Enrique A. Goytizolo

Lumbar plexus blockade reduces pain after hip arthroscopy: a prospective randomized controlled trial.

BACKGROUND:Hip arthroscopy causes moderate to severe postoperative pain. We hypothesized that performance of a lumbar plexus block (LPB) would reduce postoperative pain in the postanesthesia care unit (PACU) for patients discharged home on the day of surgery. METHODS:Patients received a combined spinal epidural with IV sedation, ondansetron, and ketorolac. Half of the patients (n = 42) also underwent a single-injection bupivacaine LPB. Postoperative analgesia (PACU and after discharge) was provided with oral hydrocodone/acetaminophen (5/500 mg) and an oral nonsteroidal antiinflammatory drug. IV hydromorphone was given as needed in the PACU. RESULTS:The LPB reduced pain at rest in the PACU (GEE: &bgr; estimate of the mean on a 0 to 10 scale = −0.9; 95% confidence interval = −1.7 to −0.1; P = 0.037). Mean PACU pain scores at rest were reduced by the LPB from 4.2 to 3.3 (P = 0.048, 95% confidence interval for difference = 0.007–1.8; uncorrected for multiple values per patient, using independent samples t test for preliminary evaluation comparing pain between the groups). There were no statistically significant differences in PACU analgesic usage, PACU pain with movement, and patient satisfaction. No permanent adverse events occurred, but 2 LPB patients fell in the PACU bathroom, without injury. Three unplanned admissions occurred; one LPB patient was admitted for epidural spread and urinary retention. Two control patients were admitted, one for oxygen desaturation and one for pain and nausea. CONCLUSION:LPB resulted in statistically significant reductions in PACU resting pain after hip arthroscopy, but the absence of improvement in most secondary outcomes suggests that assessment of risks and benefits of LPB should be individualized.

Nerve stimulator versus ultrasound guidance for placement of popliteal catheters for foot and ankle surgery.

STUDY OBJECTIVEnTo determine whether ultrasound guidance improves the quality of continuous popliteal block when compared with a nerve stimulator after major foot and ankle surgery.nnnDESIGNnProspective, randomized, double-blinded clinical trial.nnnSETTINGnOperating room, Postanesthesia Care Unit (PACU), and hospital wards of a university-affiliated hospital.nnnPATIENTSn45 ASA physical status 1, 2, and 3 patients undergoing elective major foot and ankle surgery.nnnINTERVENTIONSnPlacement of a popliteal sciactic nerve catheter using either nerve stimulator or ultrasound guidance. In the PACU, a continuous infusion of ropivacaine 0.2% was started at a basal rate of 4 mL/hr and adjusted in a standardized fashion to maintain visual analog scale (VAS) pain scores < 4. All patients also received intravenous (IV) patient-controlled analgesia with hydromorphone and oral opioids.nnnMEASUREMENTSnVAS pain scores at rest and with physical therapy, ropivacaine use, opioid use, and opioid-related side effects were recorded.nnnMAIN RESULTSnCummulative ropivacaine use was lower in patients whose catheter was placed by ultrasound than by nerve stimulator guidance (mean 50 vs 197 mL, P < 0.001). Pain scores at rest and during activity were similar between groups. Cumulative opioid consumption (mean 858 vs 809 mg oral morphine equivalents) and daily frequencies of nausea (5% to 33% vs 0 to 24%) and pruritus (0 to 21% vs 0 to 24%) were similar between groups. Length of hospital stay was similar between groups (3.5 vs 3.7 days).nnnCONCLUSIONSnUltrasound guidance was associated with less local anesthetic consumption than with the nerve stimulator; however, there was little clinical benefit, as all other outcomes were similar between groups.

A Clinical Pathway for Total Shoulder Arthroplasty—A Pilot Study

BackgroundAppropriate pain management after total shoulder arthroplasty (TSA) facilitates rehabilitation and may improve clinical outcomes.Questions/purposesThis prospective, observational study evaluated a multimodal analgesia clinical pathway for TSA.MethodsTen TSA patients received an interscalene nerve block (25xa0cm3 0.375% ropivacaine) with intraoperative general anesthesia. Postoperative analgesia included regularly scheduled non-opioid analgesics (meloxicam, acetaminophen, and pregabalin) and opioids on demand (oral oxycodone and intravenous patient-controlled hydromorphone). Patients were evaluated twice daily to assess pain, anterior deltoid strength, handgrip strength, and sensory function.ResultsThe nerve block lasted an average of 18xa0h. Patients had minimal pain after surgery; 0 (median score on a 0–10 scale) in the Post-Anesthesia Care Unit (PACU) but increased on postoperative day (POD) 1 to 2.3 (0.0, 3.8; median (25%, 75%)) at rest and 3.8 (2.1, 6.1) with movement. Half of the patients activated the patient-controlled analgesia four or fewer times in the first 24xa0h after surgery. Operative anterior deltoid strength was 0 in the PACU but returned to 68% by POD 1. Operative hand strength was 0 (median) in the PACU, but the third quartile (75%) had normalized strength 49% of preoperative value.ConclusionsPatients did well with this multimodal analgesic protocol. Pain scores were low, half of the patients used little or no intravenous opiate, and some patients had good handgrip strength. Future research can focus on increasing duration of analgesia from the nerve block, minimizing motor block, lowering pain scores, and avoiding intravenous opioids.

Buprenorphine, Clonidine, Dexamethasone, and Ropivacaine for Interscalene Nerve Blockade: A Prospective, Randomized, Blinded, Ropivacaine Dose-Response Study

OBJECTIVEnThis study investigated interscalene block for shoulder arthroplasty with various ropivacaine concentrations in the presence of clonidine, dexamethasone, and buprenorphine. The goal was prolonged analgesia with minimal motor blockade.nnnDESIGNnProspective, double-blind, randomized controlled trial.nnnSETTINGnUniversity-affiliated orthopedic hospital.nnnMETHODSnPatients (20/group) received acetaminophen, ketorolac, pregabalin, opioids, and Control; interscalene block, 0.375% ropivacaine, intravenous additives (buprenorphine, clonidine, dexamethasone); High Dose; 0.375% ropivacaine, perineural additives; Medium Dose; 0.2% ropivacaine, perineural additives; and Low Dose; 0.1% ropivacaine, perineural additives.nnnRESULTSnPain with movement at 24 hours was 4.9u2009±u20092.5 (meanu2009±u2009standard deviation [SD]) (Control), 4.5u2009±u20093.0 (High Dose), 3.4u2009±u20091.8 (Medium Dose), 4.2u2009±u20092.4 (Low Dose). The difference between Medium Dose and Control wasu2009-1.5 (95% CI:u2009-2.9,u2009-0.1) (Pu2009=u20090.040). Median time until need for opioids was 16.1 hours (Control) vs 23.7 hours (High Dose); hazard ratio 0.37 [95% CI: 0.17, 0.79]. High Dose had less pain with movement the morning after surgery, vs Control; 2.9u2009±u20092.5 vs 4.9u2009±u20092.7; Pu2009=u20090.027. Pain with movement in the Post-Anesthesia Care Unit was higher in Low Dose, vs Control; 0.9u2009±u20091.4 vs 0u2009±u20090, Pu2009=u20090.009. Low Dose had superior hand strength in the Post-Anesthesia Care Unit (meanu2009±u2009SD of pre-operative strength: 44.0u2009± 20.3%) compared to Control (27.5u2009±u200924.5%) (Pu2009=u20090.031).nnnCONCLUSIONSnFor maximum pain reduction, combining perineural additives with ropivacaine 0.375% or 0.2% is suggested. To minimize motor blockade, perineural additives can be combined with ropivacaine, 0.1%.

Prospective, Randomized Double-Blind Study: Does Decreasing Interscalene Nerve Block Volume for Surgical Anesthesia in Ambulatory Shoulder Surgery Offer Same-Day Patient Recovery Advantages?

Background and Objectives In this randomized double-blind prospective study in patients undergoing shoulder arthroscopy, we compared the effects of ultrasound-guided interscalene nerve block using 20 mL (intervention group) and 40 mL (control group) of a mepivacaine 1.5% and bupivacaine 0.5% mixture (1:1 volume) on ipsilateral handgrip strength and other postoperative end points. Methods One hundred fifty-four patients scheduled for ambulatory shoulder arthroscopy were randomly assigned to receive a single-injection interscalene block under ultrasound guidance with either 40 mL (control) or 20 mL (intervention) and intravenous sedation. The primary outcome was the change in ipsilateral handgrip strength in the postanesthesia care unit (PACU) measured with a dynamometer. Secondary end points were recorded, including negative inspiratory force, incidences of hoarseness and Horner syndrome, time to readiness for discharge from PACU, time to discharge from PACU, patient satisfaction, time to block resolution, and pain scores. Results Postoperative handgrip strength was greater in the 20-mL group compared with the 40-mL group (difference in means, 2.3 kg [95% confidence interval, 0.6–4.0 kg]; P = 0.009). A smaller proportion of patients in the intervention group experienced hoarseness postoperatively compared with the control group (odds ratio, 0.26 [95% confidence interval, 0.08–0.82]; P = 0.015). Patient satisfaction and duration of analgesia were similar in both groups. Conclusions When used for surgical anesthesia for shoulder arthroscopies in the ambulatory setting, a 20-mL volume in an ultrasound-guided interscalene block preserves greater handgrip strength on the ipsilateral side in the PACU compared with 40 mL without significant decrease in block success, duration of analgesia, and patient satisfaction.

The Effect of Regional Analgesia on Vascular Tone in Hip Arthroplasty Patients

BackgroundWhile it is assumed that neuraxial analgesia and pain management may beneficially influence perioperative hemodynamics, few studies provided data quantifying such effects and none have assessed the potential contribution of the addition of a nerve block.Questions/PurposesThis clinical trial compared the visual analog scale (VAS) scores and measurement of arterial tone using augmentation index of patients who received combined spinal–epidural (CSE) only to patients who received both CSE and lumbar plexus block.MethodsAfter obtaining written consent, 92 patients undergoing total hip arthroplasty were randomized to receive either CSE or CSE with lumbar plexus block (LPB). Perioperative pain and arterial tone were measured using VAS scores and augmentation index (AI) respectively, at baseline and at various times postoperatively.ResultsAfter the exclusion of 2 patients, 44 patients received CSE alone and 46 patients received CSE and LPB. Patient demographics and perioperative characteristics were similar in both groups. AI continuously decreased after placement of a CSE with or without LBP, beyond full resolution of neuraxial and peripheral blockade. Although the LPB group demonstrated a statistically significant reduction of VAS pain scores in the postanesthesia care unit (PACU; Pu2009<u20090.05), overall, the addition of a LPB did not significantly reduce the AI when compared to the control group.ConclusionThe addition of a LPB provided better pain control in the PACU but did not reduce the AI, compared to the control group. We conclude that the addition of a LPB may have limited ability to affect arterial tone in the presence of a continuous infusion of epidural analgesics. In summary, the addition of a LPB in patients undergoing total hip arthroplasty is clinically effective and provided better pain control, especially in the immediate postoperative period. The continuous decrease on the AI in both groups beyond the full resolution of the neuroaxial and LPB will require further studies.

Adductor Canal Block versus Femoral Nerve Block for Total Knee ArthroplastyA Prospective, Randomized, Controlled Trial

Background:This prospective double-blinded, randomized controlled trial compared adductor canal block (ACB) with femoral nerve block (FNB) in patients undergoing total knee arthroplasty. The authors hypothesized that ACB, compared with FNB, would exhibit less quadriceps weakness and demonstrate noninferior pain score and opioid consumption at 6 to 8 h postanesthesia. Methods:Patients received an ACB or FNB as a component of a multimodal analgesic. Quadriceps strength, pain score, and opioid consumption were assessed on both legs preoperatively and at 6 to 8, 24, and 48 h postanesthesia administration. In a joint hypothesis test, noninferiority was first evaluated on the primary outcomes of strength, pain score, and opioid consumption at 6 to 8 h; superiority on each outcome at 6 to 8 h was then assessed only if noninferiority was established. Results:Forty-six patients received ACB; 47 patients received FNB. At 6 to 8 h postanesthesia, ACB patients had significantly higher median dynamometer readings versus FNB patients (median [interquartile range], 6.1 kgf [3.5, 10.9] (ACB) vs. 0 kgf [0.0, 3.9] (FNB); P < 0.0001), but was not inferior to FNB with regard to Numeric Rating Scale pain scores (1.0 [0.0, 3.5] ACB vs. 0.0 [0.0, 1.0] FNB; P = 0.019), or to opioid consumption (32.2 [22.4, 47.5] ACB vs. 26.6 [19.6, 49.0]; P = 0.0115). At 24 and 48 h postanesthesia, there was no significant statistical difference in dynamometer results, pain scores, or opioid use between the two groups. Conclusion:At 6 to 8 h postanesthesia, the ACB, compared with the FNB, exhibited early relative sparing of quadriceps strength and was not inferior in both providing analgesia or opioid intake.This prospective double-blinded, randomized controlled trial compared adductor canal block (ACB) with femoral nerve block (FNB) in patients undergoing total knee arthroplasty. The authors hypothesized that ACB, compared with FNB, would exhibit less quadriceps weakness and demonstrate noninferior pain score and opioid consumption at 6 to 8 h postanesthesia. nPatients received an ACB or FNB as a component of a multimodal analgesic. Quadriceps strength, pain score, and opioid consumption were assessed on both legs preoperatively and at 6 to 8, 24, and 48 h postanesthesia administration. In a joint hypothesis test, noninferiority was first evaluated on the primary outcomes of strength, pain score, and opioid consumption at 6 to 8 h; superiority on each outcome at 6 to 8 h was then assessed only if noninferiority was established. nForty-six patients received ACB; 47 patients received FNB. At 6 to 8 h postanesthesia, ACB patients had significantly higher median dynamometer readings versus FNB patients (median [interquartile range], 6.1 kgf [3.5, 10.9] (ACB) vs. 0 kgf [0.0, 3.9] (FNB); P < 0.0001), but was not inferior to FNB with regard to Numeric Rating Scale pain scores (1.0 [0.0, 3.5] ACB vs. 0.0 [0.0, 1.0] FNB; P = 0.019), or to opioid consumption (32.2 [22.4, 47.5] ACB vs. 26.6 [19.6, 49.0]; P = 0.0115). At 24 and 48 h postanesthesia, there was no significant statistical difference in dynamometer results, pain scores, or opioid use between the two groups. nAt 6 to 8 h postanesthesia, the ACB, compared with the FNB, exhibited early relative sparing of quadriceps strength and was not inferior in both providing analgesia or opioid intake.

Adductor Canal Block : A Prospective, Randomized, Controlled Trial versus : A Prospective, Randomized, Controlled Trial Femoral Nerve Block for Total Knee Arthroplasty: A Prospective, Randomized, Controlled Trial

Background:This prospective double-blinded, randomized controlled trial compared adductor canal block (ACB) with femoral nerve block (FNB) in patients undergoing total knee arthroplasty. The authors hypothesized that ACB, compared with FNB, would exhibit less quadriceps weakness and demonstrate noninferior pain score and opioid consumption at 6 to 8 h postanesthesia. Methods:Patients received an ACB or FNB as a component of a multimodal analgesic. Quadriceps strength, pain score, and opioid consumption were assessed on both legs preoperatively and at 6 to 8, 24, and 48 h postanesthesia administration. In a joint hypothesis test, noninferiority was first evaluated on the primary outcomes of strength, pain score, and opioid consumption at 6 to 8 h; superiority on each outcome at 6 to 8 h was then assessed only if noninferiority was established. Results:Forty-six patients received ACB; 47 patients received FNB. At 6 to 8 h postanesthesia, ACB patients had significantly higher median dynamometer readings versus FNB patients (median [interquartile range], 6.1 kgf [3.5, 10.9] (ACB) vs. 0 kgf [0.0, 3.9] (FNB); P < 0.0001), but was not inferior to FNB with regard to Numeric Rating Scale pain scores (1.0 [0.0, 3.5] ACB vs. 0.0 [0.0, 1.0] FNB; P = 0.019), or to opioid consumption (32.2 [22.4, 47.5] ACB vs. 26.6 [19.6, 49.0]; P = 0.0115). At 24 and 48 h postanesthesia, there was no significant statistical difference in dynamometer results, pain scores, or opioid use between the two groups. Conclusion:At 6 to 8 h postanesthesia, the ACB, compared with the FNB, exhibited early relative sparing of quadriceps strength and was not inferior in both providing analgesia or opioid intake.This prospective double-blinded, randomized controlled trial compared adductor canal block (ACB) with femoral nerve block (FNB) in patients undergoing total knee arthroplasty. The authors hypothesized that ACB, compared with FNB, would exhibit less quadriceps weakness and demonstrate noninferior pain score and opioid consumption at 6 to 8 h postanesthesia. nPatients received an ACB or FNB as a component of a multimodal analgesic. Quadriceps strength, pain score, and opioid consumption were assessed on both legs preoperatively and at 6 to 8, 24, and 48 h postanesthesia administration. In a joint hypothesis test, noninferiority was first evaluated on the primary outcomes of strength, pain score, and opioid consumption at 6 to 8 h; superiority on each outcome at 6 to 8 h was then assessed only if noninferiority was established. nForty-six patients received ACB; 47 patients received FNB. At 6 to 8 h postanesthesia, ACB patients had significantly higher median dynamometer readings versus FNB patients (median [interquartile range], 6.1 kgf [3.5, 10.9] (ACB) vs. 0 kgf [0.0, 3.9] (FNB); P < 0.0001), but was not inferior to FNB with regard to Numeric Rating Scale pain scores (1.0 [0.0, 3.5] ACB vs. 0.0 [0.0, 1.0] FNB; P = 0.019), or to opioid consumption (32.2 [22.4, 47.5] ACB vs. 26.6 [19.6, 49.0]; P = 0.0115). At 24 and 48 h postanesthesia, there was no significant statistical difference in dynamometer results, pain scores, or opioid use between the two groups. nAt 6 to 8 h postanesthesia, the ACB, compared with the FNB, exhibited early relative sparing of quadriceps strength and was not inferior in both providing analgesia or opioid intake.