)
- Christoffer C Jørgensen
- Section for Surgical Pathophysiology and the Center for Fast-Track Hip and Knee Replacement, Rigshospitalet Copenhagen University, Copenhagen, Denmark
| | - Pelle B Petersen
- Section for Surgical Pathophysiology and the Center for Fast-Track Hip and Knee Replacement, Rigshospitalet Copenhagen University, Copenhagen, Denmark
| | - Louise O Daugberg
- Department of Orthopedics, Holstebro Hospital, Center for Fast-Track Hip and Knee Replacement, Copenhagen, Denmark
| | - Thomas Jakobsen
- Department of Orthopedics, Interdisciplinary Orthopedics and the Center for Fast-Track Hip and Knee Replacement, Aalborg University Hospital, Copenhagen, Denmark
| | - Kirill Gromov
- Department of Orthopedics and the Center for Fast-Track Hip and Knee Replacement, Hvidovre University Hospital, Copenhagen, Denmark
| | - Claus Varnum
- Department of Orthopedics and the Center for Fast-Track Hip and Knee Replacement, Lillebaelt Hospital - Vejle, Copenhagen, Denmark
| | - Mikkel R Andersen
- Department of Orthopedics and the Center for Fast-Track Hip and Knee Replacement, Gentofte Hospital, Copenhagen, Denmark
| | - Henrik Palm
- Department of Orthopedics and the Center for Fast-Track Hip and Knee Replacement, Bispebjerg Hospital, Copenhagen, Denmark
| | - Henrik Kehlet
- Section for Surgical Pathophysiology and the Center for Fast-Track Hip and Knee Replacement, Rigshospitalet Copenhagen University, Copenhagen, Denmark
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Janiak M, Kowalczyk R, Gorniewski G, Olczyk-Miiller K, Kowalski M, Nowakowski P, Trzebicki J. Efficacy and Side Effect Profile of Intrathecal Morphine versus Distal Femoral Triangle Nerve Block for Analgesia following Total Knee Arthroplasty: A Randomized Trial. J Clin Med 2022; 11:jcm11236945. [PMID: 36498519 PMCID: PMC9739122 DOI: 10.3390/jcm11236945] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 11/08/2022] [Accepted: 11/22/2022] [Indexed: 11/27/2022] Open
Abstract
(1) Background: The management of postoperative pain after knee replacement is an important clinical problem. The best results in the treatment of postoperative pain are obtained using multimodal therapy principles. Intrathecal morphine (ITM) and single-shot femoral nerve block (SSFNB) are practiced in the treatment of postoperative pain after knee replacement, with the most optimal methods still under debate. The aim of this study was to compare the analgesic efficacy with special consideration of selected side effects of both methods. (2) Materials and methods: Fifty-two consecutive patients undergoing knee arthroplasty surgery at the Department of Orthopedics and Traumatology of the Medical University of Warsaw were included in the study. Patients were randomly allocated to one of two groups. In the ITM group, 100 micrograms of intrathecal morphine were used, and in the SSFNB group, a femoral nerve block in the distal femoral triangle was used as postoperative analgesia. The other elements of anesthesia and surgery did not differ between the groups. (3) Results: The total dose of morphine administered in the postoperative period and the effectiveness of pain management did not differ significantly between the groups (cumulative median morphine dose in 24 h in the ITM group 31 mg vs. SSFNB group 29 mg). The incidence of nausea and pruritus in the postoperative period differed significantly in favor of patients treated with a femoral nerve block. (4) Conclusions: Although intrathecal administration of morphine is similarly effective in the treatment of pain after knee replacement surgery as a single femoral triangle nerve block, it is associated with a higher incidence of cumbersome side effects, primarily nausea and pruritus.
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Affiliation(s)
- Marek Janiak
- 1st Department of Anesthesiology and Intensive Care, Medical University of Warsaw, 02-091 Warszawa, Poland
- Correspondence: ; Tel.: +48-22-502-1724
| | - Rafal Kowalczyk
- 1st Department of Anesthesiology and Intensive Care, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Grzegorz Gorniewski
- Department of Anesthesiology and Intensive Care Education, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Kinga Olczyk-Miiller
- 1st Department of Anesthesiology and Intensive Care, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Marcin Kowalski
- Department of Orthopedics and Traumatology, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Piotr Nowakowski
- Department of Anesthesiology and Intensive Care, Gruca Orthopaedic and Trauma Teaching Hospital, 05-400 Otwock, Poland
| | - Janusz Trzebicki
- 1st Department of Anesthesiology and Intensive Care, Medical University of Warsaw, 02-091 Warszawa, Poland
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Fillingham YA, Hannon CP, Kopp SL, Austin MS, Sershon RA, Stronach BM, Meneghini RM, Abdel MP, Griesemer ME, Woznica A, Casambre FD, Nelson N, Hamilton WG, Della Valle CJ. The Efficacy and Safety of Regional Nerve Blocks in Total Knee Arthroplasty: Systematic Review and Direct Meta-Analysis. J Arthroplasty 2022; 37:1906-1921.e2. [PMID: 36162923 DOI: 10.1016/j.arth.2022.03.078] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/14/2022] [Accepted: 03/26/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Regional nerve blocks are widely used in primary total knee arthroplasty (TKA) to reduce postoperative pain and opioid consumption. The purpose of our study was to evaluate the efficacy and safety of regional nerve blocks after TKA in support of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Management. METHODS We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for studies published before March 24, 2020 on femoral nerve block, adductor canal block, and infiltration between Popliteal Artery and Capsule of Knee in primary TKA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of the regional nerve blocks compared to a control, local peri-articular anesthetic infiltration (PAI), or between regional nerve blocks. RESULTS Critical appraisal of 1,673 publications yielded 56 publications representing the best available evidence for analysis. Femoral nerve and adductor canal blocks are effective at reducing postoperative pain and opioid consumption, but femoral nerve blocks are associated with quadriceps weakness. Use of a continuous compared to single shot adductor canal block can improve postoperative analgesia. No difference was noted between an adductor canal block or PAI regarding postoperative pain and opioid consumption, but the combination of both may be more effective. CONCLUSION Single shot adductor canal block or PAI should be used to reduce postoperative pain and opioid consumption following TKA. Use of a continuous adductor canal block or a combination of single shot adductor canal block and PAI may improve postoperative analgesia in patients with concern of poor postoperative pain control.
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Affiliation(s)
- Yale A Fillingham
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Charles P Hannon
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Sandra L Kopp
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Matthew S Austin
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Benjamin M Stronach
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - R Michael Meneghini
- Department of Orthopaedic Surgery, Indiana University Health, Indianapolis, Indiana
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Anne Woznica
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, Illinois
| | - Francisco D Casambre
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, Illinois
| | - Nicole Nelson
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, Illinois
| | | | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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22
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Hong C, Xie HY, Ge WK, Yu M, Lin SN, Liu CJ. The efficacy of parecoxib in improving pain after total knee or total hip arthroplasty: Systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e30748. [PMID: 36197263 PMCID: PMC9509050 DOI: 10.1097/md.0000000000030748] [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: 12/04/2022] Open
Abstract
BACKGROUND The cyclooxygenase-2 (COX-2) selective inhibitor parecoxib is widely used in the treatment of pain and inflammation. Parecoxib has been adopted for use for postoperative analgesia following a range of surgical procedures (orthopedic, general, gynecological, and dental surgery). Total knee or total hip arthroplasty (THA) surgery is mostly done in older patients, so postoperative analgesics need to be used more carefully, and the safety and efficacy of parecoxib in this type of surgery need to be further verified. The aim of this study was to investigate the effects of parecoxib on patient safety, cumulative morphine consumption and was at 24 and 48 hours in the analgesic treatment of total knee or THA for meta-analysis and systematic review, with few studies in this area so far. METHODS We searched the Online Database Cochrane Library, PubMed, Web of Science, EMBASE, and CBM (SinoMed), CNKI, VIP, WANFANG up to January 2021. According to the value of I2, the random-effect model or fixed-effect model was supposed to combine data from studies, respectively. Publication bias was assessed through funneling plot and Beggs test. Review Manager 5.3 and Stata 16.0 software were applied to perform the statistical analyses. RESULTS Eleven RCTs which involved 1690 participants were included in this study. The meta-analysis indicated parecoxib sodium could not significantly reduce the incidence of adverse events after total knee or THA compared with placebo. There was no statistical significance in incidence of nausea and vomiting. 24 hours resting VAS score was statistically significant between the group. The 48-hour resting VAS scores did not indicate a significant difference between the groups. CONCLUSION Parecoxib can reduce the incidence of adverse events after total knee or total hip surgery to some extent but cannot reduce the incidence of nausea and vomiting. Twenty-four hour postoperative analgesia is better than placebo, but 48 hours after operation analgesia is the same as placebo.
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Affiliation(s)
- Chuan Hong
- Department of Orthopedics, Ninghai First Hospital, Ningbo, Zhejiang, China
| | - Hai-Yan Xie
- Department of Pharmacy, The Third Hospital of Quzhou, Zhejiang, China
| | - Wu-Kun Ge
- Department of Pharmacy, Ninghai First Hospital, Ningbo, Zhejiang, China
- * Correspondence: Wu-Kun Ge, Department of Pharmacy, Ninghai First Hospital, No. 142, Taoyuan Middle Road, Ninghai County, Ningbo City, Zhejiang Province, China (e-mail: )
| | - Min Yu
- Department of Pharmacy, Ninghai First Hospital, Ningbo, Zhejiang, China
| | - Shuai-nan Lin
- Department of Pharmacy, Ninghai First Hospital, Ningbo, Zhejiang, China
| | - Cheng-Jiang Liu
- Department of General Medicine, Affiliated Anqing First People’s Hospital of Anhui Medical University, Anhui, China
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Lavand'homme PM, Kehlet H, Rawal N, Joshi GP. Pain management after total knee arthroplasty: PROcedure SPEcific Postoperative Pain ManagemenT recommendations. Eur J Anaesthesiol 2022; 39:743-757. [PMID: 35852550 PMCID: PMC9891300 DOI: 10.1097/eja.0000000000001691] [Citation(s) in RCA: 59] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The PROSPECT (PROcedure SPEcific Postoperative Pain ManagemenT) Working Group is a global collaboration of surgeons and anaesthesiologists formulating procedure-specific recommendations for pain management after common operations. Total knee arthroplasty (TKA) is associated with significant postoperative pain that is difficult to treat. Nevertheless, pain control is essential for rehabilitation and to enhance recovery. OBJECTIVE To evaluate the available literature and develop recommendations for optimal pain management after unilateral primary TKA. DESIGN A narrative review based on published systematic reviews, using modified PROSPECT methodology. DATA SOURCES A literature search was performed in EMBASE, MEDLINE, PubMed and Cochrane Databases, between January 2014 and December 2020, for systematic reviews and meta-analyses evaluating analgesic interventions for pain management in patients undergoing TKA. ELIGIBILITY CRITERIA Each randomised controlled trial (RCT) included in the selected systematic reviews was critically evaluated and included only if met the PROSPECT requirements. Included studies were evaluated for clinically relevant differences in pain scores, use of nonopioid analgesics, such as paracetamol and nonsteroidal anti-inflammatory drugs and current clinical relevance. RESULTS A total of 151 systematic reviews were analysed, 106 RCTs met PROSPECT criteria. Paracetamol and nonsteroidal anti-inflammatory or cyclo-oxygenase-2-specific inhibitors are recommended. This should be combined with a single shot adductor canal block and peri-articular local infiltration analgesia together with a single intra-operative dose of intravenous dexamethasone. Intrathecal morphine (100 μg) may be considered in hospitalised patients only in rare situations when both adductor canal block and local infiltration analgesia are not possible. Opioids should be reserved as rescue analgesics in the postoperative period. Analgesic interventions that could not be recommended were also identified. CONCLUSION The present review identified an optimal analgesic regimen for unilateral primary TKA. Future studies to evaluate enhanced recovery programs and specific challenging patient groups are needed.
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Affiliation(s)
- Patricia M Lavand'homme
- From the Department of Anaesthesiology and Perioperative Pain Service, Cliniques Universitaires St Luc, University Catholic of Louvain (UCL), Brussels, Belgium (PML), Section of Surgical Pathophysiology 7621, Rigshospitalet, Copenhagen, Denmark (HK), Department of Anaesthesiology, Orebro University, Orebro, Sweden (NR) and Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, United States (GPJ)
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24
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Shbeer A. Regional Anesthesia (2012-2021): A Comprehensive Examination Based on Bibliometric Analyses of Hotpots, Knowledge Structure and Intellectual Dynamics. J Pain Res 2022; 15:2337-2350. [PMID: 35996451 PMCID: PMC9391991 DOI: 10.2147/jpr.s372303] [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: 04/26/2022] [Accepted: 07/31/2022] [Indexed: 11/23/2022] Open
Abstract
In the last decade, there has been a significant advancement in the area of regional anesthesia (RA). Continuous evaluation of research in any developing field using modern technologies and available software is critical to identify future trends, hot spots, and intellectual dynamics. The current study was designed to bibliometrically evaluate the global research in RA using VOSviewer, MS Excel, and CVS-Scopus bibliographic data (2012–2021). Knowledge structure and intellectual dynamics were analyzed using clustering of keyword co-occurrence. Literature screening in the last decade found 6092 original articles (96.1%) and conference papers (3.9%). The top four countries producing articles were the United States (n = 30.57%), India (7.51), the United Kingdom (7.22%), and Canada (6.06%). A significant positive correlation was found in global publication productivity (R2 = 0.9161). The most productive organizations were Harvard University, the University of Toronto, and the Hospital for Special Surgery – New York. A tremendous collaboration was spotted nationally and internationally, especially in pediatric RA. This comprehensive study, which summarizes and evaluates 6902 original research materials on regional anesthesia, may serve as a resource for anesthesiologists, physicians, researchers, and students.
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25
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Cuñat T, Martínez-Pastor JC, Dürsteler C, Hernández C, Sala-Blanch X. Perioperative medicine role in painful knee prosthesis prevention. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:411-420. [PMID: 35869007 DOI: 10.1016/j.redare.2022.07.002] [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: 05/20/2020] [Accepted: 03/25/2021] [Indexed: 06/15/2023]
Abstract
Total knee arthroplasty is one of the most frequently performed orthopaedic surgeries. However, up to 20% of patients develop persistent postoperative pain. Persistent postoperative pain may be an extension of acute postoperative pain, but can also occur after more than 3 months without symptoms. Risk factors associated with persistent postoperative pain after arthroplasty have now been characterised within the patient's perioperative context (preoperative, intraoperative and postoperative), and can be grouped under genetic, demographic, clinical, surgical, analgesic, inflammatory and psychological factors. Identification and prevention of persistent postoperative pain through a multimodal and biopsychosocial approach is essential in the context of perioperative medicine, and has been shown to prevent or ameliorate postoperative pain.
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Affiliation(s)
- T Cuñat
- Servicio de Anestesiología, Reanimación y Tratamiento del dolor, Hospital Clínic de Barcelona, Barcelona, Spain.
| | - J C Martínez-Pastor
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Clinic de Barcelona, Barcelona, Spain
| | - C Dürsteler
- Servicio de Anestesiología, Reanimación y Tratamiento del dolor, Hospital Clínic de Barcelona, Barcelona, Spain
| | - C Hernández
- Servicio de Anestesiología y Reanimación, Hospital Sant Joan de Déu de Barcelona, Esplugues de Llobregat, Barcelona, Spain
| | - X Sala-Blanch
- Servicio de Anestesiología, Reanimación y Tratamiento del dolor, Hospital Clínic de Barcelona, Barcelona, Spain
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26
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Joshi GP, Stewart J, Kehlet H. Critical appraisal of randomised trials assessing regional analgesic interventions for knee arthroplasty: implications for postoperative pain guidelines development. Br J Anaesth 2022; 129:142-144. [PMID: 35618537 DOI: 10.1016/j.bja.2022.04.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 04/22/2022] [Accepted: 04/23/2022] [Indexed: 02/07/2023] Open
Abstract
Guidelines are increasingly being used for clinical decision-making. Such guidelines are usually based on meta-analyses, which are generally derived from RCTs. However, their interpretations are often hindered as they do not always consider current clinical relevance. Analyses of RCTs assessing analgesic efficacy of advanced regional analgesic techniques in knee arthroplasty show that the majority of trials do not include a package of basic analgesics such as paracetamol, NSAIDs or cyclooxygenase-2 specific inhibitors, dexamethasone, and local infiltration analgesia in the comparator group. Consequently, the current approach to analyse meta-analyses of pain interventions is not optimal, and may lead to inadequate or inappropriate conclusions and clinical guidance.
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Affiliation(s)
- Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Jesse Stewart
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen, Denmark
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27
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Wood D, Moy SF, Zhang S, Lightfoot N. Impact of a prescriber and patient educational intervention on discharge analgesia prescribing and hospital readmission rates following elective unilateral total hip and knee arthroplasty. BMJ Open Qual 2022; 11:bmjoq-2021-001672. [PMID: 35914816 PMCID: PMC9345064 DOI: 10.1136/bmjoq-2021-001672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 07/11/2022] [Indexed: 11/03/2022] Open
Abstract
IntroductionPain management after elective, unilateral total hip and knee arthroplasty (THA and TKA) should use a multimodal approach. At discharge, challenges include ensuring correct prescribing practices to optimise analgesia and rationalise opioid use as well as ensuring patients are adequately educated to take these medications safely and effectively in the community. This audit cycle reports on a prescriber and patient education intervention using printed guidelines, educational outreach and prescription standardisation along with a patient information sheet to address the high unplanned readmission rate following THA and TKA at our institution.MethodsTwo cohorts of patients were identified before (2016) and after (2019) the introduction of the educational package. The primary outcome was the unplanned hospital readmission rate in the 42 days following discharge. Secondary outcomes were the compliance with the set prescribing standards and the prescription of strong opioid medications (morphine or oxycodone) on discharge.ResultsThere was a reduction in the readmission rate from 20.4% to 10.0% (p=0.004). Readmission rates for pain and constipation were also reduced. The prescribing of tramadol (p<0.001) and non-steroidal anti-inflammatory drugs (p<0.001) both increased while the number of patients who received a strong opioid at discharge decreased (p<0.001) as did the number of patients who received a sustained release strong opioid (p<0.001).ConclusionWe have observed significant improvement in discharge prescribing which coincided with a reduction in unplanned readmissions after elective TKA and THA. Our approach used prescriber guidelines, education and standardisation with printed information for patients to enhance understanding and recall.
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Affiliation(s)
- Daniel Wood
- Anaesthesia and Pain Medicine, Middlemore Hospital, Auckland, New Zealand
| | - Shuh Fen Moy
- Anaesthesia, Auckland City Hospital, Auckland, New Zealand
| | - Shiran Zhang
- Orthopaedics, Middlemore Hospital, Auckland, New Zealand
| | - Nicholas Lightfoot
- Anaesthesia and Pain Medicine, Middlemore Hospital, Auckland, New Zealand
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No Benefits of Adding Dexmedetomidine, Ketamine, Dexamethasone and Nerve Blocks to an Established Multimodal Analgesic Regimen after Total Knee Arthroplasty. Anesthesiology 2022; 137:459-470. [PMID: 35867857 DOI: 10.1097/aln.0000000000004326] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND. An optimal opioid-sparing multimodal analgesic regimen to treat severe pain can enhance recovery after total knee arthroplasty. We hypothesized that adding 5 recently described IV and regional interventions to multimodal analgesic regimen can further reduce opioid consumption. METHODS. In a double-blinded fashion, seventy-eight patients undergoing elective total knee arthroplasty were randomized to either (1) a control group (n=39) that received spinal anesthesia with intrathecal morphine, periarticular local anesthesia infiltration, IV dexamethasone and a single injection adductor canal block or (2) a study group (n=39) that received the same set of analgesic treatments plus 5 additional interventions - local anesthetic infiltration between the popliteal artery and capsule of the posterior knee, intraoperative IV dexmedetomidine and ketamine, and postoperatively, 1 additional IV dexamethasone bolus, and 2 additional adductor canal block injections. The primary outcome measure was 24-hour cumulative opioid consumption after surgery and secondary outcomes were other analgesic, patient recovery and functional outcomes and adverse events. RESULTS. Opioid consumption was not different between groups at 24 hours (oral morphine equivalents, mean ± SD), study: 23.7 ± 18.0 mg vs. control: 29.3 ± 18.7 mg; mean difference [95% CI], -5.6 mg [-2.7, 13.9]; P = 0.189) and all other time points after surgery. There were no major differences in pain scores, quality of recovery, or time to reach rehabilitation milestones. Hypotensive episodes occurred more frequently in the study group (25/39 (64.1%) vs. 13/39 (33.3%), p= 0.010). CONCLUSIONS. In the presence of periarticular local anesthesia infiltration, intrathecal morphine, single shot adductor canal block and dexamethasone, the addition of 5 analgesic interventions - local anesthetic infiltration between the popliteal artery and capsule of the posterior knee, IV dexmedetomidine, IV ketamine, an additional IV dexamethasone dose and repeated adductor canal block injections - failed to further reduce opioid consumption, pain scores or improve functional outcomes after total knee arthroplasty.
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Combined application of adductor canal block and local infiltration anesthesia in primary total knee arthroplasty: an updated meta-analysis of randomized controlled trials. Arch Orthop Trauma Surg 2022; 142:913-926. [PMID: 33417022 DOI: 10.1007/s00402-020-03706-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 12/06/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Perioperative pain after total knee arthroplasty (TKA) may seriously affect the rapid recovery of patients. The purpose of this study was to assess whether the combined use of adductor canal block (ACB) and local infiltration anesthesia (LIA) can further reduce postoperative pain and improve early functional recovery. MATERIALS AND METHODS PubMed, Web of Science, EMBASE, and Cochrane Central Register of Controlled Trials were systematically searched for randomized controlled trials (RCTs) comparing ACB + LIA and LIA alone in primary TKA. The primary outcomes were visual analog scale (VAS) scores at rest and walking, morphine consumption, range of motion (ROM) at 24 and 48 h postoperatively and distance walked. The secondary outcomes were the length of stay, the incidence of nausea and vomiting, and the total complications. Subgroup analyses were performed on the VAS at rest and walking, morphine consumption, and distance walked at 24, 48, and 72 h postoperatively. RESULTS A total of 10 RCTs involving 797 patients were enrolled in this meta-analysis. The results demonstrated that the combined application of ACB + LIA had a lower resting VAS at 24 h postoperatively (p = 0.02) and the walking score at 24 (p = 0.0002) and 48 h (p = 0.02) postoperatively compared with LIA alone. Similarly, the combined ACB + LIA group also had less morphine consumption at 48 h postoperatively (p = 0.0005) and had a higher ROM score at 24 h (p = 0.01) postoperatively compared to the LIA group. There were no statistical differences in length of stay, distance walked, and incidence of nausea and vomiting. CONCLUSION The current meta-analysis showed that ACB + LIA significantly reduced postoperative walking pain and morphine consumption and promoted rapid recovery in the early postoperative period. There is no statistical difference in the length of stay and ROM after 72 h in the two groups.
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Meloxicam versus Celecoxib for Postoperative Analgesia after Total Knee Arthroplasty: Safety, Efficacy and Cost. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202204000-00002. [PMID: 35389917 PMCID: PMC8989775 DOI: 10.5435/jaaosglobal-d-22-00032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 01/28/2022] [Indexed: 12/03/2022]
Abstract
Introduction: Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used as part of multimodal analgesia in total knee arthroplasty (TKA). Selective cyclooxygenase (COX)-2 inhibitors (e.g., celecoxib) are believed to have fewer gastrointestinal (GI) adverse effects than nonselective NSAIDS. Meloxicam is less selective for COX-2 than celecoxib is and partially inhibits COX-1 at higher doses. Nonetheless, some surgeons prefer using nonselective NSAIDs because of their lower expense. Methods: Four thousand nine hundred ninety-four patients who underwent TKA between January 2015 and February 2020 and took either celecoxib (n = 3,174), meloxicam 15 mg/d (n = 1,819), or meloxicam 7.5 mg/d (n = 451) were studied. Mutlimodal postoperative analgesia protocols were otherwise similar. GI bleeding and wound complication incidence were determined, as well as average 30-day prescription costs. Results: GI bleeding incidence was similar in the three cohorts (P = 0.4). The incidence of wound complications did not significantly differ between the groups: 0.06%, 0.07%, and 0.22% in the celecoxib, meloxicam 15 mg/d, and meloxicam 7.5 mg/d groups, respectively (P = 0.06). Subsituting meloxicam for celecoxib results in an average savings of $183 per prescription. Discussion: Meloxicam used at higher doses (15 mg/d) does not markedly increase the risk of GI or wound complications associated with COX-1 inhibition and is less costly for multimodal analgesia after TKA.
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Et T, Korkusuz M, Basaran B, Yarımoğlu R, Toprak H, Bilge A, Kumru N, Dedeli İ. Comparison of iPACK and periarticular block with adductor block alone after total knee arthroplasty: a randomized clinical trial. J Anesth 2022; 36:276-286. [PMID: 35157136 PMCID: PMC8853355 DOI: 10.1007/s00540-022-03047-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/01/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE The infiltration between the popliteal artery and the capsule of the posterior knee (iPACK) has been described to provide analgesia without loss of muscle strength and is effective in functional recovery. This study compared iPACK + ACB (adductor canal block) with PAI (periarticular infiltration) + ACB and ACB alone in terms of postoperative analgesia and functional improvement. METHODS This double-blinded randomized controlled trial included 105 patients undergoing unilateral total knee arthroplasty. Patients received ACB, iPACK + ACB, and PAI + ACB along with spinal anesthesia. The primary outcome was the area under the curve (AUC) numeric rating scale (NRS) at 48 h. Secondary outcomes were cumulative postoperative analgesic consumption within 48 h, timed up-and-go test, range of motion, length of hospital stay, patient satisfaction, and adverse events. RESULTS The 48-h AUC movement NRS score in the iPACK + ACB group was significantly lower than in the PAI + ACB and ACB groups (p < 0.05). At the postoperative 48th h, the opioid consumption of the iPACK + ACB group was lower than those of the ACB and PAI + ACB groups (p < 0.001). The patients in the iPACK + ACB group had significantly shorter discharge and mobilization days than the ACB and PAI + ACB groups (p < 0.001). CONCLUSIONS The adding of an iPACK block to the ACB improves postoperative analgesia and reduces opioid consumption. In addition, this approach improves functional performance and reduces hospital stay.
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Affiliation(s)
- Tayfun Et
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Karamanoglu Mehmetbey University, Karaman, Turkey.
- Department of Anesthesiology and Intensive Care Medicine, Karaman Training and Research Hospital, Karaman, Turkey.
| | - Muhammet Korkusuz
- Department of Anesthesiology and Intensive Care Medicine, Karaman Training and Research Hospital, Karaman, Turkey
| | - Betül Basaran
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Karamanoglu Mehmetbey University, Karaman, Turkey
| | - Rafet Yarımoğlu
- Department of Anesthesiology and Intensive Care Medicine, Karaman Training and Research Hospital, Karaman, Turkey
| | - Hatice Toprak
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Karamanoglu Mehmetbey University, Karaman, Turkey
| | - Ayşegül Bilge
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Karamanoglu Mehmetbey University, Karaman, Turkey
| | - Nuh Kumru
- Department of Anesthesiology and Intensive Care Medicine, Karaman Training and Research Hospital, Karaman, Turkey
| | - İlker Dedeli
- Department of Orthopedics and Traumatology, Karaman Training and Research Hospital, Karaman, Turkey
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Xiao R, Liu LF, Luo YR, Liu C, Jin XB, Zhou W, Xu GH. Dexmedetomidine Combined with Femoral Nerve Block Provides Effective Analgesia Similar to Femoral Nerve Combined with Sciatic Nerve Block in Patients Undergoing Total Knee Arthroplasty: A Randomized Controlled Study. Drug Des Devel Ther 2022; 16:155-164. [PMID: 35046640 PMCID: PMC8763581 DOI: 10.2147/dddt.s334415] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 12/13/2021] [Indexed: 01/07/2023] Open
Abstract
Background Total knee arthroplasty (TKA) is a severe traumatic procedure, and femoral nerve block (FNB) combined with a sciatic nerve block (SNB) is widely used in TKA. However, injury of the sciatic nerve is clinically reported. Dexmedetomidine (DEX) could reduce stress and inflammation, as well as improve pain in TKA. This study aims to observe the analgesic impact of DEX combined with FNB in TKA. Methods Eighty-eight patients undergoing TKA were included and randomly divided into two groups: DF group (FNB combined with DEX 0.6μg/kg before surgery, followed by DEX 0.2–0.4μg/kg/h until articular closure) and SF group (FNB combined with SNB). Each nerve was blocked with 0.375% ropivacaine 20mL, and all patients received general anesthesia routinely. The primary endpoint was the pain visual analog scale (VAS) score during activities at postoperative 24 hours. Results There was no statistical difference in the pain VAS scores at any time point. The mean duration of analgesia for patients with rescue analgesic requests was comparable between the two groups: 25.4 ± 6.3 hours in the DF group vs 24.8 ± 6.4 hours in the SF group (two-sample t-test, p=0.738). The total dose of sufentanil was similar between groups (P=0.355). The maintenance dose of propofol and dose of rescue analgesics were comparable (all P>0.05). There were no statistical differences in the incidence of adverse events. However, the time to extubate in the DF group was significantly longer than those in the SF group (P<0.001). Conclusion DEX combined with FNB could provide effective analgesia similar to SNB combined with FNB in TKA. Clinical Trial Registration The trial was registered at the Chinese Clinical Trial Registry on November 17, 2019 (identifier: ChiCTR1900027552).
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Affiliation(s)
- Rui Xiao
- Department of Anesthesiology, First Affiliated Hospital, Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
| | - Li-Fang Liu
- Department of Anesthesiology, First Affiliated Hospital, Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
| | - Ya-Ru Luo
- Department of Anesthesiology, First Affiliated Hospital, Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
| | - Chang Liu
- Department of Anesthesiology, 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
| | - Wei Zhou
- 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
- Correspondence: Guang-Hong Xu Department of Anesthesiology, First Affiliated Hospital, Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of ChinaTel +86-551-62922344Fax +86 551 62923704 Email
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Sonawane K, Dixit H, Mistry T, Balavenkatasubramanian J. Comparing Analgesic Efficacy of a Novel Dual Subsartorial Block Using Two Different Volumes in Patients Undergoing Total Knee Arthroplasty: A Prospective, Double-Blind, Monocentric, Randomised Trial. Cureus 2021; 13:e20488. [PMID: 34934599 PMCID: PMC8683700 DOI: 10.7759/cureus.20488] [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] [Accepted: 12/14/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction: Total knee arthroplasty (TKA) is a life-changing joint surgery that improves health-related quality of life and functional status. Patients in need of this surgery mostly belong to the geriatric age group with limited functional reserves and multiple co-morbidities requiring utmost perioperative care with the most suitable analgesic modalities. Regional analgesia (RA) should provide effective analgesia while allowing early mobility, reduced opioid consumption, and early discharge. Dual subsartorial block (DSB) is a novel procedure-specific, motor-sparing, and opioid-sparing RA technique for TKA surgeries. Our study compared the analgesic efficacy of the two different combinations of volumes used in DSB. Methods: This prospective randomized comparative study included patients between 25-75 years of age of American Society of Anesthesiology (ASA) I-II grades who underwent an elective cemented unilateral total knee replacement performed via medial approaches under neuraxial anesthesia. A total of 104 patients were divided into two equal groups based on the local anesthetic (LA) volumes (Group A 10/20 ml and Group B 20/10 ml) used in the DSB. Postoperative pain scores (using a visual analog scale) and quadriceps strengths (using neurological exam), and opioid consumption were measured at regular intervals till discharge. Results: Most patients (71.2%) remained pain-free and comfortable until discharge, while 28.8% complained of pain within 12 hours of DSB. Mean quadriceps strength remained almost normal (4-5/5) until the discharge with no incidences of buckling or fall in either group. Over time, the postoperative trend between the groups showed a significant difference for dynamic pain (p = 0.002) and quadriceps strength (p = <0.001). There was an insignificant difference (p = 0.161) between the groups regarding opioid consumption, with the median oral morphine equivalent of zero in both groups. Discussion: The effective analgesic coverage of DSB is based on the involvement of all innervations of the procedure-specific pain generators of TKR surgeries. The specific focus on selective sensory innervations and the type/volume of the LA used makes DSB a motor-sparing RA alternative that facilitates early mobility and discharge. It can provide effective postoperative analgesia without compromising the motor strength of the quadriceps muscle when administered in either 10/20 or 20/10 volumes.
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Affiliation(s)
- Kartik Sonawane
- Anesthesiology, Ganga Medical Centre and Hospitals, Pvt. Ltd, Coimbatore, IND
| | - Hrudini Dixit
- Anesthesiology, Ganga Medical Centre and Hospitals, Pvt. Ltd, Coimbatore, IND
| | - Tuhin Mistry
- Anesthesiology, Ganga Medical Centre and Hospitals, Pvt. Ltd, Coimbatore, IND
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Tsang AM, Jagannathan R, Amundson AW, Smith HM, Dankbar EC, Zavaleta KW, Abdel MP, Jacob AK. Defining the Value of Analgesia for Total Knee Arthroplasty Using Time-Driven Activity-Based Costing: A Novel Approach to Clinical Practice Transformation. Mayo Clin Proc Innov Qual Outcomes 2021; 5:1042-1049. [PMID: 34765887 PMCID: PMC8572874 DOI: 10.1016/j.mayocpiqo.2021.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objective To compare the relative value of 3 analgesic pathways for total knee arthroplasty (TKA). Patients and Methods Time-driven activity-based costing analyses were performed on 3 common analgesic pathways for patients undergoing TKA: periarticular infiltration (PAI) only, PAI and single-injection adductor canal blockade (SACB), and PAI and continuous adductor canal blockade (CACB). Additionally, adult patients who underwent elective primary TKA from November 1, 2017, to May 1, 2018, were retrospectively identified to analyze analgesic (pain score, opiate use) and hospital outcomes (distance walked, length of stay) after TKA based on analgesic pathway. Results There was no difference in patient demographic characteristics, specifically complexity (American Society of Anesthesiologists score) or preoperative opiate use, between groups. Compared with PAI, total cost (labor and material) was 1.4-times greater for PAI plus SACB and 2.3-times greater for PAI plus CACB. The addition of SACB to PAI resulted in lower average and maximum pain scores and opiate use on the day of operation compared with PAI alone. Average and maximum pain scores and opiate use between SACB and CACB were not significantly different. Walking distance and hospital length of stay were not significantly different between groups. Conclusion Perioperative care teams should consider the cost and relative value of pain management when selecting the optimal analgesic strategy for TKA. Despite slightly higher relative cost, the combination of SACB with PAI may offer short-term analgesic benefit compared with PAI alone, which could enhance its relative value in TKA.
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Affiliation(s)
- Alvin M Tsang
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Ram Jagannathan
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Adam W Amundson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Hugh M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Eugene C Dankbar
- Department of Management Engineering and Consulting, Mayo Clinic, Rochester, MN
| | - Kathryn W Zavaleta
- Department of Management Engineering and Consulting, Mayo Clinic, Rochester, MN
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Adam K Jacob
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
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Drudis R, Colomina J, Torra M, Sabate S, Villalba P, Marco G, Triquell X, Del Pozo D, Palliso F, Montero A. Adductor canal block performed 20 hours after total knee arthroplasty to improve postoperative analgesia and functional recovery: a double-blind randomized controlled clinical trial. Minerva Anestesiol 2021; 88:238-247. [PMID: 34709013 DOI: 10.23736/s0375-9393.21.15838-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The goal of postoperative pain protocols in total knee arthroplasty (TKA) is to get pain free patients throughout severe pain period without impairing walking ability. The aim of the study was to investigate if an adductor canal block performed 20 hours after TKA, in patients treated with systemic analgesia and intraoperative local infiltration anaesthesia (LIA), improves postoperative pain and functional outcomes. METHODS A prospective randomized, double blinded controlled study was conducted. One hundred eighty-three patients undergoing primary TKA were randomized to receive either a sham block or an adductor canal block with 20 ml of ropivacaine 0.5%. The primary outcome was resting and dynamic pain scores using the numerical pain rating scale (NPRS). Secondary outcomes included opioid rescue requirements, quadriceps and adductor muscle strength, patient ability for ambulation and complications. RESULTS Two hours after the block, in adductor canal block group NPRS was significantly lower at rest (1[0-2] vs. 3[2-5], P<0.001) and with mobilization (5[3-6] vs. 6[5-8], P<0.001), and quadriceps strength was significantly higher (3.7[2.7-6] vs. 3(1.7-4.9), P=0.023). The differences were not maintained beyond 24 hours post-block. In the first 24 hours the percentage of patients with tramadol requirements was lower in the adductor canal block group (36[38.3] vs 52[58,4], P =0.006). Other secondary outcomes were similar between groups. There were no patient falls. CONCLUSIONS An adductor canal block done 20 hours after total knee arthroplasty reduces pain and opioid requirements without increasing the risk of falls. An optimal pain control, especially at movement was not achieved.
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Affiliation(s)
- Reis Drudis
- Department of Anaesthesiology, Hospital Universitari de Santa Maria, Lleida, Spain -
| | - Jordi Colomina
- Department of Orthopaedic Surgery, Hospital Universitari de Santa Maria, Lleida, Spain
| | - Montserrat Torra
- Department of Anaesthesiology, Hospital Universitari de Santa Maria, Lleida, Spain
| | - Sergi Sabate
- Department of Anaesthesiology, Hospital Universitari Santa Creu i Sant Pau, Fundació Puigvert, Barcelona, Spain
| | - Paz Villalba
- Department of Anaesthesiology, Hospital Universitari de Santa Maria, Lleida, Spain
| | - Gregorio Marco
- Department of Anaesthesiology, Hospital Universitari de Santa Maria, Lleida, Spain
| | - Xenia Triquell
- Department of Anaesthesiology, Hospital Universitari de Santa Maria, Lleida, Spain
| | - Dolors Del Pozo
- Department of Anaesthesiology, Hospital Universitari de Santa Maria, Lleida, Spain
| | - Francesc Palliso
- Department of Orthopaedic Surgery, Hospital Universitari de Santa Maria, Lleida, Spain
| | - Antonio Montero
- Department of Anaesthesiology, Hospital Universitari Arnau de Vilanova, Av. Lleida, Spain
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Efficacy of Two Unique Combinations of Nerve Blocks on Postoperative Pain and Functional Outcome After Total Knee Arthroplasty: A Prospective, Double-Blind, Randomized Controlled Study. J Arthroplasty 2021; 36:3421-3431. [PMID: 34090689 DOI: 10.1016/j.arth.2021.05.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/06/2021] [Accepted: 05/11/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND This study aimed to explore the efficacy of two unique combinations of nerve blocks on postoperative pain and functional outcome after total knee arthroplasty (TKA). METHODS Patients scheduled for TKA were randomized to receive a combination of adductor canal block (ACB) + infiltration between the popliteal artery and capsule of the posterior knee block (IPACK) + sham obturator nerve block (ONB) + sham lateral femoral cutaneous nerve block (LFCNB) (control group), or a combination of ACB + IPACK + ONB + sham LFCNB (triple nerve block group), or a combination of ACB + IPACK + ONB + LFCNB (quadruple nerve block group). All patients received local infiltration analgesia. Primary outcome was postoperative morphine consumption. Secondary outcomes were the time until first rescue analgesia, postoperative pain assessed on the visual analog scale (VAS), QoR-15 score, functional recovery of knee, and postoperative complications. RESULTS Compared with the control group, the triple and quadruple nerve block groups showed significantly lower postoperative morphine consumption (17.2 ± 9.7 mg vs. 11.2 ± 7.0 mg vs. 11.4 ± 6.4 mg, P = .001). These two groups also showed significantly longer time until first rescue analgesia (P = .007 and .010, respectively, analyzed with Kaplan-Meier method), significantly lower VAS scores on postoperative day 1 (P < .01), significantly better QoR-15 scores on postoperative days 1 and 2 (P < .001), and significantly better functional recovery of knee including range of motion (P = .002 and .001 on postoperative days 1 and 2), and daily ambulation distance (P < .001 and P = .004 on postoperative days 1 and 2). However, the absolute change in morphine consumption, VAS scores, and QoR-15 scores did not exceed the reported minimal clinically important differences (MCIDs) (morphine consumption: 10 mg; VAS scores: 1.5 at rest and 1.8 during movement; QoR-15 scores: 8.0). The MCIDs of other outcomes have not been reported in literature. The triple and quadruple nerve block groups showed no significant differences in these outcomes between each other. The three groups did not show a significant difference in complication rates. CONCLUSION Adding ONB or ONB + LFCNB to ACB + IPACK can statistically reduce morphine consumption, improve early pain relief, and functional recovery. However, the absolute change in morphine consumption, VAS scores, and QoR-15 scores did not exceed the MCIDs. Based on our findings and considering the sample size of this study, there is not enough clinical evidence to support the triple or quadruple nerve block use within a multimodal analgesic pathway after TKA.
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Chaturvedi R, Tram J, Chakravarthy K. Reducing opioid usage in total knee arthroplasty postoperative pain management: a literature review and future directions. Pain Manag 2021; 12:105-116. [PMID: 34551582 DOI: 10.2217/pmt-2020-0107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Total knee arthroplasty (TKA) is a common orthopedic surgery performed with a projected 3.5 million procedures to be done by 2030. Current postoperative pain management for TKA is insufficient, as it results in extensive opioid consumption and functional decline postoperatively. This study identifies the best practices for postoperative TKA pain management through a literature review of the last three years. Studies utilizing interventional techniques (local infiltration analgesia, nerve blocks) and pharmacologic options were reviewed on PubMed, Embase, Ovid Medline and Scopus. Primary outcomes analyzed were the effect of different analgesic approaches on pain reduction, opioid use reduction and improvements in functional mobility or quadriceps strength postoperatively. Additionally, this paper explores the use of cooled radiofrequency ablation, a minimally invasive therapy, for preoperative and postoperative TKA pain management.
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Affiliation(s)
- Rahul Chaturvedi
- Department of Anesthesiology, Division of Pain Medicine, University of California San Diego, 9400 Campus Point Dr, La Jolla, CA 92037, USA
| | - Jennifer Tram
- Department of Anesthesiology, Division of Pain Medicine, University of California San Diego, 9400 Campus Point Dr, La Jolla, CA 92037, USA
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Cuñat T, Martínez-Pastor JC, Dürsteler C, Hernández C, Sala-Blanch X. Perioperative medicine role in painful knee prosthesis prevention. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 69:S0034-9356(21)00142-0. [PMID: 34325900 DOI: 10.1016/j.redar.2021.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 01/07/2021] [Accepted: 03/25/2021] [Indexed: 11/25/2022]
Abstract
Total knee arthroplasty is one of the most frequently performed orthopaedic surgeries. However, up to 20% of patients develop persistent postoperative pain. Persistent postoperative pain may be an extension of acute postoperative pain, but can also occur after more than 3 months without symptoms. Risk factors associated with persistent postoperative pain after arthroplasty have now been characterised within the patient's perioperative context (preoperative, intraoperative and postoperative), and can be grouped under genetic, demographic, clinical, surgical, analgesic, inflammatory and psychological factors. Identification and prevention of persistent postoperative pain through a multimodal and biopsychosocial approach is essential in the context of perioperative medicine, and has been shown to prevent or ameliorate postoperative pain.
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Affiliation(s)
- T Cuñat
- Servicio de Anestesiología, Reanimación y Tratamiento del dolor, Hospital Clínic de Barcelona, Barcelona, España.
| | - J C Martínez-Pastor
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Clínic de Barcelona, Barcelona, España
| | - C Dürsteler
- Servicio de Anestesiología, Reanimación y Tratamiento del dolor, Hospital Clínic de Barcelona, Barcelona, España
| | - C Hernández
- Servicio de Anestesiología y Reanimación, Hospital Sant Joan de Déu de Barcelona, Esplugues de Llobregat, Barcelona, España
| | - X Sala-Blanch
- Servicio de Anestesiología, Reanimación y Tratamiento del dolor, Hospital Clínic de Barcelona, Barcelona, España
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Fillingham YA, Hanson TM, Leinweber KA, Lucas AP, Jevsevar DS. Generalized Anxiety Disorder: A Modifiable Risk Factor for Pain Catastrophizing After Total Joint Arthroplasty. J Arthroplasty 2021; 36:S179-S183. [PMID: 33648840 DOI: 10.1016/j.arth.2021.02.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/26/2021] [Accepted: 02/08/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Patients with mood disorders undergoing total joint arthroplasty (TJA) are at increased risk for poor outcomes. This study seeks to examine the effect of anxiety disorders on pain following TJA and evaluate if anxiety disorders are a modifiable risk factor. METHODS Between March 2019 and July 2020, 319 TJA patients had preoperative anxiety screening using the Generalized Anxiety Disorder 2-item screening tool (GAD-2) and 6-week postoperative Pain Catastrophizing Scale scores. Patients were organized into 4 cohorts based on preoperative selective serotonin reuptake inhibitor/serotonin-norepinephrine reuptake inhibitor (SSRI/SNRI) use and GAD-2 scores: Group 1: no SSRI/SNRI use and GAD-2 score <3 (control patients); Group 2: SSRI/SNRI use and GAD-2 score <3 (appropriately treated GAD patients); Group 3: no SSRI/SNRI use and GAD-2 score ≥3 (untreated GAD patients); and Group 4: SSRI/SNRI use and GAD-2 score ≥3 (poorly treated GAD patients). The cohorts underwent multivariate linear regression analysis and equivalence testing. RESULTS Patients with preoperative GAD-2 scores ≥3 had worse postoperative pain with significantly higher average 6-week postoperative Pain Catastrophizing Scale score than patients with GAD-2 scores <3 (9.90 vs 5.19, P < .001). Patients with appropriately treated GAD and the control group had statistically equivalent postoperative pain, while patients with poorly treated or untreated GAD had worse postoperative pain. CONCLUSION Preoperative GAD is a risk factor for poor postoperative pain control but is a modifiable risk factor when patients are appropriately treated. Screening for preoperative GAD with GAD-2 and referral for treatment may improve patient outcomes and reduce opioid consumption following TJA.
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Affiliation(s)
- Yale A Fillingham
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Thomas M Hanson
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Kathleen A Leinweber
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Adriana P Lucas
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - David S Jevsevar
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Selective periarticular blocks for postoperative pain after hip and knee arthroplasty. Curr Opin Anaesthesiol 2021; 34:544-552. [PMID: 34184643 DOI: 10.1097/aco.0000000000000943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review aims to provide an overview of selective periarticular blocks for postoperative pain after hip and knee arthroplasty and the current evidence for their use. RECENT FINDINGS Most interventional analgesia techniques for hip and knee arthroplasty result in a motor block and muscle weakness. Therefore, these are not well suited for fast-track protocols. In contrast, selective pericapsular infiltration techniques provide selective joint sensory block without an associated motor block. This facilitates postoperative pain management and avoids impairing ambulation and early rehabilitation. SUMMARY The pericapsular blocks of the hip (pericapsular nerve group block, iliopsoas plane block, hip block), genicular nerves block, and infiltration between the popliteal artery and the capsule of the knee play an increasingly important role in providing postoperative analgesia after hip and knee arthroplasty without impeding fast-track protocols.
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Hahm KD, Jin SJ, Cho SS, Park J, Park H, Kim DH, Choi SS. Relationship of epidural patient-controlled analgesia with postoperative bleeding after unilateral total knee arthroplasty: a propensity score-matching analysis. Sci Rep 2021; 11:11284. [PMID: 34050250 PMCID: PMC8163755 DOI: 10.1038/s41598-021-90946-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 05/19/2021] [Indexed: 11/09/2022] Open
Abstract
Although epidural patient-controlled analgesia (PCA) to control postoperative pain after total knee arthroplasty (TKA), the relationship of epidural PCA with postoperative bleeding remains controversial. Therefore, we aimed to evaluate the effect of epidural and intravenous PCA on postoperative bleeding in patients undergoing unilateral TKA. Total of 2467 patients who underwent TKA were divided to intravenous PCA (n = 2339) or epidural PCA (n = 128) group. After 1:1 propensity score-matching, 212 patients were analyzed to assess the associations between the perioperative blood loss and epidural PCA between the groups. Mean postoperative blood loss was significantly greater in epidural PCA than in intravenous PCA (900.9 ± 369.1 mL vs. 737.8 ± 410.1 mL; P = 0.007). The incidence of red blood cell (RBC) administration (> 3 units) was significantly higher in epidural PCA than in intravenous PCA (30.2% vs. 16.0%; OR 2.5; 95% CI 1.201–5.205; P = 0.014). Epidural PCA may be strongly related to postoperative bleeding and the incidence of RBC transfusion of more than 3 units after unilateral TKA, as compared to intravenous PCA. Therefore, the use of epidural PCA may be carefully considered for postoperative pain management in TKA.
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Affiliation(s)
- Kyung-Don Hahm
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Seok-Joon Jin
- Department of Pain, Shinshinplus Clinic, Anyang-si, 14401, Korea
| | - Seong-Sik Cho
- Department of Occupational and Environmental Medicine, College of Medicine, Dong-A University, Busan, 49201, Korea
| | - Jihoon Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Han Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Doo-Hwan Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
| | - Seong-Soo Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
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Patil SS, Kane D, Dhamangaonkar A, Avhad V. Retrospective Analysis of Pain Relief in Total Knee Replacement Surgeries. Anesth Essays Res 2021; 14:555-560. [PMID: 34349319 PMCID: PMC8294426 DOI: 10.4103/aer.aer_117_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/17/2021] [Accepted: 02/20/2021] [Indexed: 11/04/2022] Open
Abstract
Background and Aims The aim of the study is to measure the postoperative adequacy of pain relief and functional recovery after unilateral primary total knee arthroplasty or total knee replacement (TKR) with a multimodal approach. Settings and Design This was a retrospective observational study done in a tertiary care center. Materials and Methods Eighty patients aged 18-65 years (yrs) with ASA Physical Status Classes I, II, and III operated for unilateral primary TKR surgery under suitable Anaesthesia and was administered ultrasound-guided adductor canal block + periarticular infiltration (PI) from January 2018 to January 2019 were included. Thereafter, the patients visual analog scale (VAS) scores at rest, 45° knee flexion, and mobilization as well as additional analgesia given were noted after going through the records at following time points: 12 hourly for 24 h and thereafter on postoperative day 1 (POD1) and POD2. Level of block, adverse events, and functional recovery (time up and go [TUG] test, 10 s walk test) on POD1 and POD2 were also noted. Statistical Analysis and Results The statistical software namely SPSS 18.0 were used for the analysis of the data. The mean VAS score at 12 h was 4.33 ± 1.3 which worsened at 24 h with steady improvement over the next 2 days. Similarly, the case with a mean VAS score at 45° flexion and on mobilization showed a similar trend. At 12 h postadductor block, besides intravenous (i.v.) paracetamol, 32.6% of patients were given tramadol 50 mg i.v. whereas one patient was given a buprenorphine patch in addition to tramadol. The number of patients requiring additional tramadol and buprenorphine patch steadily increased over the next 2 days. The average time taken for the TUG test at 24 h was 30.98 ± 4.77 s, and the average time taken for the 10 s walk test at 24 h was 6.16 ± 1.10 steps with improvement in performance over the next 2 days. Conclusion In our study, our multimodal analgesia model did not provide satisfactory analgesia though mobilization was not hampered.
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Affiliation(s)
| | - Deepa Kane
- Department of Anaesthesiology, GSMC and KEMH, Mumbai, Maharashtra, India
| | - Anoop Dhamangaonkar
- Department of Orthopaedics, LTMMC and LTMG Hospital, Mumbai, Maharashtra, India
| | - Valmik Avhad
- Department of Anaesthesiology, GSMC and KEMH, Mumbai, Maharashtra, India
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Chan E, Howle R, Onwochei D, Desai N. Infiltration between the popliteal artery and the capsule of the knee (IPACK) block in knee surgery: a narrative review. Reg Anesth Pain Med 2021; 46:784-805. [PMID: 33990439 DOI: 10.1136/rapm-2021-102681] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/29/2021] [Accepted: 04/29/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND The infiltration between the popliteal artery and the capsule of the knee (IPACK) block has been described as an alternative analgesic strategy for knee pain. OBJECTIVE Our aim was to perform a narrative review to examine the place and value that the IPACK block has in comparison to and in conjunction with other regional anesthesia modalities. EVIDENCE REVIEW Following an extensive search of electronic databases, we included anatomical studies, letters, comparative observational studies, and non-randomized and randomized controlled trials that examined the IPACK block in relation to surgery on the knee under general or neuraxial anesthesia. FINDINGS In all, 35 articles were included. Cadaveric studies demonstrated the potential for injected dye to spread to the nerves responsible for the innervation of the posterior as well as anteromedial and anterolateral aspects of the knee. Of the comparative observational studies (n=15) and non-randomized (n=1) and randomized controlled trials (n=13), 2 and 27 were conducted in the context of anterior cruciate ligament reconstruction and knee replacement surgery, respectively. The role of the IPACK block with each different permutation of regional anesthesia techniques was investigated by a small number of studies. Clinical studies, in the setting of knee replacement surgery, revealed variation in the manner in which the IPACK block was performed, and indicated the possible superiority of distal injection at the level of the femoral condyles for the management of posterior knee pain. Evidence suggested the following: the IPACK block in combination with single shot adductor canal block (ACB) may be beneficial for analgesic and functional outcomes; in conjunction with single shot or continuous ACB, the IPACK block might be superior to local infiltration analgesia (LIA); and functional outcomes may be improved with the supplementation of continuous ACB and LIA with the IPACK block. The IPACK block did not commonly result in the occurrence of foot drop. Relative to tibial nerve block (TNB), the IPACK block reduced the occurrence of foot drop and increased the proportion of patients who were able to be discharged on the third postoperative day. CONCLUSIONS The IPACK block was potentially complementary to the ACB and might be preferable to the TNB as a motor-sparing regional anesthesia technique in knee surgery. Definitive recommendations were not reached in the presence of the heterogeneous and limited evidence base.
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Affiliation(s)
- Edmund Chan
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ryan Howle
- Department of Anaesthesia, St Vincent's University Hospital, Dublin, Ireland
| | - Desire Onwochei
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Honorary Senior Clinical Lecturer, King's College London, London, UK
| | - Neel Desai
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK .,Honorary Senior Clinical Lecturer, King's College London, London, UK
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Kelleher DC, Lippell R, Lui B, Ma X, Tedore T, Weinberg R, White RS. Hospital safety-net burden is associated with increased inpatient mortality after elective total knee arthroplasty: a retrospective multistate review, 2007-2018. Reg Anesth Pain Med 2021; 46:663-670. [PMID: 33990442 DOI: 10.1136/rapm-2020-101731] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 04/22/2021] [Accepted: 04/25/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Total knee arthroplasty (TKA) is among the most common surgical procedures performed in the USA and comprises an outsized proportion of Medicare expenditures. Previous work-associated higher safety-net burden hospitals with increased morbidity and in-hospital mortality following total hip arthroplasty. Here, we examine the association of safety-net burden on postoperative outcomes after TKA. METHODS We retrospectively analyzed 1 141 587 patients aged ≥18 years undergoing isolated elective TKA using data from the State Inpatient Databases for Florida, Kentucky, Maryland, New York and Washington from 2007 through 2018. Hospitals were grouped into tertiles by safety-net burden status, defined by the proportion of inpatient cases billed to Medicaid or unpaid (low: 0%-16.83%, medium: 16.84%-30.45%, high: ≥30.45%). Using generalized estimating equation models, we assessed the association of hospital safety-net burden status on in-hospital mortality, patient complications and length of stay (LOS). We also analyzed outcomes by anesthesia type in New York State (NYS), the only state with this data. RESULTS Most TKA procedures were performed at medium safety-net burden hospitals (n=6 16 915, 54%), while high-burden hospitals performed the fewest (n=2 04 784, 17.9%). Overall in-patient mortality was low (0.056%), however, patients undergoing TKA at medium-burden hospitals were 40% more likely to die when compared with patients at low-burden hospitals (low: 0.043% vs medium: 0.061%, adjusted OR (aOR): 1.40, 95% CI 1.09 to 1.79, p=0.008). Patients who underwent TKA at medium or high safety-net burden hospitals were more likely to experience intraoperative complications (low: 0.2% vs medium: 0.3%, aOR: 1.94, 95% CI 1.34 to 2.83, p<0.001; low: 0.2% vs high: 0.4%, aOR: 1.91, 95% CI 1.35 to 2.72, p<0.001). There were no statistically significant differences in other postoperative complications or LOS between the different safety-net levels. In NYS, TKA performed at high safety-net burden hospitals was more likely to use general rather than regional anesthesia (low: 26.7% vs high: 59.5%, aOR: 4.04, 95% CI 1.05 to 15.5, p=0.042). CONCLUSIONS Patients undergoing TKA at higher safety-net burden hospitals are associated with higher odds of in-patient mortality than those at low safety-net burden hospitals. The source of this mortality differential is unknown but could be related to the increased risk of intraoperative complications at higher burden centers.
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Affiliation(s)
| | - Ryan Lippell
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Briana Lui
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Xiaoyue Ma
- Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - Tiffany Tedore
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Roniel Weinberg
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Robert S White
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
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D'Souza RS, Langford BJ, Olsen DA, Johnson RL. Ultrasound-Guided Local Anesthetic Infiltration Between the Popliteal Artery and the Capsule of the Posterior Knee (IPACK) Block for Primary Total Knee Arthroplasty: A Systematic Review of Randomized Controlled Trials. Local Reg Anesth 2021; 14:85-98. [PMID: 34012290 PMCID: PMC8126972 DOI: 10.2147/lra.s303827] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 04/13/2021] [Indexed: 11/23/2022] Open
Abstract
Posterior knee pain after total knee arthroplasty (TKA) is common despite multimodal analgesia and regional anesthesia use. This review included randomized controlled trials (RCTs) comparing analgesic outcomes after inclusion of local anesthetic infiltration between the popliteal artery and capsule of the knee (iPACK) block versus pathways without iPACK. Electronic databases (MEDLINE, Cochrane Library, Web of Science, Scopus) were searched from inception to 10/11/2020. Eligible studies evaluated iPACK use on primary outcomes: opioid consumption and pain scores with movement. Secondary outcomes included rest pain, patient satisfaction, length of stay (LOS), gait distance, knee range of motion (ROM), and complications. Bias and quality were appraised using the Cochrane Risk of Bias tool and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) guidelines. Eight RCTs (777 patients) were included. iPACK block use demonstrated similar opioid consumption in the PACU (4/7 RCTs) and 24 hours after TKA (5/7 RCTs) compared to without iPACK (moderate-quality GRADE evidence). Additionally, iPACK block use demonstrated lower movement pain scores in PACU (3/5 RCTs) but similar or higher pain scores after 24 hours (5/7 RCTs; low-quality GRADE evidence). Studies consistently reported no difference in gait distance (4/4 RCTs) or complications (7/7 RCTs) between treatment arms (high-quality GRADE evidence), although differing effect estimates were observed with resting pain, satisfaction, LOS, and knee ROM. This review provides a foundation of knowledge on iPACK efficacy. While evidence does not currently support widespread inclusion of iPACK within enhanced recovery pathways for TKA, limitations suggest further study is warranted.
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Affiliation(s)
- Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - Brendan J Langford
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - David A Olsen
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - Rebecca L Johnson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
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Gola W, Bialka S, Owczarek AJ, Misiolek H. Effectiveness of Fascia Iliaca Compartment Block after Elective Total Hip Replacement: A Prospective, Randomized, Controlled Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18094891. [PMID: 34064427 PMCID: PMC8124308 DOI: 10.3390/ijerph18094891] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/28/2021] [Accepted: 04/29/2021] [Indexed: 12/21/2022]
Abstract
Objective: An assessment of the feasibility of fascia iliaca compartment block (FICB) combined with nonopioid analgesics and patient controlled analgesia (PCA), oxycodone, in the perioperative anaesthetic management for elective total hip replacement (THR). Design: A randomised, single-center, open-label study. Setting: A single hospital. The study was conducted from October 2018 to May 2019. Participants: In total, 109 patients were scheduled for elective total hip replacement. Interventions: Postoperative FICB with 0.375% ropivacaine in conjunction with nonopioid analgesics (paracetamol, metamizole, and pregabalin) and oxycodone as rescue analgesia. Measurements: Pain intensity was measured using the Numeric Pain Rating Scale (NRS) at rest and during rehabilitation, the total dose of postoperative oxycodone required, the occurrence of opioid-related adverse events, patient hospitalisation time, and level of satisfaction. Follow-up period: 48 h. Main Results: A total of 109 patients were randomised into two groups and, of these, 9 were subsequently excluded from the analysis (three conversions to general anaesthesia, two failures to perform FICB, four failures to use the PCA pump). Patients in the FICB group received standard intravenous analgesia with FICB, and those in the control group were managed with standard intravenous analgesia only. Pain level measured with NRS was significantly lower at rest and during rehabilitation in the FICB group. Oxycodone use in the first 48 h was significantly higher in the control group (p < 0.001); additionally, the time to the first dose of rescue analgesia was significantly shorter (p < 0.001). In the control group, there was a higher rate of side effects and a significantly longer hospitalisation time (p < 0.001). Similarly, higher satisfaction with the applied analgesic treatment was noted in the FICB group. Conclusions: FICB in elective THR treatments is an effective form of analgesia, which reduces the need for opioids, the number of complications, the length of hospitalisation, and which ensures a high level of patient satisfaction with the analgesic treatment used. Trial registration: ClinicalTrials.gov No. NCT04690647.
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Affiliation(s)
- Wojciech Gola
- Department of Anaesthesia and Intensive Care, Saint Lucas Hospital, Konskie 26-200, Poland
- Faculty of Medicine and Health Sciences, Jan Kochanowski University, Kielce 25-369, Poland
- Correspondence: or (W.G.); (S.B.); Tel.: +48-504-606-247 (W.G.)
| | - Szymon Bialka
- Intensive Care and Emergency Medicine, Department of Anaesthesiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice 40-055, Poland;
- Correspondence: or (W.G.); (S.B.); Tel.: +48-504-606-247 (W.G.)
| | - Aleksander J. Owczarek
- Health Promotion and Obesity Management Unit, Department of Pathophysiology, Medical Faculty in Katowice, Medical University of Silesiain, Katowice 40-055, Poland;
| | - Hanna Misiolek
- Intensive Care and Emergency Medicine, Department of Anaesthesiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice 40-055, Poland;
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Abstract
BACKGROUND The primary goal of this study was to evaluate patterns in acute postoperative pain in a mixed surgical patient cohort with the hypothesis that there would be heterogeneity in these patterns. METHODS This study included 360 patients from a mixed surgical cohort whose pain was measured across postoperative days 1 through 7. Pain was characterized using the Brief Pain Inventory. Primary analysis used group-based trajectory modeling to estimate trajectories/patterns of postoperative pain. Secondary analysis examined associations between sociodemographic, clinical, and behavioral patient factors and pain trajectories. RESULTS Five distinct postoperative pain trajectories were identified. Many patients (167 of 360, 46%) were in the moderate-to-high pain group, followed by the moderate-to-low (88 of 360, 24%), high (58 of 360, 17%), low (25 of 360, 7%), and decreasing (21 of 360, 6%) pain groups. Lower age (odds ratio, 0.94; 95% CI, 0.91 to 0.99), female sex (odds ratio, 6.5; 95% CI, 1.49 to 15.6), higher anxiety (odds ratio, 1.08; 95% CI, 1.01 to 1.14), and more pain behaviors (odds ratio, 1.10; 95% CI, 1.02 to 1.18) were related to increased likelihood of being in the high pain trajectory in multivariable analysis. Preoperative and intraoperative opioids were not associated with postoperative pain trajectories. Pain trajectory group was, however, associated with postoperative opioid use (P < 0.001), with the high pain group (249.5 oral morphine milligram equivalents) requiring four times more opioids than the low pain group (60.0 oral morphine milligram equivalents). CONCLUSIONS There are multiple distinct acute postoperative pain intensity trajectories, with 63% of patients reporting stable and sustained high or moderate-to-high pain over the first 7 days after surgery. These postoperative pain trajectories were predominantly defined by patient factors and not surgical factors. EDITOR’S PERSPECTIVE
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Reducing Acute Hospitalization Length of Stay After Total Knee Arthroplasty: A Quality Improvement Study. J Arthroplasty 2021; 36:837-844. [PMID: 33616066 DOI: 10.1016/j.arth.2020.09.054] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/16/2020] [Accepted: 09/30/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The introduction of bundled funding for total knee arthroplasty (TKA) has motivated hospitals to improve quality of care while minimizing costs. The aim of our quality improvement project is to reduce the acute hospitalization length of stay to less than 2 days and decrease the percentage of TKA patients discharged to inpatient rehabilitation using an enhanced recovery after surgery bundle. METHODS This study used a before-and-after design. The pre-intervention period was January to December 2017 and the post-intervention period was January 2018 to August 2019. A root cause analysis was performed by a multidisciplinary team to identify barriers for rapid recovery and discharge. Four new interventions were chosen as part of an improvement bundle based on existing local practices, literature review, and feasibility analysis: (1) perioperative peripheral nerve block; (2) prophylactic antiemetic medication; (3) avoidance of routine preoperative urinary catheterization; and (4) preoperative patient education. RESULTS The pre-intervention and post-intervention groups included 232 and 383 patients, respectively. Mean length of stay decreased from 2.82 to 2.13 days (P < .001). The need for inpatient rehabilitation decreased from 20.2% to 10.7% (P = .002). Mean 24-hour oral morphine consumption decreased from 60 to 38 mg (P < .001). The percentage of patients experiencing moderate-to-severe pain and postoperative nausea and vomiting within the first 24 hours decreased by 25% and 15%, respectively (P < .001). Thirty-day emergency department visits following discharge decreased from 12.9% to 7.3% (P = .030). CONCLUSION Significant improvements in the recovery of patients after TKA were achieved by performing a root cause analysis and implementing a multidisciplinary, patient-centered enhanced recovery after surgery bundle. LEVEL OF EVIDENCE Level III.
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Factors associated with success and failure of patient-controlled oral analgesia after total hip and knee arthroplasty: a historical comparative cohort study. Can J Anaesth 2020; 68:324-335. [PMID: 33205265 DOI: 10.1007/s12630-020-01864-5] [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: 01/12/2020] [Revised: 08/25/2020] [Accepted: 08/31/2020] [Indexed: 10/23/2022] Open
Abstract
PURPOSE Patient-controlled oral analgesia (PCOA) is a novel method of oral opioid administration using set doses of short-acting oral opioids self-administered by patients with a "lockout" period as part of a multimodal regimen. Failure of PCOA can result in severe postoperative pain necessitating use of intravenous patient-controlled analgesia (IV-PCA) with its potential complications. This study evaluated factors related to success or failure of PCOA following total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS We conducted a retrospective cohort study of all adults who underwent THA and TKA at our institution by extracting data from the proprietary database of our acute pain service. Patient, anesthetic, and surgical variables associated with PCOA failure defined as inadequate analgesia requiring conversion to IV-PCA within 24 hr following THA and TKA were evaluated. Univariable and multivariable logistic regression analyses were performed to identify predictors of PCOA failure. RESULTS Of the 926 patients who underwent THA or TKA (n = 411 and 515, respectively), 147 (15.9%) patients (67 THA and 80 TKA patients) had PCOA failure with moderate-to-severe pain. Multivariable regression analysis showed that PCOA failure occurred in those with younger age (adjusted odds ratio [aOR] per year of age, 0.97; 99% CI, 0.95 to 0.99; P < 0.001), preoperative chronic use of controlled-release opioids (aOR, 3.45; 99% CI, 1.60 to 7.35; P < 0.001), and with the use of general anesthesia vs spinal anesthesia (aOR, 2.86; 99% CI, 1.20 to 6.84; P = 0.002). CONCLUSION The use of PCOA provides adequate analgesia to a majority of patients undergoing THA and TKA. Factors predictive for PCOA failure should be considered when choosing the primary breakthrough analgesic modality following THA/TKA.
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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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