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Maniar A, Kulkarni R. The radial trinity block of the upper extremity: combined block of the radial, median and lateral cutaneous nerves of the forearm for radial fracture. Br J Anaesth 2024:S0007-0912(24)00455-0. [PMID: 39181819 DOI: 10.1016/j.bja.2024.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Revised: 06/29/2024] [Accepted: 07/01/2024] [Indexed: 08/27/2024] Open
Affiliation(s)
| | - Rammurthy Kulkarni
- Axon Anaesthesia Associates, Bengaluru, India; South West Acute Hospital, Enniskillen, Northern Ireland, UK.
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2
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Ganta A, Fisher ND, Gibbons K, Ferati SR, Furgiuele D, Konda SR, Egol KA. Regional anesthesia is safe for use in intramedullary nailing of low-energy tibial shaft fractures. Injury 2024; 55:111636. [PMID: 38870608 DOI: 10.1016/j.injury.2024.111636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 04/06/2024] [Accepted: 05/27/2024] [Indexed: 06/15/2024]
Abstract
PURPOSE The purpose was to compare perioperative outcomes of patients who underwent general or regional anesthesia for intramedullary (IM) nailing of tibial shaft fractures (TSFs). METHODS Retrospective chart review was performed on a consecutive series of low-energy TSF patients who presented to a single academic medical center and a level 1 trauma center who underwent operative repair with a reamed IM nail. Collected information included demographics, injury information, anesthesia type (general or regional i.e. peripheral nerve block), intra-operative opiate consumption (converted to morphine milliequivalents [MME], and post-operative pain visual-analog scale [VAS] pain scores. Patients were divided into 3 groups based on the type of anesthesia received and univariate analysis was performed to compare the 3 groups. RESULTS Seventy-six patients were included, with an average age of 44.47±16.0 years. There were 38 (50 %) who were administered general anesthesia and 38 (50 %) who were administered regional anesthesia in the form of a peripheral nerve block. There were no differences between the groups with respect to demographics, medical co-morbidities, rate of open fractures or AO/OTA fracture classification. Regional anesthesia patients received less intra-operative MME than general anesthesia patients (17.57±10.6, 28.96±13.8, p < 0.001). Patients who received regional anesthesia also spent less time in the operating room, received less MME on post-operative day 1, and ambulated further on post-operative day 1, however none of these differences were statistically significant. There were no cases of missed post-operative compartment syndrome or complications related to the administration of the peripheral nerve block. CONCLUSIONS Regional anesthesia in TSF surgery received less intra-operative opioid requirements, without any untoward effects. LEVEL OF EVIDENCE Therapeutic Level III.
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Affiliation(s)
- Abhishek Ganta
- NYU Langone Orthopedic Hospital, 301 E 17th St, New York, NY 10003, USA; Jamaica Hospital Medical Center, 8900 Van Wyck Expressway, Richmond Hill, NY 11418, USA.
| | - Nina D Fisher
- NYU Langone Orthopedic Hospital, 301 E 17th St, New York, NY 10003, USA
| | - Kester Gibbons
- NYU Langone Orthopedic Hospital, 301 E 17th St, New York, NY 10003, USA
| | | | - David Furgiuele
- NYU Langone Orthopedic Hospital, 301 E 17th St, New York, NY 10003, USA
| | - Sanjit R Konda
- NYU Langone Orthopedic Hospital, 301 E 17th St, New York, NY 10003, USA; Jamaica Hospital Medical Center, 8900 Van Wyck Expressway, Richmond Hill, NY 11418, USA
| | - Kenneth A Egol
- NYU Langone Orthopedic Hospital, 301 E 17th St, New York, NY 10003, USA
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Lockhorst EW, Schormans PMJ, Berende CAS, van Hensbroek PB, Vos DI. Carbon footprint in trauma surgery, is there a way to reduce it? JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:46. [PMID: 39020415 PMCID: PMC11256432 DOI: 10.1186/s44158-024-00181-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 07/09/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND Inhaled anaesthetic agents like sevoflurane contribute for approximately 5% to healthcare's carbon footprint. Previous studies suggested that the use of these agents should be minimized. Although multiple trauma surgeries can be performed under regional anaesthesia, most are performed under general anaesthesia. This study aims to evaluate the environmental benefits of using regional anaesthesia over general anaesthesia and to compare the associated complication rates. METHODS This retrospective study included all trauma patients (≥ 18 years) who underwent surgical intervention for hand, wrist, hip, or ankle fractures from 2017 to 2021. The hypothetical environmental gain was calculated based on the assumption that all surgeries were performed under regional anaesthesia. Complication rates were compared between regional and general anaesthesia. RESULTS Of the 2,714 surgeries, 15% were hand, 26% wrist, 36% hip, and 23% ankle fractures. General anaesthesia was used in 95%, regional in 5%. Switching this 95% to regional anaesthesia would reduce the sevoflurane use by 92 k, comparable to driving 406,553 km by car. The complication rate was higher with general anaesthesia compared to regional (7.7% vs 6.9%, p = 0.75). CONCLUSION The potential gain of the reduction of sevoflurane in trauma surgeries which can be performed under regional anaesthesia can be significant.
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Affiliation(s)
- Elize W Lockhorst
- Department of Surgery, Amphia Hospital, Molengracht 21, 4818 CK, Breda, The Netherlands.
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC University Cancer Institute, Dr. Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands.
| | - Philip M J Schormans
- Department of Surgery, Amphia Hospital, Molengracht 21, 4818 CK, Breda, The Netherlands
| | - Cornelis A S Berende
- Department of Surgery, Amphia Hospital, Molengracht 21, 4818 CK, Breda, The Netherlands
| | | | - Dagmar I Vos
- Department of Surgery, Amphia Hospital, Molengracht 21, 4818 CK, Breda, The Netherlands
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4
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Héroux J, Bessette PO, Bédard S, Lamarche D, Gagnon A, Échavé P, Loignon MJ, Patenaude N, Baillargeon JP, D'Aragon F. Functional recovery of wrist surgery with regional versus general anesthesia: a prospective observational study. Can J Anaesth 2024; 71:761-772. [PMID: 37932649 DOI: 10.1007/s12630-023-02615-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: 12/20/2022] [Revised: 05/17/2023] [Accepted: 05/21/2023] [Indexed: 11/08/2023] Open
Abstract
PURPOSE Regional anesthesia may favour postoperative rehabilitation by inhibiting peripheral sensitization and secondary hyperalgesia. The literature on this subject is limited. In the present FUNCTION study, we sought to compare the functional recovery post orthopedic wrist surgery with regional versus general anesthesia. METHODS We conducted a single-centre prospective observational cohort study in adult patients with a distal radial fracture. Functional recovery was assessed with validated psychometrics questionnaires (Quick Disabilities of Arm, Shoulder and Hand [QuickDASH] and Patient-Rated Wrist Evaluation [PRWE]), range of motion, and grip strength. We used a linear mixed regression model to assess the impact of the anesthesia technique on functional recovery. Postoperative pain and patient satisfaction were evaluated using a visual analog scale. RESULTS We recruited 76 patients. At 12 weeks post surgery, there was no difference between the type of anesthesia and functional recovery with the QuickDASH (higher scores worse; regional anesthesia [RA], 22.7 vs general anesthesia [GA], 19.3; adjusted mean difference [aMD], -0.3; 95% confidence interval [CI], -9.6 to 9.0; P = 0.9) and PRWE (higher scores worse; RA group, 21.0 vs GA group, 20.5; aMD, -3.3; 95% CI, -12.1 to 5.6; P = 0.93) questionnaires. Range of motion, satisfaction, and postoperative pain were similar between groups. Right-hand grip strength was higher in the GA group. CONCLUSION Regional anesthesia was not associated with improved functional recovery compared with general anesthesia. The dominance of the operated limb was a confusion factor in all evaluation modalities. Further research taking into account the dominance of the hand is necessary to establish the effects of regional anesthesia on functional recovery. STUDY REGISTRATION ClinicalTrials.gov (NCT04541745); registered 9 September 2020.
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Affiliation(s)
- Jennifer Héroux
- Department of Anesthesiology, Université de Sherbrooke, Sherbrooke, QC, Canada.
- Department of Anesthesiology, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, 3001 12e Avenue Nord, Sherbrooke, QC, J1H 5H3, Canada.
| | | | - Sonia Bédard
- Department of Orthopedic Surgery, Université de Sherbrooke, Sherbrooke, QC, Canada
- Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Daphnée Lamarche
- Department of Anesthesiology, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Anthony Gagnon
- Department of Anesthesiology, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Pablo Échavé
- Department of Anesthesiology, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Marie-Josée Loignon
- Department of Anesthesiology, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Nicolas Patenaude
- Department of Orthopedic Surgery, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Jean-Patrice Baillargeon
- Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
- Division of Endocrinology, Department of Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Frédérick D'Aragon
- Department of Anesthesiology, Université de Sherbrooke, Sherbrooke, QC, Canada
- Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
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Admiraal M, Marhofer P, Hopkins PM, Hollmann MW. Peripheral regional anaesthesia and outcomes: a narrative review of the literature from 2013 to 2023. Br J Anaesth 2024; 132:1082-1096. [PMID: 37957079 PMCID: PMC11103102 DOI: 10.1016/j.bja.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/02/2023] [Accepted: 10/06/2023] [Indexed: 11/15/2023] Open
Abstract
The use of peripheral regional anaesthesia continues to increase, yet the evidence supporting its use and impact on relevant outcomes often lacks scientific rigour, especially when considering the use of specific blocks for a particular surgical indication. In this narrative review, we consider the relevant literature in a 10-yr period from 2013. We performed a literature search (MEDLINE and EMBASE) for articles reporting randomised controlled trials and other comparative trials of peripheral regional anaesthetic blocks vs systemic analgesia in adult patients undergoing surgery. We evaluated measures of effective treatment and complications. A total of 128 studies met our inclusion criteria. There remains variability in the technical conduct of blocks and the outcomes used to evaluate them. There is a considerable body of evidence to support the use of interscalene blocks for shoulder surgery. Saphenous nerve (motor-sparing) blocks provide satisfactory analgesia after knee surgery and are preferred to femoral nerve blocks which are associated with falls when patients are mobilised early as part of enhanced recovery programmes. There are additional surgical indications where the efficacy of cervical plexus, intercostal nerve, and ilioinguinal/iliohypogastric nerve blocks have been demonstrated. In the past 10 yr, there has been a consolidation of the evidence indicating benefit of peripheral nerve blocks for specific indications. There remains great scope for rigorous, multicentre, randomised controlled trials of many peripheral nerve blocks. These would benefit from an agreed set of patient-centred outcomes.
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Affiliation(s)
- Manouk Admiraal
- Department of Anaesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Peter Marhofer
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria.
| | - Philip M Hopkins
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Markus W Hollmann
- Department of Anaesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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Sellbrant I, Nellgård B, Karlsson J, Albert J, Jakobsson JG. Anaesthesia practice, quality indices including all-cause 30-day mortality associate to wrist fracture repositioning and surgery in Sweden: A perioperative register-based study 2018-2021. Acta Anaesthesiol Scand 2024; 68:402-409. [PMID: 37952557 DOI: 10.1111/aas.14358] [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: 05/24/2023] [Revised: 10/03/2023] [Accepted: 10/31/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Wrist fracture is one of most common fractures frequently requiring surgical anaesthesia. There is limited information related to the anaesthetic practice and quality including 30-day mortality associated with wrist fracture in Sweden in recent years. AIM The aim of the present register-based study was to investigate the anaesthesia techniques used and quality indices including 30-day mortality associated with wrist fracture surgery in Sweden during the period 2018-2021. MATERIALS AND METHODS All fracture repositions, and surgical interventions related to wrist fracture requiring anaesthesia in patients aged >18 years registered in the Swedish Perioperative Register (SPOR) between 2018 and 2021 were included in the analysis. Information on age, ASA class, anaesthesia technique, severe operative events, most reported side-effects during recovery room stay and all-cause 30-day mortality was collected. RESULTS The data set included 25,147 procedures split into 14,796 females and 10,252 males (missing information n = 99) with a mean age of 52.9 ± 18.7 years and a significant age difference between females and males, 60.3 ± 15.4 and 42.2 ± 17.7 years, respectively. Mean age and ASA class increased during the study period (2018-2021), from 52.8 ± 18.6 to 54.0 ± 18.4 and ASA class 3-5 from 8.1% to 9.4% (p < .001 and p < .041, respectively). General anaesthesia (GA), GA combined with regional anaesthesia (RA), RA with or without sedation and sedation only was used in 41%, 13%, 40% and 6% of procedures, respectively, with minor changes over the study period. Pain at arrival in the recovery room (RR), (3.4%), severe pain during RR stay (2.1%), hypothermia (1.4%), postoperative nausea and vomiting (PONV) (1.2%) and urinary retention (0.5%) were the most reported side-effects during the RR stay. (RA) was associated with significantly lower occurrence of pain and PONV, and shorter RR stay, compared with GA (p < .001). The all-cause 30-day mortality was low (19 of 25,147 (0.08%)) with no differences over the period studied or anaesthetic technique. CONCLUSION General anaesthesia or general anaesthesia combined with regional anaesthesia are the most used anaesthetic techniques for wrist fracture procedures in Sweden. Recovery room pain, PONV, hypothermia and urinary retention is reported in overall low frequencies, with no change over the period studied, but in lower frequencies for regional anaesthesia. All-cause 30-day mortality was low; 0.08% with no change over time or between anaesthetic techniques. Thus, the present quality review based on SPOR data supports high quality of perioperative anaesthesia care.
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Affiliation(s)
- Iren Sellbrant
- Department of Anaesthesia and Intensive Care, Sahlgrenska University Hospital and Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Bengt Nellgård
- Department of Anaesthesia and Intensive Care, Sahlgrenska University Hospital and Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Jon Karlsson
- Department of Orthopaedics, Sahlgrenska University Hospital and Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Johanna Albert
- Department of Anaesthesia and Intensive Care, Department for Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Jan G Jakobsson
- Department of Anaesthesia and Intensive Care, Department for Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
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Nguyen TB, Weitzel N, Hogan C, Kacmar RM, Williamson KM, Pattee J, Jevtovic-Todorovic V, Simmons CG, Faruki AA. Comparing Anesthesia and Surgery Controlled Time for Primary Total Knee and Hip Arthroplasty Between an Academic Medical Center and a Community Hospital: Retrospective Cohort Study. JMIR Perioper Med 2024; 7:e45126. [PMID: 38407957 DOI: 10.2196/45126] [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: 12/16/2022] [Revised: 11/23/2023] [Accepted: 12/22/2023] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND Osteoarthritis is a significant cause of disability, resulting in increased joint replacement surgeries and health care costs. Establishing benchmarks that more accurately predict surgical duration could help to decrease costs, maximize efficiency, and improve patient experience. We compared the anesthesia-controlled time (ACT) and surgery-controlled time (SCT) of primary total knee (TKA) and total hip arthroplasties (THA) between an academic medical center (AMC) and a community hospital (CH) for 2 orthopedic surgeons. OBJECTIVE This study aims to validate and compare benchmarking times for ACT and SCT in a single patient population at both an AMC and a CH. METHODS This retrospective 2-center observational cohort study was conducted at the University of Colorado Hospital (AMC) and UCHealth Broomfield Hospital (CH). Cases with current procedural terminology codes for THA and TKA between January 1, 2019, and December 31, 2020, were assessed. Cases with missing data were excluded. The primary outcomes were ACT and SCT. Primary outcomes were tested for association with covariates of interest. The primary covariate of interest was the location of the procedure (CH vs AMC); secondary covariates of interest included the American Society of Anesthesiologists (ASA) classification and anesthetic type. Linear regression models were used to assess the relationships. RESULTS Two surgeons performed 1256 cases at the AMC and CH. A total of 10 THA cases and 12 TKA cases were excluded due to missing data. After controlling for surgeon, the ACT was greater at the AMC for THA by 3.77 minutes and for TKA by 3.58 minutes (P<.001). SCT was greater at the AMC for THA by 11.14 minutes and for TKA by 14.04 minutes (P<.001). ASA III/IV classification increased ACT for THA by 3.76 minutes (P<.001) and increased SCT for THA by 6.33 minutes after controlling for surgeon and location (P=.008). General anesthesia use was higher at the AMC for both THA (29.2% vs 7.3%) and TKA (23.8% vs 4.2%). No statistically significant association was observed between either ACT or SCT and anesthetic type (neuraxial or general) after adjusting for surgeon and location (all P>.05). CONCLUSIONS We observed lower ACT and SCT at the CH for both TKA and THA after controlling for the surgeon of record and ASA classification. These findings underscore the efficiency advantages of performing primary joint replacements at the CH, showcasing an average reduction of 16 minutes in SCT and 4 minutes in ACT per case. Overall, establishing more accurate benchmarks to improve the prediction of surgical duration for THA and TKA in different perioperative environments can increase the reliability of surgical duration predictions and optimize scheduling. Future studies with study populations at multiple community hospitals and academic medical centers are needed before extrapolating these findings.
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Affiliation(s)
- Thy B Nguyen
- University of Colorado School of Medicine, Aurora, CO, United States
| | - Nathaen Weitzel
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Craig Hogan
- Department of Orthopaedic Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Rachel M Kacmar
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Kayla M Williamson
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado - Anschutz Medical Campus, Aurora, CO, United States
| | - Jack Pattee
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado - Anschutz Medical Campus, Aurora, CO, United States
| | - Vesna Jevtovic-Todorovic
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Colby G Simmons
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Adeel Ahmad Faruki
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Department of Anesthesiology and Perioperative Medicine, MD Anderson Cancer Center, Houston, TX, United States
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8
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Gouveia K, Harbour E, Gazendam A, Bhandari M. Fixation of Distal Radius Fractures Under Wide-Awake Local Anesthesia: A Systematic Review. Hand (N Y) 2024; 19:58-67. [PMID: 35880346 PMCID: PMC10786102 DOI: 10.1177/15589447221109632] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The purpose of this systematic review was to analyze the available literature on fixation of distal radius fractures (DRFs) under wide-awake local anesthesia no-tourniquet (WALANT), and to examine postoperative pain scores and functional outcomes, operative data including operative time and blood loss, and the frequency of adverse events. METHODS Embase, MEDLINE, Web of Science, and SCOPUS were searched from inception until May 2022 for relevant studies. Studies were screened in duplicate, and data on pain scores, functional outcomes, and adverse events were recorded. Due to methodological and statistical heterogeneity, the results are presented in a descriptive fashion. RESULTS Ten studies were included comprising 456 patients with closed, unilateral DRFs, of whom 226 underwent fixation under WALANT. These patients had a mean age of 52.8 ± 8.3 years, were 48% female, and had a mean follow-up time of 11.6 months (range: 6-24). Operative time for WALANT patients averaged 60.4 ± 6.5 minutes, with mean postoperative pain scores of 1.4 ± 0.6 on a 10-point scale. Studies that compared WALANT to general anesthesia found shorter hospital stays with most WALANT patients being sent home the same day, decreased postoperative pain scores, and decreased costs to the healthcare system. No adverse events were reported for WALANT patients. CONCLUSIONS A growing body of literature reports that for closed, unilateral DRF, surgical fixation under WALANT is a safe and effective option. It allows patients to have surgery sooner, with improved pain scores and good functional outcomes, with a very low incidence of adverse events.
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Affiliation(s)
- Kyle Gouveia
- Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada
| | - Eric Harbour
- School of Medicine, University of Limerick, Ireland
| | - Aaron Gazendam
- Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada
| | - Mohit Bhandari
- Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada
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Lee JH, Kim HJ, Kim JK, Cheon S, Shin YH. Does intravenous patient-controlled analgesia or continuous block prevent rebound pain following infraclavicular brachial plexus block after distal radius fracture fixation? A prospective randomized controlled trial. Korean J Anesthesiol 2023; 76:559-566. [PMID: 37089120 PMCID: PMC10718626 DOI: 10.4097/kja.23076] [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: 01/31/2023] [Revised: 04/17/2023] [Accepted: 04/23/2023] [Indexed: 04/25/2023] Open
Abstract
BACKGROUND The purpose of this study was to investigate the role of opioid-based intravenous patient-controlled analgesia (IV PCA) or continuous brachial plexus block (BPB) in controlling rebound pain after distal radius fracture (DRF) fixation under BPB as well as total opioid consumption. METHODS A total of 66 patients undergoing surgical treatment for a displaced DRF with volar plate fixation were randomized to receive a single infraclavicular BPB (BPB only group) (n = 22), a single infraclavicular BPB with IV PCA (IV PCA group) (n = 22), or a single infraclavicular BPB with continuous infraclavicular BPB (continuous block group) (n = 22). The visual analog scale (VAS) for pain and the amount of pain medication were recorded at 4, 6, 9, 12, 24, and 48 h and two weeks postoperatively. RESULTS At postoperative 9 h, the pain VAS score was significantly higher in the BPB only group (median: 2; Q1, Q3 [1, 3]) than in the IV PCA (0 [0, 1.8], P = 0.006) and continuous block groups (0 [0, 0.5], P = 0.009). At postoperative 12 h, the pain VAS score was significantly higher in the BPB only group (3 [3, 4]) than in the continuous block group (0.5 [0, 3], P = 0.004). The total opioid equivalent consumption (OEC) was significantly higher in the IV PCA group (350.3 [282.1, 461.3]) than in the BPB only group (37.5 [22.5, 75], P < 0.001) and continuous block group (30 [15, 75], P < 0.001); however, OEC was not significantly different between the BPB only group and the continuous block group (P = 0.595). CONCLUSIONS Although continuous infraclavicular BPB did not reduce total opioid consumption compared to BPB only, this method is effective for controlling rebound pain at postoperative 9 and 12 h following DRF fixation under BPB.
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Affiliation(s)
- Jong-hyuk Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ha-jung Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Kwang Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sungjoo Cheon
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Ho Shin
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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10
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Roh YH, Park SG, Lee SH. Regional versus General Anesthesia in Postoperative Pain Management after Distal Radius Fracture Surgery: Meta-Analysis of Randomized Controlled Trials. J Pers Med 2023; 13:1543. [PMID: 38003859 PMCID: PMC10671853 DOI: 10.3390/jpm13111543] [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: 09/23/2023] [Revised: 10/17/2023] [Accepted: 10/25/2023] [Indexed: 11/26/2023] Open
Abstract
Distal radius fractures are the most prevalent upper extremity fractures, posing a significant public health concern. Recent studies comparing regional and general anesthesia for postoperative pain management after these fractures have yielded conflicting results. This meta-analysis aimed to compare the effectiveness of regional and general anesthesia concerning postoperative pain management and opioid consumption following distal radius fracture surgery. A comprehensive search was conducted in PubMed, Cochrane Library, and EMBASE databases to identify relevant randomized controlled trials. Four randomized trials involving 248 participants were included in the analysis. A pooled analysis revealed that regional anesthesia led to significantly reduced postoperative pain scores at 2 h compared to general anesthesia (SMD -2.03; 95% CI -2.88--1.17). However, no significant differences in pain scores were observed between the two anesthesia types after 12 h post-surgery. Regional anesthesia was associated with lower total opioid consumption (SMD -0.76; 95% CI -1.25--0.26) and fewer occurrences of nausea and vomiting compared to the general anesthesia. Nonetheless, opioid consumption on the first day post-discharge was significantly higher in the regional anesthesia group (SMD 0.83; 95% CI 0.47-1.20). The analgesic superiority of regional anesthesia is confined to the early postoperative hours with overall lower opioid use but a notable increase in opioid consumption on the first day post-discharge, potentially attributable to rebound pain.
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Affiliation(s)
- Young Hak Roh
- Department of Orthopaedic Surgery, Ewha Womans University Medical Center, Ewha Womans University College of Medicine, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul 07985, Republic of Korea; (S.G.P.); (S.H.L.)
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Sciard D, Xu K, Soulier A, Dufour G, Ursino M, Alberti C, Beaussier M. Postoperative analgesia after surgical repair of distal radius fracture: a randomized comparison between distal peripheral nerve blockade and surgical site infiltration. Minerva Anestesiol 2023; 89:876-883. [PMID: 36800809 DOI: 10.23736/s0375-9393.23.16956-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
BACKGROUND Pain following open reduction and internal fixation of distal radius fracture (DRF) can be significant. This study compared the intensity of pain up to 48 hours after volar plating for DRF, associated to either an ultrasound guided distal nerve block (DNB) or surgical site infiltration (SSI). METHODS In this prospective single blind randomized study, 72 patients scheduled for DRF surgery under 1.5% lidocaine axillary block were allocated to receive, at the end of surgery, either an ultrasound-guided median and radial nerves block with ropivacaine 0.375% (DNB) performed by the anesthesiologist or a SSI with the same drug regimen, performed by the surgeon. Primary outcome was the duration between analgesic technique (H0) and pain reappearance (Numerical Rating Scale (NRS 0-10)>3). Secondary outcomes were the quality of analgesia, the quality of sleep, the magnitude of motor blockade, and the patient satisfaction. The study was built on a statistical hypothesis of equivalence. RESULTS Fifty-nine patients were included in the final per-protocol analysis (DNB=30, SSI=29). Time to reach NRS>3 was (in median [95%CI]) 267 min [155;727] and 164 min [120;181] respectively after DNB and SSI (difference=103 min [-22;594] - rejection of equivalence hypothesis). Pain intensity throughout the 48 hours, quality of sleep, opiate consumption, motor blockade and patient satisfaction was not significantly different between groups. CONCLUSIONS Although DNB provides a longer analgesia than SSI, both techniques gave comparable level of pain control during the first 48 hours after surgery, without any difference in the incidence of side effects or patient satisfaction.
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Affiliation(s)
- Didier Sciard
- Department of Anesthesiology, Montsouris Mutualist Institute, Paris, France
| | - Kailai Xu
- Department of Anesthesiology and Intensive Care, St Antoine Hospital, Hospitals of Paris, Paris, France
| | - Anne Soulier
- Department of Anesthesiology and Intensive Care, St Antoine Hospital, Hospitals of Paris, Paris, France
| | - Guillaume Dufour
- Department of Anesthesiology, Montsouris Mutualist Institute, Paris, France
| | - Moreno Ursino
- Unit of Clinical Epidemiology, Public Assistance, Hospitals of Paris, CHU Hôpital Robert Debré, Paris, France
- Inserm, Center of research of Cordeliers, Sorbonne University, University of Paris, Paris, France
| | - Corinne Alberti
- Unit of Clinical Epidemiology, Public Assistance, Hospitals of Paris, CHU Hôpital Robert Debré, Paris, France
| | - Marc Beaussier
- Department of Anesthesiology, Montsouris Mutualist Institute, Paris, France -
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12
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Kim MK, Park YH, Lee JS, Jung HS. How Does the Addition of Dexamethasone to a Brachial Plexus Block Change Pain Patterns After Surgery for Distal Radius Fractures? A Randomized, Double-blind Study. Clin Orthop Relat Res 2023; 481:1966-1974. [PMID: 37053082 PMCID: PMC10499086 DOI: 10.1097/corr.0000000000002640] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/27/2023] [Accepted: 03/07/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Although brachial plexus block in volar plating surgery for distal radius fractures is reportedly associated with lower postoperative pain scores, rebound pain has been reported to occur after the initial block wears off. Dexamethasone can be used in multimodal strategies for antiemesis and to control pain postoperatively. Although prior studies have suggested that anesthesia can be prolonged by adding dexamethasone to regional blocks, no randomized trials we are aware of have ascertained whether doing so will make a clinically important difference in pain after surgery for distal radius fractures. QUESTIONS/PURPOSES Do patients who receive supplemental dexamethasone in a brachial plexus block for volar plating of unstable distal radius fractures have (1) better pain scores at 4, 8, 24, and 48 hours postoperatively than patients who have not received dexamethasone, and (2) lower fentanyl consumption and administration of antiemetic drugs without change in serum blood glucose, as well as a longer analgesic duration from the block after surgery than patients who have not received dexamethasone? METHODS This randomized, double-blind trial included 69 patients undergoing surgery for distal radius fractures under ultrasound-guided supraclavicular brachial plexus blocks who were randomly allocated into two groups: a nondexamethasone group receiving a brachial plexus block with 0.5% ropivacaine and a dexamethasone group receiving 0.5% ropivacaine and 5 mg of dexamethasone. Thirty-four patients were allocated to the dexamethasone group and 35 were allocated to the nondexamethasone group. Nine patients (four in the dexamethasone group and five in the nondexamethasone group) were excluded after randomization because local anesthetics were used during their surgical procedures owing to an incomplete block or they requested patient-controlled analgesia after surgery. The treatment groups did not differ in any important ways, including age, gender, BMI, hand dominance, and AO/Orthopaedic Trauma Association classification. All patients received the same surgical procedure and perioperative care protocol, except for the injected agents during their brachial plexus block. The primary outcome was postoperative pain, evaluated using a 10-mm VAS at 4, 8, 12, 24, and 48 hours after surgery. The minimum clinically important difference for the VAS score was 2 of 10 points. Secondary outcome variables included fentanyl administration as a rescue analgesic, the number of patients receiving antiemetic medications because of fentanyl administration, and the duration of brachial plexus block. Serum blood glucose was measured 1 day before, immediately after, and 24 hours after surgery. Patients, surgeons, and outcome assessors were blinded to treatment allocation. RESULTS The only clinically important between-group difference in VAS pain scores was at 8 hours, favoring the group that received dexamethasone over the group that did not (1.9 ± 1.6 versus 4.7 ± 2.7; mean difference -2.8 [95% CI -3.9 to -1.6]; p < 0.001). After brachial plexus block, the most severe pain score in both groups was reported at 12 hours postoperatively and gradually diminished over time. There was no between-group difference in fentanyl use between those who received dexamethasone and those who did not (21 ± 38 mcg versus 31 ± 29 mcg; mean difference -10 [95% CI -27.4 to 7.4]; p = 0.26). Furthermore, the use of antiemetics did not differ between the groups (27% [eight of 30] versus 37% [11 of 30]; odds ratio 1.6 [95% CI 0.5 to 4.8]; p = 0.41). Baseline and 24-hour postoperative serum blood glucose level did not differ between the groups. However, the immediately postoperative serum blood glucose level was higher in the dexamethasone group than in the nondexamethasone group (121 ± 29 versus 104 ± 20; mean difference 16 [95% CI 3.3 to 28.8]; p = 0.02). The brachial plexus block duration was 3 hours longer (95% CI 0.8 to 5.2 hours) in the dexamethasone group than that in the nondexamethasone group (11 ± 5 hours versus 8 ± 3 hours; p = 0.01). CONCLUSION The postoperative pain level in patients who received supplemental dexamethasone in a regional block was not clinically different from that of patients who received conventional brachial plexus block anesthesia when undergoing volar plating for distal radius fractures. However, patients who received a brachial plexus block with dexamethasone experienced slight prolongation of their block and decrease in pain 8 hours after surgery. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
- Min Kyoung Kim
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Korea
| | - Yong-Hee Park
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, Seoul, Korea
| | - Jae Sung Lee
- Department of Orthopaedic Surgery, Chung-Ang University Hospital, Seoul, South Korea
| | - Hyoung-Seok Jung
- Department of Orthopaedic Surgery, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, South Korea
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13
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Farrell N, Greenfield PT, Rutkowski PT, Weller WJ. Perioperative Pain Management for Distal Radius Fractures. Orthop Clin North Am 2023; 54:463-470. [PMID: 37718085 DOI: 10.1016/j.ocl.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Distal radius fractures have a high incidence among both young and elderly patients, and in many instances require operative intervention. When operative intervention is employed, adequate pain management is essential to decrease postoperative complications, such as chronic pain and disability, while minimizing the risk of prolonged opioid use and dependence. Strategies to optimize pain management include regional anesthesia, preoperative dosing of medication, multimodal regimens, long-acting selective opioids at the time of surgery, corticosteroids, and non-pharmacologic therapies.
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Affiliation(s)
- Nolan Farrell
- Campbell Clinic, Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Paul T Greenfield
- Campbell Clinic, Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Paul T Rutkowski
- Campbell Clinic, Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, Memphis, TN, USA
| | - William Jacob Weller
- Campbell Clinic, Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, Memphis, TN, USA
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14
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Droog W, Walbeehm ET, Konijn JB, Lucas BMJ, Coert JH, Stolker RJ, Galvin EM. A Systematic Review on Long-Term Postsurgical Pain Outcomes; What Is the Effect of Upper Extremity Regional Anesthesia? Anesth Analg 2023; 137:365-374. [PMID: 37227939 DOI: 10.1213/ane.0000000000006529] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND Chronic pain is a recognized complication of surgery, and it has been hypothesized that regional anesthesia might reduce the risk of development of chronic pain after upper extremity surgery. METHODS A systematic literature review was performed to assess whether in patients undergoing elective upper extremity surgery (P), regional anesthesia (I), compared to general anesthesia (C), would result in lower long-term (>3 months) postoperative pain intensity (O). We included randomized and nonrandomized controlled trials (RCTs). Our primary outcome was numerical rating score or visual analogue scale for pain, at >3 months postoperatively. The Embase, Medline ALL, Web of Science Core Collections, Cochrane Central Register of Controlled Trials, and Google Scholar databases were searched for all reports assessing pain at >3 months after upper extremity surgery under general versus regional anesthesia. Secondary outcomes were: opioid prescription filling, complex regional pain syndrome (CRPS) incidence, the Mayo Wrist Score (MWS), and scores on the Disability of the Arm, Shoulder and Hand (DASH) questionnaire. Quality (or certainty) of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Risk-of-bias was assessed using the Cochrane tool for randomized trials (RoB 2.0) and nonrandomized trials (ROBINS-I). RESULTS This review included 14 studies, comprising 7 RCTs and 7 nonrandomized studies. Six of the 7 studies (4 RCTs, N = 273; 2 nonrandomized studies, N = 305) using a pain score, our primary outcome, report comparable long-term postoperative pain scores after regional and general anesthesia. Six of the 7 studies using our secondary outcomes report comparable long-term outcomes in terms of opioid prescription filling (2 retrospective cohort studies [RCSs], N = 89,256), CRPS incidence (1 RCT, N = 301), MWS (1 RCT and 1 RCS, N = 215), and DASH score (1 RCT, N = 36). Comparable outcomes were reported in all 7 RCTs (N = 778) and in 5 of the 7 nonrandomized studies, comprising 5 RCSs (N = 89,608). Two prospective observational studies (POSTs), comprising 279 patients, report a statistically significant difference in outcomes, with less pain and better DASH scores after brachial plexus anesthesia. All 14 studies provided moderate to very low certainty evidence, and there was a serious risk of bias due to confounding bias in 5 of the 7 nonrandomized studies (N = 631). CONCLUSIONS The results of this review indicate that upper extremity regional anesthesia, compared to general anesthesia, is unlikely to change pain intensity at >3 months postoperatively.
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Affiliation(s)
- Wouter Droog
- From the Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Erik T Walbeehm
- Department of Plastic Surgery, Lange Land Hospital, Zoetermeer, The Netherlandsand
| | - Julia B Konijn
- From the Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Benthe M J Lucas
- From the Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - J Henk Coert
- Department of Plastic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Robert Jan Stolker
- From the Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Eilish M Galvin
- From the Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
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15
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Carlson Strother CR, Dittman LE, Rizzo M, Moran SL, Rhee PC. Safety of Cubital Tunnel Release Under General versus Regional Anesthesia. Local Reg Anesth 2023; 16:91-98. [PMID: 37441505 PMCID: PMC10335303 DOI: 10.2147/lra.s389011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 06/01/2023] [Indexed: 07/15/2023] Open
Abstract
Purpose The aim of this study was to evaluate the occurrence of early (<6 weeks) post-operative complications following ulnar nerve decompressions at the cubital tunnel performed under regional anesthesia compared to those performed under general anesthesia. Methods In situ ulnar nerve decompressions at the cubital tunnel performed at a single institution from 2012 through 2019 were retrospectively reviewed. Post-operative complications were compared between subjects who underwent the procedure with regional versus general anesthesia. Results Ninety-one ulnar nerve in situ decompressions were included in the study, which were performed under regional anesthesia in 55 and general anesthesia in 36 cases. The occurrence of post-operative complications was not significantly different between patients who received regional (n = 7) anesthesia and general (n = 8) anesthesia. None of the complications were directly attributed to the type of anesthesia administered. The change in pre- and post-operative McGowan scores were not significantly different between anesthesia groups (p = 0.81). Conclusion In situ ulnar nerve decompression at the cubital tunnel under regional anesthesia does not result in increased post-operative complications compared to those surgeries performed under general anesthesia. In situ ulnar nerve decompression performed under regional anesthesia is a safe and reliable option for patients who wish to avoid general anesthesia. Level of Evidence III.
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Affiliation(s)
| | - Lauren E Dittman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Marco Rizzo
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Steven L Moran
- Department of Plastic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Peter C Rhee
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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16
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Héroux J, Bessette PO, Belley-Côté E, Lamarche D, Échavé P, Loignon MJ, Patenaude N, Baillargeon JP, D'Aragon F. Functional recovery with peripheral nerve block versus general anesthesia for upper limb surgery: a systematic review. BMC Anesthesiol 2023; 23:91. [PMID: 36964490 PMCID: PMC10037794 DOI: 10.1186/s12871-023-02038-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 03/08/2023] [Indexed: 03/26/2023] Open
Abstract
BACKGROUND Peripheral nerve block is a common anesthetic technique used during orthopedic upper limb surgery. Injection of local anesthetics around the target nerve inhibits the action of voltage-dependent sodium channels, inhibiting neurotransmission of pain impulses and providing motor immobility. Compared to general anesthesia, it could improve functional recovery by inhibiting nociceptive impulses and inflammation, thus reducing postoperative pain and immobilization and improving postoperative rehabilitation. This systematic review evaluates the impact of peripheral nerve block versus general anesthesia on postoperative functional recovery following orthopedic upper limb surgery. METHODS We searched CENTRAL, MEDLINE, CINHAL, EMBASE, and Scopus trial databases from inception until September 2021 for studies comparing peripheral nerve block to general anesthesia. We collected data on functional recovery, range of motion, patient satisfaction, quality of life, and return to work. We pooled studies using a random-effects model and summarized the quality of evidence with the GRADE approach. RESULTS We assessed 373 citations and 19 full-text articles for eligibility, and included six studies. Six studies reported on functional recovery, but failed to detect a significant superiority of peripheral nerve block over general anesthesia (3 RCT studies, N = 160; SMD -0.15; CI at 95% -0.60-0.3; I2 = 45%; p = 0.07; low quality of evidence and 3 observational studies, N = 377; SMD -0.35; CI at 95% -0.71-0.01; I2 = 64%; p = 0.06; very low quality of evidence). CONCLUSIONS Current literature is limited and fails to identify the benefit of peripheral nerve block on functional recovery. More studies are needed to assess the impact on long-term recovery. Considering the potential impact on clinical practice and training, a prospective study on functional recovery is ongoing (NCT04541745). TRIAL REGISTRATION PROSPERO ID CRD42018116298. Registered on December 4, 2018.
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Affiliation(s)
- Jennifer Héroux
- Department of Anesthesiology, Université de Sherbrooke, Sherbrooke, QC, Canada.
| | | | - Emilie Belley-Côté
- Divisions of Cardiology and Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Daphnée Lamarche
- Department of Anesthesiology, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Pablo Échavé
- Department of Anesthesiology, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Marie-Josée Loignon
- Department of Anesthesiology, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Nicolas Patenaude
- Department of Orthopedic Surgery, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Jean-Patrice Baillargeon
- Division of Endocrinology, Department of Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Frédérick D'Aragon
- Department of Anesthesiology, Université de Sherbrooke, Sherbrooke, QC, Canada
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
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17
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Cunningham D, LaRose M, Kinamon T, MacAlpine E, Au S, Paniagua A, Klifto C, Gage MJ. The impact of regional anesthesia on opioid demand in distal radius fracture surgery. J Plast Surg Hand Surg 2023; 57:299-307. [PMID: 35544584 DOI: 10.1080/2000656x.2022.2070178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE Regional anesthesia (RA) is commonly used in distal radius fracture surgery to reduce pain and opioid consumption. The purpose of this study was to evaluate the real-world impact of RA on inpatient and outpatient opioid consumption and demand in patients undergoing distal radius fracture surgery. METHODS All patients ages 18 and older undergoing distal radius fracture surgery between 7/2013 and 7/2018 at a single institution (n = 969) were identified. Inpatient opioid consumption and outpatient opioid prescribing in oxycodone 5-mg equivalents (OE's) up to 90-d post-operative were recorded for patients with and without RA. Adjusted models were used to evaluate the impact of RA on opioid outcomes. RESULTS Adjusted models demonstrated decreases in inpatient opioid consumption in patients with RA (10.7 estimated OE's without RA vs. 7.6 OE's with RA from 0 to 24 h post-op, 10.2 vs. 5.3 from 24 to 48 h post-op and 7.5 vs. 5.0 from 48 to 72 h post-op, p<.05). Estimated cumulative outpatient opioid demand was significantly higher in patients with RA (65.3 OE's without RA vs. 81.0 with RA from 1-month pre-op to 2-week post-discharge, 76.1 vs. 87.7 OE's to 6-weeks, and 80.8 vs. 93.5 OE's to 90-d, all p values for RA <.05) though rates of refill were significantly lower in patients with RA from 2-week to 6-week post-op compared to patients without RA. CONCLUSIONS Patients undergoing RA in distal radius fracture surgery had decreased inpatient opioid consumption but increased outpatient demand after adjustment for patient and operative characteristics. LEVEL OF EVIDENCE Level III, retrospective, therapeutic cohort study.
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Affiliation(s)
- Daniel Cunningham
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Micaela LaRose
- Duke University School of Medicine, Duke University Medical Center, NC, USA
| | - Tori Kinamon
- Duke University School of Medicine, Duke University Medical Center, NC, USA
| | - Elle MacAlpine
- Duke University School of Medicine, Duke University Medical Center, NC, USA
| | - Sandra Au
- Duke University School of Medicine, Duke University Medical Center, NC, USA
| | - Ariana Paniagua
- Duke University School of Medicine, Duke University Medical Center, NC, USA
| | - Christopher Klifto
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mark J Gage
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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18
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Kır MÇ, Özen V, Mutlu M, Çabuk H, Kır G. Is Pregabalin Addition to Infraclavicular Block, Effective in Distal Radius Surgery? JOURNAL OF ACADEMIC RESEARCH IN MEDICINE 2022. [DOI: 10.4274/jarem.galenos.2022.50251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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19
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Lee R, Lee D, Ramamurti P, Fassihi S, Heyer JH, Stadecker M, Webber M, Hughes A, Pandarinath R. Complications following regional anesthesia versus general anesthesia for the treatment of distal radius fractures. Eur J Trauma Emerg Surg 2022; 48:4569-4576. [PMID: 34050773 PMCID: PMC8164052 DOI: 10.1007/s00068-021-01704-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 05/13/2021] [Indexed: 11/23/2022]
Abstract
PURPOSE Open reduction and internal fixation (ORIF) are commonly utilized for the repair of distal radius fractures (DRF). While general anesthesia (GA) is typically administered for ORIF, recent studies have also demonstrated promising results with the usage of regional anesthesia (RA) in the surgical treatment of distal radius fractures. This study will compare complication rates between the use of RA versus GA for ORIF of DRFs. METHODS A multi-institutional surgical registry was utilized to identify patients who had undergone ORIF for DRFs from 2005 to 2018-these patients were stratified into GA and RA cohorts. Patients were matched utilizing coarsened-exact-matching (CEM) to compare postoperative outcomes and rates of 30-day complications were compared between the two cohorts. RESULTS Upon CEM-matching, 1191 patients receiving RA were matched to 9250 patients who had received GA, with a multivariate imbalance measure (L1) statistic of < 0.001. In the matched-cohort analysis, no significant differences were observed in rates of any complication (all p ≥ 0.083). On multivariate regression analyses, RA was not associated with increased risk for any complication (p = 0.445), minor complications (p = 0.093), major complications (p = 0.758), unplanned reoperations (p = 0.355), unplanned readmissions (p = 0.799), or mortality (p = 0.579). CONCLUSION With similar safety profiles, RA is a safe and reasonable alternative to GA when managing DRFs surgically. RA may be the preferred anesthetic technique for ORIF of DRFs in patients at high risk with GA, such as those with reactions to GA in the past or with significant cardiopulmonary risk factors.
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Affiliation(s)
- Ryan Lee
- The George Washington University School of Medicine and Health Sciences, The George Washington University in Washington, 2300 M St, Washington, DC 20037 USA
| | - Danny Lee
- Department of Orthopaedic Surgery, University of Miami-Jackson Memorial Health System in Miami, Miami, FL USA
| | - Pradip Ramamurti
- The George Washington University School of Medicine and Health Sciences, The George Washington University in Washington, 2300 M St, Washington, DC 20037 USA
| | - Safa Fassihi
- Department of Orthopaedic Surgery, The George Washington University Hospital in Washington, Washington, DC USA
| | - Jessica H. Heyer
- Department of Orthopaedic Surgery, The George Washington University Hospital in Washington, Washington, DC USA
| | - Monica Stadecker
- Department of Orthopaedic Surgery, The George Washington University Hospital in Washington, Washington, DC USA
| | - Michael Webber
- Department of Orthopaedic Surgery, The George Washington University Hospital in Washington, Washington, DC USA
| | - Alice Hughes
- Department of Orthopaedic Surgery, The George Washington University Hospital in Washington, Washington, DC USA
| | - Rajeev Pandarinath
- Department of Orthopaedic Surgery, The George Washington University Hospital in Washington, Washington, DC USA
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20
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Multimodal Analgesia in the Aesthetic Plastic Surgery: Concepts and Strategies. Plast Reconstr Surg Glob Open 2022; 10:e4310. [PMID: 35572190 PMCID: PMC9094416 DOI: 10.1097/gox.0000000000004310] [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: 03/11/2022] [Accepted: 03/17/2022] [Indexed: 12/13/2022]
Abstract
Postoperative pain management is crucial for aesthetic plastic surgery procedures. Poorly controlled postoperative pain results in negative physiologic effects and can affect length of stay and patient satisfaction. In light of the growing opioid epidemic, plastic surgeons must be keenly familiar with opioid-sparing multimodal analgesia regimens to optimize postoperative pain control. Methods A review study based on multimodal analgesia was conducted. Results We present an overview of pain management strategies pertaining to aesthetic plastic surgery and offer a multimodal analgesia model for outpatient aesthetic surgery practices. Conclusion This review article presents an evidence-based approach to multimodal pain management for aesthetic plastic surgery.
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21
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Kanakamedala AC, Bookman JS, Furgiuele DL, Hacquebord JH. Posterior Shoulder Instability After Infraclavicular Block for Outpatient Hand Surgery. Hand (N Y) 2022; 17:NP9-NP13. [PMID: 34963364 PMCID: PMC9112739 DOI: 10.1177/15589447211065072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Regional blocks are being increasingly utilized for anesthesia for various orthopedic procedures. Several studies have shown that regional anesthesia has fewer side effects and improved postoperative pain relief compared to general anesthesia, but regional blocks are not without risks. We present case reports of 2 patients who experienced posterior shoulder instability, one of whom had a posterior shoulder dislocation, immediately in the postanesthesia care unit after undergoing hand surgery with regional anesthesia. This paper highlights the importance of being aware that patients might be at increased risk of shoulder instability after upper extremity regional anesthesia, and appropriate perioperative precautions should be taken.
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Affiliation(s)
- Ajay C. Kanakamedala
- NYU Langone Health, New York, NY, USA,Ajay C. Kanakamedala, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, 14th Floor, 301 East 17th Street, New York, NY 10003, USA.
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22
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Cunningham DJ, LaRose MA, Zhang GX, Au S, MacAlpine EM, Paniagua AR, Klifto CS, Gage MJ. Regional anesthesia reduces inpatient and outpatient perioperative opioid demand in periarticular elbow surgery. J Shoulder Elbow Surg 2022; 31:e48-e57. [PMID: 34481050 DOI: 10.1016/j.jse.2021.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/31/2021] [Accepted: 08/03/2021] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS Regional anesthesia (RA) can be used to manage perioperative pain in the treatment of periarticular elbow fracture fixation. However, the opioid-sparing benefit is not well-characterized. The hypothesis of this study was that RA had reduced inpatient opioid consumption and outpatient opioid demand in patients who had undergone periarticular elbow fracture surgery. METHODS This study retrospectively reviews inpatient opioid consumption and outpatient opioid demand in all patients aged ≥18 years at a single Level I trauma center undergoing fixation of periarticular elbow (distal humerus and proximal forearm) fracture surgery (n=418 patients). In addition to RA vs. no RA, additional patient and operative characteristics were recorded. Unadjusted and adjusted models were constructed to evaluate the impact of RA and other factors on inpatient opioid consumption and outpatient opioid demand. RESULTS Adjusted models demonstrated decreases in inpatient opioid consumption postoperation in patients with RA (13.7 estimated oxycodone 5-mg equivalents or OEs without RA vs. 10.4 OEs with RA from 0 to 24 hours postoperation, P = .003; 12.3 vs. 9.2 OEs from 24 to 48 hours postoperation, P = .045). Estimated cumulative outpatient opioid demand differed significantly in patients with RA (166.1 vs. 132.1 OEs to 6 weeks, P = .002; and 181 vs. 138.6 OEs to 90 days, P < .001). DISCUSSION In proximal forearm and distal humerus fracture surgery, RA was associated with decreased inpatient and outpatient opioid demand after adjusting for baseline patient and treatment characteristics. These results encourage utilization of perioperative RA to reduce opioid use.
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Affiliation(s)
- Daniel J Cunningham
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Micaela A LaRose
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Gloria X Zhang
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Sandra Au
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Elle M MacAlpine
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Ariana R Paniagua
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Christopher S Klifto
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mark J Gage
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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Sellbrant I, Karlsson J, Jakobsson JG, Nellgård B. Supraclavicular block with Mepivacaine vs Ropivacaine, their impact on postoperative pain: a prospective randomised study. BMC Anesthesiol 2021; 21:273. [PMID: 34753423 PMCID: PMC8577027 DOI: 10.1186/s12871-021-01499-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 10/31/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Supraclavicular block (SCB) with long-acting local anaesthetic is commonly used for surgical repair of distal radial fractures (DRF). Studies have shown a risk for rebound pain when the block fades. This randomised single-centre study aimed to compare pain and opioid consumption the first three days post-surgery between SCB-mepivacaine vs. SCB-ropivacaine, with general anaesthesia (GA) as control. METHODS Patients (n = 90) with ASA physical status 1-3 were prospectively randomised to receive; SCB with mepivacine 1%, 25-30 ml (n = 30), SCB with ropivacaine 0.5%, 25-30 ml (n = 30) or GA (n = 30) with propofol/fentanyl/sevoflurane. Study objectives compared postoperative pain with Numeric Rating Scale (NRS) and sum postoperative Opioid Equivalent Consumption (OEC) during the first 3 days post-surgery between study-groups. RESULTS The three groups showed significant differences in postoperative pain-profile. Mean NRS at 24 h was significantly lower for the SCB-mepivacaine group (p = 0.018). Further both median NRS and median OEC day 0 to 3 were significanly lower in the SCB-mepivacaine group as compared to the SCB-ropivacaine group during the first three days after surgery; pain NRS 1 (IQR 0.3-3.3) and 2.7 (IQR 1.3-4.2) (p = 0.017) and OEC 30 mg (IQR 10-80) and 85 mg (IQR 45-125) (p = 0.004), respectively. The GA-group was in between both in pain NRS and median sum OEC. Unplanned healthcare contacts were highest among SCB-ropivacaine patients (39.3%) vs. SCB-mepivacaine patients (0%) and GA-patients (3.4%). CONCLUSIONS The potential benefit of longer duration of analgesia, associated to a long-acting local anaesthetic agent, during the early postoperative course must be put in perspective of potential worse pain progression following block resolution. TRIAL REGISTRATION NCT03749174 (clinicaltrials.gov, Nov 21, 2018, retrospectively registered).
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Affiliation(s)
- Irén Sellbrant
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Jon Karlsson
- Department of Orthopedic Surgery, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jan G Jakobsson
- Department of Anaesthesia & Intensive Care, Institute of Clinical Science, Karolinska Institute, Danderyd University Hospital, Stockholm, Sweden
| | - Bengt Nellgård
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
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Comeau-Gauthier M, Bhandari M. Cochrane in CORR®: Peripheral Nerve Blocks for Hip Fracture Surgery in Adults. Clin Orthop Relat Res 2021; 479:885-891. [PMID: 33835102 PMCID: PMC8052078 DOI: 10.1097/corr.0000000000001764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Marianne Comeau-Gauthier
- M. Comeau-Gauthier, Orthopedic Surgery Resident, Division of Orthopedic Surgery, McMaster University, Hamilton, ON, Canada
- M. Bhandari, Professor and Academic Head of the Division of Orthopedic Surgery, McMaster University, Hamilton, ON, Canada
| | - Mohit Bhandari
- M. Comeau-Gauthier, Orthopedic Surgery Resident, Division of Orthopedic Surgery, McMaster University, Hamilton, ON, Canada
- M. Bhandari, Professor and Academic Head of the Division of Orthopedic Surgery, McMaster University, Hamilton, ON, Canada
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Muñoz-Leyva F, Cubillos J, Chin KJ. Managing rebound pain after regional anesthesia. Korean J Anesthesiol 2020; 73:372-383. [PMID: 32773724 PMCID: PMC7533186 DOI: 10.4097/kja.20436] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 12/19/2022] Open
Abstract
Rebound pain after regional anesthesia can be defined as transient acute postoperative pain that ensues following resolution of sensory blockade, and is clinically significant, either with regard to the intensity of pain or the impact on psychological well-being, quality of recovery, and activities of daily living. Current evidence suggests that it represents an unmasking of the expected nociceptive response in the absence of adequate systemic analgesia, rather than an exaggerated hyperalgesic phenomenon induced by local anesthetic neural blockade. In the majority of patients, it does not appear to significantly impact cumulative postoperative opioid consumption, quality of recovery, or patient satisfaction, and is not associated with longer-term sequelae such as persistent post-surgical pain. Nevertheless, it must be considered whenever regional anesthesia is incorporated into perioperative management. Strategies to mitigate the impact of rebound pain include routine prescribing of a systemic multimodal analgesic regimen, as well as patient education on appropriate expectations regarding block offset and expected surgical pain, and timely initiation of analgesic medication. Prolonging the duration of action of regional anesthesia with continuous catheter techniques or local anesthetic adjuncts may also help alleviate rebound pain, although further research is required to confirm this.
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Affiliation(s)
- Felipe Muñoz-Leyva
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Javier Cubillos
- Department of Anesthesia and Perioperative Medicine, University Hospital, London Health Sciences Center, Western University, London, ON, Canada
| | - Ki Jinn Chin
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
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Wong SS, Chan WS, Fang C, Chan CW, Lau TW, Leung F, Cheung CW. Infraclavicular nerve block reduces postoperative pain after distal radial fracture fixation: a randomized controlled trial. BMC Anesthesiol 2020; 20:130. [PMID: 32466746 PMCID: PMC7254671 DOI: 10.1186/s12871-020-01044-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 05/20/2020] [Indexed: 12/22/2022] Open
Abstract
Background It is unclear whether regional anesthesia with infraclavicular nerve block or general anesthesia provides better postoperative analgesia after distal radial fracture fixation, especially when combined with regular postoperative analgesic medications. The aim of this study was to compare the postoperative analgesic effects of regional versus general anesthesia. Methods In this prospective, observer blinded, randomized controlled trial, 52 patients undergoing distal radial fracture fixation received either general anesthesia (n = 26) or regional anesthesia (infraclavicular nerve block, n = 26). Numerical rating scale pain scores, analgesic consumption, patient satisfaction, adverse effects, upper limb functional scores (Patient-Rated Wrist Evaluation, QuickDASH), health related quality of life (SF12v2), and psychological status were evaluated after surgery. Result Regional anesthesia was associated with significantly lower pain scores both at rest and with movement on arrival to the post-anesthetic care unit; and at 1, 2, 24 and 48 h after surgery (p ≤ 0.001 at rest and with movement). Morphine consumption in the post-anesthetic care unit was significantly lower in the regional anesthesia group (p<0.001). There were no differences in oral analgesic consumption. Regional anesthesia was associated with lower incidences of nausea (p = 0.004), and vomiting (p = 0.050). Patient satisfaction was higher in the regional anesthesia group (p = 0.003). There were no long-term differences in pain scores and other patient outcomes. Conclusion Regional anesthesia with ultrasound guided infraclavicular nerve block was associated with better acute pain relief after distal radial fracture fixation, and may be preferred over general anesthesia. Trial registration Before subject enrollment, the study was registered at ClinicalTrials.gov (NCT03048214) on 9th February 2017.
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Affiliation(s)
- Stanley S Wong
- Laboratory and Clinical Research Institute for Pain, Department of Anaesthesiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Room 424, Block K, 102, Pokfulam Road, Hong Kong SAR, China.
| | - Wing S Chan
- Laboratory and Clinical Research Institute for Pain, Department of Anaesthesiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Room 424, Block K, 102, Pokfulam Road, Hong Kong SAR, China
| | - Christian Fang
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Chi W Chan
- Department of Anaesthesiology, Queen Mary Hospital, Hong Kong SAR, China
| | - Tak W Lau
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong SAR, China
| | - Frankie Leung
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Chi W Cheung
- Laboratory and Clinical Research Institute for Pain, Department of Anaesthesiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Room 424, Block K, 102, Pokfulam Road, Hong Kong SAR, China
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