Comparison of Continuous Epidural Analgesia, Patient-Controlled Analgesia with Morphine, and Continuous Three-in-One Femoral Nerve Block on Postoperative Outcomes after Total Hip Arthroplasty

A subanesthetic dose of esketamine combined with hip peripheral nerve block has good sedative and analgesic effects in elderly patients undergoing total hip arthroplasty: A randomized-controlled trial

OBJECTIVES

This study aims to observe the postoperative anesthetic effect of esketamine combined with hip capsule peripheral nerve block (PNB) in elderly patients undergoing total hip arthroplasty (THA).

PATIENTS AND METHODS

A total of 120 elderly patients (67 males, 53 females; mean age: 72.5±6.1 years; range, 60 to 89 years) who underwent THA between January 2020 and May 2021 were randomly divided into three groups including 40 patients in each group. The observation group (Group A) was treated with a subanesthetic dose of esketamine combined with hip capsule PNB; control group (Group B) was treated with a subanesthetic dose of esketamine combined with lumbar plexus block; and control group (Group C) was treated with a subanesthetic dose of esketamine for general anesthesia. The onset time of anesthesia, duration of block, postoperative recovery time, postoperative extubation time, mean arterial pressure (MAP), heart rate (HR) indexes, Visual Analog Scale (VAS) and Ramsay Sedation Scale (RSS) scores were recorded.

RESULTS

The onset time of anesthesia, duration of block, postoperative recovery time and postoperative extubation time in Group A were significantly lower than those in Groups B and C (p<0.001). Compared to Groups B and C, the MAP was higher at T1-T3 and the HR was significantly higher at T0-T1 (p<0.05) in Group A. The VAS scores after the operation in Group A were significantly lower than those in Groups B and C (p<0.001), and the RSS scores after the operation were significantly higher in this group than in Groups B and C (p<0.001).

CONCLUSION

A subanesthetic dose of esketamine combined with hip capsule PNB for elderly patients undergoing THA has better postoperative analgesic effects.

Quadratus Lumborum Block Reduces Postoperative Pain Scores and Opioids Consumption in Total Hip Arthroplasty: A Meta-Analysis

Quadratus lumborum block (QL) is a relatively new regional anesthesia technique that has been used in different surgeries for improved outcomes. There are few case reports and studies about its role in total hip arthroplasty with variable effects. This study aimed to evaluate the effect of QL block on postoperative pain control, opioid consumption, and the incidence of postoperative adverse events in total hip arthroplasty surgeries.

A systematic review of the scientific literature addressing the use of QL block in hip arthroplasty was performed following the PRISMA guidelines and using the online database databases, Medline and Science Direct. We registered this review with the PROSPERO database in May 2021 (reference number-CRD42021247055). Two authors performed the literature searches in June 2021 and repeated them in July 2021 to ensure accuracy. Review Manager software (RevMan for Mac, version 5.4; Cochrane Collaboration, Oxford, United Kingdom) was used to perform a meta-analysis of studies included in our review. Five randomized controlled trials were identified for inclusion (n=394) in our meta-analysis.

The results demonstrated a beneficial effect of QL block in pain control at 6, 12, and 24 hours postoperatively after hip arthroplasty (p <0.05). Opioid consumption for 24 hours was significantly reduced in the QL group (p=0.010). Our study also demonstrated that QL block is associated with a significant reduction in postoperative nausea and vomiting (PONV) (p=0.04). In conclusion, QL block can provide significantly better pain control after total hip arthroplasty at 6, 12, and 24 hours postoperatively. It also results in significantly reduced 24 hour-opioid consumption. This block is also associated with a lesser incidence of PONV and a better satisfaction level postoperatively.

Effects of Intraoperative Dexmedetomidine Infusion on Postoperative Delirium in Elderly Patients Undergoing Total Hip Arthroplasty

Objective

To investigate the effects of dexmedetomidine on postoperative delirium in elderly patients undergoing total hip arthroplasty.

Methods

A total of 100 patients, 42 male and 58 female, ages 60 to 85 years, American Society of Anesthesiologists grade I or II, who were undergoing total hip arthroplasty were randomly divided into 2 groups: a dexmedetomidine group (group D; n = 50) and a control group (group C; n = 50). Group D patients were infused with 0.3 μg · kg−1 · h−1 of dexmedetomidine from 5 minutes prior to anesthesia induction until the end of surgery. Group C patients received an equal volume of saline. Heart rate and mean arterial pressure (MAP) were recorded before anesthesia induction (T0), 1 minute before extubation (T1), and 30 minutes after extubation (T2). The Visual Analog Score (VAS) at 1, 2, and 3 days after surgery, the incidence and duration of postoperative delirium, and the length of hospital stay were recorded. Adverse reactions, such as nausea, vomiting, and lethargy, were also recorded.

Results

The Visual Analog Scores in the 2 groups were similar. In group D, there was no significant difference in heart rate (P = 0.232) and MAP (P = 0.056) between T0 and T1. However, in group C, heart rate significantly increased by 15.3 bpm (P = 0.000) and MAP significantly increased by 10.7 mmHg (P = 0.001) at T1 compared with those at T0. The incidence of postoperative delirium in group D (10%) was significantly lower than that in group C (26%; P = 0.037). The duration of delirium in group D (1.3 ± 0.6 days) was shorter than that in group C (3.0 ± 0.5 days; P = 0.000). The length of hospital stay in group D (13.2 ± 0.9 days) was shorter than that in group C (16.1 ± 0.7 days; P = 0.000). No significant differences were observed in adverse effects between the 2 groups.

Conclusion

Intravenous infusion of dexmedetomidine can not only reduce the incidence and duration of postoperative delirium, but also shorten the length of hospital stay in elderly patients undergoing total hip arthroplasty.

Factors Affecting the Length of Convalescent Hospital Stay Following Total Hip and Knee Arthroplasty

Objectives

: An important role of convalescent rehabilitation wards is the short-term improvement of mobility and activities of daily living (ADL). We aimed to identify predictors associated with the length of stay (LOS) in a convalescent hospital after total hip and knee arthroplasty.

Methods

: This study included 308 patients hospitalized in a convalescent ward following total hip or total knee arthroplasty. The following factors were examined: age, sex, orthopedic comorbidities, motor component of the functional independence measure (M-FIM), M-FIM gain, pain, 10-m walk test, timed up and go (TUG) test, functional ambulation category (FAC), cognitive function, and nutritional status. LOS was categorized as shorter (≤40 days) or longer (>40 days), based on the national average LOS in a convalescent ward, and was statistically analyzed with predictor variables.

Results

: In our hospital, the average LOS was 36.9 ± 21.4 days, and the average M-FIM at admission to the convalescent ward and the M-FIM gain were 71.1 ± 7.0 and 16.3 ± 6.9, respectively. In univariate analysis, there was a significant correlation between LOS and M-FIM at admission and M-FIM gain, pain, TUG time, and FAC. Logistic multivariate analysis identified M-FIM at admission (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.88–0.98) and TUG time (OR 1.10, 95% CI 1.03–1.18) as independent predictors of LOS.

Conclusions

: The M-FIM and TUG test can be used to accurately estimate LOS and to plan rehabilitation treatment in a convalescent rehabilitation ward after lower-limb arthroplasty. Furthermore, preoperative or early postoperative intervention may lead to better quality motor activity and shorter LOS during the convalescent period.

Comparison of the suprainguinal fascia iliaca compartment block with continuous epidural analgesia in patients undergoing hip surgeries: a retrospective study

Background and objective

Pain control is one of the major concerns after major hip surgeries. Suprainguinal fascia iliaca compartment block (S-FICB) is an alternative analgesic technique that can be considered as an effective and less invasive method than epidural analgesia (EA). In this retrospective study, we compared postoperative analgesic efficacy of single shot ultrasound guided S-FICB and EA after major hip surgery.

Methods

We retrospectively examined 150 patients who underwent major hip surgeries and who received S-FICB or EA. Seventy-two patients submitted to EA and 78 patients who received S-FICB were included and their medical records retrospectively reviewed. Morphine consumptions, VAS scores, and side effects were recorded. Patients under antiplatelet or anticoagulant theraphy were also registered. Morphine consumption and VAS scores were the primary endpoints, succes rate and complications were the secondary endpoints of our study. P-values less than 0.05 were considered statistically significant.

Results

Morphine consumption was lower at the emergence in the EA group but there was no statistically significant difference between the two groups according to total opioid consumption (0 [0-0] vs 0 [0-0]; p = 0.52). There was no difference between VAS scores in the first 18 hours. Hypotension was significantly higher in the EA group (9 vs 21; p = 0.04).

Conclusion

In conclusion, S-FICB can provide comparable analgesia with EA in the early postoperative period after hip surgery but VAS scores were found lower in the EA group than S-FICB group after 18^th hour. Hypotension has occured more frequently in patients receiving EA.

Procedure-specific acute pain trajectory after elective total hip arthroplasty: systematic review and data synthesis

BACKGROUND

For most procedures, there is insufficient evidence to guide clinicians in the optimal timing of advanced analgesic methods, which should be based on the expected time course of acute postoperative pain severity and aimed at time points where basic analgesia has proven insufficient.

METHODS

We conducted a systematic search of the literature of analgesic trials for total hip arthroplasty (THA), extracting and pooling pain scores across studies, weighted for study size. Patients were grouped according to basic anaesthetic method used (general, spinal), and adjuvant analgesic interventions such as nerve blocks, local infiltration analgesia, and multimodal analgesia. Special consideration was given to high-risk populations such as chronic pain or opioid-dependent patients.

RESULTS

We identified and analysed 71 trials with 5973 patients and constructed pain trajectories from the available pain scores. In most patients undergoing THA under general anaesthesia on a basic analgesic regimen, postoperative acute pain recedes to a mild level (<4/10) by 4 h after surgery. We note substantial variability in pain intensity even in patients subjected to similar analgesic regimens. Chronic pain or opioid-dependent patients were most often actively excluded from studies, and never analysed separately.

CONCLUSIONS

We have demonstrated that it is feasible to construct procedure-specific pain curves to guide clinicians on the timing of advanced analgesic measures. Acute intense postoperative pain after THA should have resolved by 4-6 h after surgery in most patients. However, there is a substantial gap in knowledge on the management of patients with chronic pain and opioid-dependent patients.

Transmuscular Quadratus Lumborum and Lateral Femoral Cutaneous Nerve Block in Total Hip Arthroplasty

OBJECTIVES

Adequate pain control after total hip arthroplasty is essential for patient satisfaction and surgical outcome.

METHODS

A retrospective study with before and after design was performed in 210 elective total hip arthroplasty patients. The control group (N=132) received spinal anesthesia with periarticular injection (PAI) and the treatment group (N=78) received transmuscular quadratus lumborum block and lateral femoral cutaneous nerve block in addition to spinal anesthesia and PAI. The primary outcome was visual analog scale (VAS) pain score on postoperative day (POD) 1, and secondary outcomes included VAS and opioid consumption on each POD, hospitalization cost, length of stay, and discharge acuity.

RESULTS

The mean VAS and opioid consumption (MME) were significantly lower in the treatment group than that in the control group on POD 1, with VAS difference -1.10 (95% confidence interval, -1.64 to -0.55), false discover rate corrected (P<0.001), and MME difference -26.19 (95% confidence interval, -39.16 to -13.23, P<0.001). A significant difference was also found for both VAS (P=0.007) and opioid consumption (P=0.018) on POD 2 and for opioid consumption on POD 3 (P=0.008). Length of stay (days) in the control group versus the treatment group was 2.50±1.38 versus 1.36±0.95 (P=0.002), and the total cost of hospitalization was over 20% higher in the control group than that in the treatment group (P=0.002).

DISCUSSION

The addition of transmuscular quadratus lumborum and lateral femoral cutaneous nerve block in total hip arthroplasty provides improved analgesia indicated by lower pain scores and opioid reduction and accelerated recovery with shorter hospitalization and decreased hospitalization cost.

Effectiveness of Ultrasound-guided Single-injection Triple Nerve Block Before Cementless Bipolar Hip Hemiarthroplasty in Femoral Neck Fractures

Purpose

To compare efficacy of ultrasound (US)-guided single-injection nerve blocks (SINB) before bipolar hemiarthroplasty (BHA) of the hip in patients with femoral neck fractures.

Materials and Methods

Clinical outcomes of 89 patients who underwent BHA between September 2016 and February 2018 were retrospectively compared. Eight patients were excluded according to exclusion criteria and the remaining patients were divided into two groups: patients who received SINB before surgery (Group I; n=40), and patients who did not (Group II; n=41). The femoral, obturator, and lateral femoral cutaneous nerves were each blocked separately under US guidance. Pain scores determined using the visual analogue scale (VAS) were recorded 6, 12, 24, and 48 hours postoperatively, and all use of analgesics were recorded separately for 72 hours after surgery. Duration of hospitalization, general complications, and local complications due to SINB were also compared among the groups.

Results

Significant differences were observed between the two groups: I) VAS at 6 hours and at 12 hours after the operation, II) total amounts of analgesics used. VAS at 24 hours and at 48 hours were not significantly different between the two groups. General complications and duration of hospitalization were also not significantly different between the groups.

Conclusion

US-guided lower limb nerve blocks provide excellent immediate postoperative pain relief and can be used as a safe, and effective method of pain control after BHA.

Multimodal Analgesia (MMA) Versus Patient-Controlled Analgesia (PCA) for One or Two-Level Posterior Lumbar Fusion Surgery

A multimodal analgesic method was known to avoid the high-dose requirements and dose-dependent adverse events of opioids, and to achieve synergistic effects. The purpose of this study was to compare the efficacy of our multimodal analgesia (MMA) regimen with that of the patient-controlled analgesia (PCA) method for acute postoperative pain management. Patients who underwent one or two-level posterior lumbar fusion (PLF) followed by either MMA or PCA administration at our hospital were compared for pain score, additional opioid and non-opioid consumption, side effects, length of hospital stay, cost of pain control, and patient satisfaction. From 2016 through 2017, a total 146 of patients were screened. After propensity score matching, 66 remained in the PCA and 34 in the MMA group. Compared with the PCA group, the MMA group had a shorter length of hospital stay (median (interquartile range): 7 days (5-8) vs. 8 (7-11); P = 0.001) and lower cost of pain control (70.6 ± 0.9 USD vs. 173.4 ± 3.3, P < 0.001). Baseline data, clinical characteristics, pain score, additional non-opioid consumption, side effects, and patient subjective satisfaction score were similar between the two groups. The MMA seems to be a good alternative to the PCA after one or two-level PLF.

Continuous quadratus lumborum block and femoral nerve block for total hip arthroplasty: a randomized study

BACKGROUND

Continuous femoral nerve block (FNB) has been effectively used after total hip arthroplasty (THA). Recently the anterior approach to quadratus lumborum block (QLB) has been shown to produce postoperative pain relief after THA. Continuous QLB would benefit from a catheter insertion site that is farther away from the surgical site compared with continuous FNB. In this randomized controlled study, we compared analgesic effects of the two techniques in patients undergoing THA.

METHODS

Thirty patients undergoing THA were randomly allocated into two groups receiving continuous QLB and FNB. Under ultrasound guidance, QLB and FNB were conducted before general anesthesia using 0.25% levobupivacaine 30 ml and 0.5% levobupivacaine 15 ml, respectively, and a catheter was introduced. Postoperatively, all patients received continuous infusion of 0.125% levobupivacaine at 4 ml/h. Postoperative measurements included visual analog scale (VAS) pain scores at rest and on movement, postoperative analgesic demands, cutaneous sensory blockade and adverse events for 48 h.

RESULTS

Six patients were excluded and 24 patients (13 and 11 patients in QLB group and FNB, respectively) were analyzed. VAS scores on movement at 6 h [median (IQR): 67 (41-80) and 38 (22-41) in QLB and FNB groups, respectively, p = 0.008] and 24 h [60 (40-80) and 39 (28-64) in QLB and FNB groups, respectively, p = 0.018] were lower with FNB than with QLB. QLB did not produce consistent cutaneous sensory blockade.

CONCLUSIONS

Analgesic effects of continuous QLB were inferior to those of continuous FNB in patients undergoing THA under the current study condition.

Endogenous Opiates and Behavior: 2016

This paper is the thirty-ninth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2016 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia, stress and social status, tolerance and dependence, learning and memory, eating and drinking, drug abuse and alcohol, sexual activity and hormones, pregnancy, development and endocrinology, mental illness and mood, seizures and neurologic disorders, electrical-related activity and neurophysiology, general activity and locomotion, gastrointestinal, renal and hepatic functions, cardiovascular responses, respiration and thermoregulation, and immunological responses.

Comparison of intravenous and oral acetaminophen for pain control after total knee and hip arthroplasty: A systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy between intravenous and oral acetaminophen as adjunct to multimodal analgesia regimens for pain management after total knee and hip arthroplasties.

METHODS

We conduct electronic searches of Medline (1966-2017.09), PubMed (1966-2017.09), Embase (1980-2017.09), ScienceDirect (1985-2017.09), and the Cochrane Library. Only randomized controlled trials (RCTs) are included. The quality assessment is performed according to the Cochrane systematic review method. Fixed/random effect model is adopted according to the heterogeneity tested by I statistic. Meta-analysis is performed using Stata 11.0 software.

RESULTS

Two RCTs are included involving 236 patients. The present meta-analysis demonstrated that there were no significant differences between groups regarding pain scores at 12, 24, or 48 hours. No significant differences were observed in terms of opioid consumption at 12, 24, or 48 hours after arthroplasties.

CONCLUSION

Intravenous acetaminophen to multimodal analgesia dose not demonstrate a significant benefit in reducing pain and opioid consumption compared oral formulation after total knee arthroplasty and total hip arthroplasty. Higher-quality RCTs are required for further research.

Essential Elements of Multimodal Analgesia in Enhanced Recovery After Surgery (ERAS) Guidelines

Perioperative multimodal analgesia uses combinations of analgesic medications that act on different sites and pathways in an additive or synergistic manner to achieve pain relief with minimal or no opiate consumption. Although all medications have side effects, opiates have particularly concerning, multisystemic, long-term, and short-term side effects, which increase morbidity and prolong admissions. Enhanced recovery is a systematic process addressing each aspect affecting recovery. This article outlines the evidence base forming the current multimodal analgesia recommendations made by the Enhanced Recovery After Surgery Society (ERAS). We describe current evidence and important future directions for effective perioperative multimodal analgesia in enhanced recovery pathways.

Femoral Nerve Catheters Improve Home Disposition and Pain in Hip Fracture Patients Treated With Total Hip Arthroplasty

BACKGROUND

Opioids have been the mainstay of treatment in the physiologically young geriatric hip fracture patient undergoing total hip arthroplasty (THA). However opioid-related side effects increase morbidity. Regional anesthesia may provide better analgesia, while decreasing opioid-related side effects. The goal of this study was to examine the effect of perioperative continuous femoral nerve blockade with regards to pain scores, opioid-related side effects and posthospital disposition in hip fracture patients undergoing THA.

METHODS

Twenty-nine consecutive geriatric hip fracture patients (22 women/7 men) underwent THA. Average follow-up was 8.3 months (6 weeks-39 months). Fifteen patients were treated with standard analgesia (SA). Fourteen patients received an ultrasound-guided insertion of a femoral nerve catheter after radiographic confirmation of a hip fracture. All complications and readmissions that occurred within 6 weeks of surgery were noted.

RESULTS

Continuous femoral nerve catheter (CFNC) patients were discharged home more frequently than SA patients (43% for CFNC vs 7% for SA; P = .023). CFNC patients reported lower average pain scores preoperatively (P < .0001), on postoperative day 1 (P = .005) and postoperative day 2 (P = .037). Preoperatively, CFNC patients required 61% less morphine equivalent (P = .007). CFNC patients had a lower rate of opioid-related side effects compared with SA patients (7% vs 47%; P = .035).

CONCLUSION

CFNC patients were discharged to home more frequently. Use of a CFNC decreased daily average patient-reported pain scores, preoperative opioid usage, and opioid-related side effects after THA for hip fracture. Based on these data, we recommend routine use of perioperative CFNC in hip fracture patients undergoing THA.

Comparison of Anesthetic Administration According to Method of Hip Surgery

OBJECTIVE

The aim of this study is to compare total hip prosthesis (THP), partial hip prosthesis (PHP), and proximal femoral nail (PFN) patients in terms of the chosen anesthetic method.

METHODS

A total of 850 patients who underwent hip surgery were divided into 3 groups according to the operation type: PHP (n=281), PFN (n=393), and THP (n=176). The type of anesthesia administered, interventions during anesthesia, and complications were retrospectively evaluated. The groups were compared in terms of patient age, American Society of Anesthesiologists (ASA) scores, chosen anesthetic method, operation duration, colloid use during operation, use of antihypertensive medication, use of vasoconstrictor medication, development of hypotension, blood transfusion administered, development of cardiac arrest, requirements for intensive care after operation, and use of a central catheter.

RESULTS

In the THP group, the mean age of patients was significantly lower as compared to the PHP and PFN groups. The duration of operation was lower in the PFN group as compared to the other two groups. In the THP group, general anesthesia was significantly high, while in the PFN group, regional anesthetic administration was high. While colloid use was greater in the PFN group, the blood transfusion rate was higher in the THP group. The use of antihypertensive medication was higher in the THP group as compared to the other groups.

CONCLUSION

Although all three anesthetic methods could be used in hip surgery, the type of anesthesia should be chosen according to the type of hip surgery considering the duration of operation, age of the patient, and blood lost during the operation.

Combination Therapy with Continuous Three-in-One Femoral Nerve Block and Periarticular Multimodal Drug Infiltration after Total Hip Arthroplasty

Background. Various postoperative pain relief modalities, including continuous femoral nerve block (CFNB), local infiltration analgesia (LIA), and combination therapy, have been reported for total knee arthroplasty. However, no studies have compared CFNB with LIA for total hip arthroplasty (THA). The aim of this study was to compare the efficacy of CFNB versus LIA after THA. Methods. We retrospectively reviewed the postoperative outcomes of 93 THA patients (20 men, 73 women; mean age 69.2 years). Patients were divided into three groups according to postoperative analgesic technique: CFNB, LIA, or combined CFNB+LIA. We measured the following postoperative outcome parameters: visual analog scale (VAS) for pain at rest, supplemental analgesia, side effects, mobilization, length of hospital stay, and Harris Hip Score (HHS). Results. The CFNB+LIA group had significantly lower VAS pain scores than the CFNB and LIA groups on postoperative day 1. There were no significant differences among the three groups in use of supplemental analgesia, side effects, mobilization, length of hospital stay, or HHS at 3 months after THA. Conclusions. Although there were no clinically significant differences in outcomes among the three groups, combination therapy with CFNB and LIA provided better pain relief after THA than CFNB or LIA alone, with few side effects.

Perioperative Pain Management in Total Hip Arthroplasty: Korean Hip Society Guidelines

Effective perioperative pain management techniques and accelerated rehabilitation programs can improve health-related quality of life and functional status of patients after total hip arthroplasty. Traditionally, postoperative analgesia following arthroplasty was provided by intravenous patient-controlled analgesia or epidural analgesia. Recently, peripheral nerve blockade has emerged alternative analgesic approach. Multimodal analgesia strategy combines analgesics with different mechanisms of action to improve pain management. Intraoperative periarticular injection of multimodal drugs is one of the most important procedures in perioperative pain control for total hip arthroplasty. The goal of this review article is to provide a concise overview of the principles of multimodal pain management regimens as a practical guide for the perioperative pain management for total hip arthroplasty.