François Singelyn

Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty

In this study, we assessed the influence of three analgesic techniques on postoperative knee rehabilitation after total knee arthroplasty (TKA).Forty-five patients scheduled for elective TKA under general anesthesia were randomly divided into three groups. Postoperative analgesia was provided with IV patient-controlled analgesia (PCA) with morphine in Group A, continuous 3-in-1 block in Group B, and epidural analgesia in Group C. Immediately after surgery, the three groups started identical physical therapy regimens. Pain scores, supplemental analgesia, side effects, degree of maximal knee flexion, day of first walk, and duration of hospital stay were recorded. Patients in Groups B and C reported significantly lower pain scores than those in Group A. Supplemental analgesia was comparable in the three groups. Compared with Groups A and C, a significantly lower incidence of side effects was noted in Group B. Significantly better knee flexion (until 6 wk after surgery), faster ambulation, and shorter hospital stay were noted in Groups B and C. However, these benefits did not affect outcome at 3 mo. We conclude that, after TKA, continuous 3-in-1 block and epidural analgesia provide better pain relief and faster knee rehabilitation than IV PCA with morphine. Because it induces fewer side effects, continuous 3-in-1 block should be considered the technique of choice. Implications: In this study, we determined that, after total knee arthroplasty, loco-regional analgesic techniques (epidural analgesia or continuous 3-in-1 block) provide better pain relief and faster postoperative knee rehabilitation than IV patient-controlled analgesia with morphine. Because it causes fewer side effects than epidural analgesia, continuous 3-in-1 block is the technique of choice. (Anesth Analg 1998;87:88-92)

Continuous peripheral nerve blocks in hospital wards after orthopedic surgery: a multicenter prospective analysis of the quality of postoperative analgesia and complications in 1,416 patients.

Background:Continuous peripheral nerve block (CPNB) is the technique of choice for postoperative analgesia after painful orthopedic surgery. However, the incidence of neurologic and infectious adverse events in the postoperative period are not well established. This issue was the aim of the study. Methods:Patients scheduled to undergo orthopedic surgery performed with a CPNB were prospectively included during 1 yr in a multicenter study. Efficacy of postoperative analgesia, bacteriologic cultures of the catheter, and acute neurologic and infectious adverse events were evaluated after surgery in 1,416 patients at arrival in the postanesthesia care unit, at hour 1, and every 24 h up to day 5. Risk factors for adverse events were determined using logistic regression. Results:The median duration of CPNB was 56 h. Both general anesthesia and CPNB were performed in 73.6% of the patients. Postoperative analgesia was effective in 96.3%, but an increase in pain scores was noted at hour 24 (P = 0.01). Hypoesthesia or numbness occurred in 3% and 2.2%, respectively, and paresthesia occurred in 1.5%. Three neural lesions (0.21%) were noted after continuous femoral nerve block. Two of these patients were anesthetized during block procedure. Nerve damage completely resolved 36 h to 10 weeks later. Cultures from 28.7% of the catheters were positive. Three percent of patients had local inflammatory signs. The bacterial species most frequently found were coagulase-negative staphylococcus (61%) and gram-negative bacillus (21.6%). A Staphylococcus aureus psoas abscess (0.07%) was reported in one diabetic woman. Independent risk factors for paresthesia/dysesthesia were postoperative monitoring in intensive care, age less than 40 yr, and use of bupivacaine. Risk factors for local inflammation/infection were postoperative monitoring in intensive care, catheter duration greater than 48 h, male sex, and absence of antibiotic prophylaxis. Conclusion:CPNB is an effective technique for postoperative analgesia. Minor incidents and bacterial colonization of catheters are frequent, with no adverse clinical consequences in the large majority of cases. Major neurologic and infectious adverse events are rare.

Interscalene brachial plexus analgesia after open shoulder surgery: continuous versus patient-controlled infusion.

UNLABELLED In this prospective, randomized, double-blinded study, we assessed the efficacy of patient-controlled analgesia (PCA) for continuous interscalene analgesia after open shoulder surgery. Sixty patients were divided into three groups of 20. During a 48-h period, they received, via an interscalene catheter, a continuous infusion of 0.125% bupivacaine with sufentanil 0.1 microg/mL and clonidine 1 microg/mL at 10 mL /h in Group 1; a continuous infusion of the same solution at 5 mL/h plus PCA boluses (2.5 mL/30 min) in Group 2; and only PCA boluses (5 mL/30 min) of the same solution in Group 3. Pain scores, sensory block, supplemental analgesia, bupivacaine consumption, side effects, and satisfaction scores were recorded. At 24 and 48 h, sensory block was more frequent and pain control was significantly better in Groups 1 and 2 than in Group 3 (P < 0.001). In Group 3, larger doses of paracetamol were required. Bupivacaine consumption was significantly less in Groups 2 and 3 than in Group 1 (P < 0.001). Satisfaction was significantly higher in Groups 1 and 2 than in Group 3 (P < 0.01). Side effects were comparable in the three groups. We conclude that continuous interscalene analgesia requires a background infusion after open shoulder surgery. Because it reduces the local anesthetic consumption and allows the patients to rapidly reinforce the block shortly before physiotherapy, a basal infusion rate of 5 mL/h combined with PCA boluses (2.5 mL/ 30 min) is the recommended technique. IMPLICATIONS In this study, we demonstrated that continuous interscalene analgesia requires a background infusion to provide efficient pain relief after open shoulder surgery. A basal infusion of 5 mL/h combined with patient-controlled analgesia boluses (2.5 mL/30 min) seems to be the most appropriate technique.

A minimum dose of clonidine added to mepivacaine prolongs the duration of anesthesia and analgesia after axillary brachial plexus block.

This study assessed the minimum dose of clonidine required to prolong the duration of both anesthesia and analgesia after axillary brachial plexus blockade.Eighty patients scheduled for elective hand surgery were divided into eight groups in a randomized, double-blind fashion. An axillary brachial plexus block was performed with 40 mL 1% mepivacaine plus 1:200,000 epinephrine. The control group received no clonidine. In the other groups, increasing doses of clonidine (0.1, 0.2, 0.3, 0.4, 0.5, 1, and 1.5 micro g/kg) were added to the local anesthetic solution. Onset time, duration of anesthesia and analgesia, postoperative pain score, intake of analgesics, and adverse effects were recorded. The eight groups were comparable in terms of onset time, postoperative pain score, and analgesic requirement. The minimum dose of clonidine required to significantly prolong the duration of analgesia and anesthesia was, respectively, 0.1 and 0.5 micro g/kg. No side effects (sedation, drowsiness, bradycardia, arterial hypotension) were reported. We conclude that the dose of clonidine required to prolong significantly the duration of both anesthesia and analgesia after axillary brachial plexus blockade is 0.5 micro g/kg and that, at this dose, clonidine may be used without important reported side effects even in outpatients. (Anesth Analg 1996;83:1046-50)

Continuous popliteal sciatic nerve block: an original technique to provide postoperative analgesia after foot surgery.

Our study describes an original technique of continuous popliteal sciatic nerve block (CPSB) (Group A, 60 patients) and compares its analgesic efficacy after foot surgery with intramuscular (IM) opioids (Group B, 15 patients) and intravenous patient-controlled analgesia (IV PCA) with morphine (Group C, 45 patients). CPSB was performed using Singelyns landmarks. The sciatic nerve was localized with a short-beveled needle connected to a peripheral nerve stimulator. A 20-gauge catheter was placed at the same depth as the needle with a Seldinger technique. Thirty milliliters of 1% mepivacaine with epinephrine 1/200,000 was injected and followed by a continuous infusion of 0.125% bupivacaine with sufentanil 0.1 micro g/mL and clonidine 1 micro g/mL at 7 mL/h for 48 h. Postoperative analgesia (intravenous [IV] propacetamol [PRO] and/or IM piritramide [DIPI]) was standardized. Postoperative pain score (PPS), supplemental analgesia, and side effects were noted. CPSB was easy to perform in 55 patients (92%). In Group A, highest and mean PPS were significantly lower, and the mean dose of PRO was reduced by 62% and 36% when compared with Groups B and C, respectively. Only 8% of patients required postoperative opioid in Group A compared with 91% and 100% in Groups B and C, respectively. No immediate or delayed complications other than postoperative technical problems (kinked or broken catheter 25%) were noted in Group A. In conclusion, CPSB is easy to perform, safe, and a more efficient technique than parenteral opioid for providing postoperative analgesia after foot surgery. (Anesth Analg 1997;84:383-6)

Extended femoral nerve sheath block after total hip arthroplasty : continuous versus patient-controlled techniques

We assessed the efficacy of patient-controlled analgesia (PCA) techniques for extended femoral nerve sheath block after total hip arthroplasty. Forty-five patients were divided into three groups of 15. Over 48 h, all patients received 0.125% bupivacaine with clonidine 1 &mgr;g/mL and sufentanil 0.1 &mgr;g/mL via a femoral nerve sheath catheter as a continuous infusion at 10 mL/h in Group 1, as PCA boluses only of 10 mL/h in Group 2, or as PCA boluses of 5 mL per 30 min in Group 3. Pain scores, sensory block, supplemental analgesia, bupivacaine consumption, side effects, and satisfaction scores were recorded. Pain scores at rest and supplemental analgesia were comparable in the three groups. At 48 h, pain relief on movement was significantly better in Group 3 than in Group 1 (P = 0.01). Bupivacaine consumption was significantly less in Groups 2 and 3 than in Group 1 (P < 0.001). Side effects were comparable in the three groups. Satisfaction scores were significantly higher in Group 3 than in the other groups (P < 0.01). We conclude that, to maintain extended femoral nerve sheath block after total hip arthroplasty, PCA techniques reduce the local anesthetic consumption without compromise in patient satisfaction or visual analog scale scores. Of the two PCA techniques tested, PCA boluses (5 mL per 30 min) of 0.125% bupivacaine with clonidine 1 &mgr;g/mL and sufentanil 0.1 &mgr;g/mL are associated with the smallest local anesthetic consumption and the most patient satisfaction. Implications This study demonstrated that, after total hip arthroplasty, an extended femoral nerve sheath block consisting of patient-controlled analgesia boluses (5 mL per 30 min) of 0.125% bupivacaine with clonidine 1 &mgr;g/mL and sufentanil 0.1 &mgr;g/mL provides efficient postoperative analgesia and significantly minimizes local anesthetic consumption.

Extended "three-in-one" block after total knee arthroplasty: continuous versus patient-controlled techniques.

This prospective, randomized, double-blinded study assessed the efficacy of patient-controlled analgesia (PCA) techniques for extended “3-in-1” block after total knee arthroplasty. A total of 45 patients were divided into three groups of 15. Over 48 h, all patients received 0.125% bupivacaine with 1 &mgr;g/mL clonidine via a femoral nerve sheath catheter in the following manner: as a continuous infusion at 10 mL/h in Group 1; as a continuous infusion at 5 mL/h plus PCA boluses (2.5 mL/30 min) in Group 2; or as PCA boluses only (10 mL/60 min) in Group 3. Pain scores, sensory block, supplemental analgesia, bupivacaine consumption, side effects, and satisfaction scores were recorded. Pain scores and supplemental analgesia were comparable in the three groups. Bupivacaine consumption was significantly less in Groups 2 and 3 than in Group 1 (P < 0.01), and in Group 3 than in Group 2 (P < 0.01). Side effects and satisfaction were comparable in the three groups. We conclude that extended “3-in-1” block provides efficient pain relief after total knee arthroplasty and that, compared with a continuous infusion, PCA techniques reduce the local anesthetic consumption without compromise in patient satisfaction or visual analog scale scores. Of the two PCA techniques tested, PCA boluses (10-mL lockout; time, 60 min) of 0.125% bupivacaine with 1 &mgr;g/mL clonidine was associated with the smallest local anesthetic consumption, and is, therefore, the recommended extended “3-in-1” block technique. Implications We demonstrated that, after total knee arthroplasty, an extended “3-in-1” block consisting of patient-controlled analgesia boluses (10 mL/60 min) of 0.125% bupivacaine with 1 &mgr;g/mL clonidine provides efficient postoperative analgesia and significantly minimizes local anesthetic consumption.

The analgesic efficacy of bilateral combined superficial and deep cervical plexus block administered before thyroid surgery under general anesthesia.

In this study we evaluated the analgesic efficacy of combined deep and superficial cervical plexus block in patients undergoing thyroidectomy under general anesthesia. For this purpose, 39 patients undergoing elective thyroid surgery were randomized to receive a bilateral combined deep and superficial cervical block (14 mL per side) with saline (Group 1;n = 13), ropivacaine 0.5% (Group 2;n = 13), or ropivacaine 0.5% plus clonidine 7.5 &mgr;g/mL (Group 3;n = 13). Deep cervical plexus block was performed with a single injection (8 mL) at the C3 level. Superficial cervical plexus block consisted of a subcutaneous injection (6 mL) behind the lateral border of the sternocleidomastoid muscle. During surgery, the number of additional alfentanil boluses was significantly reduced in Groups 2 and 3 compared with Group 1 (1.3 ± 1.0 and 1.1 ± 1.0 vs 2.6 ± 1.0;P < 0.05). After surgery, the opioid and non-opioid analgesic requirements were also significantly reduced in Groups 2 and 3 (P < 0.05) during the first 24 h. Except for one patient in Group 3, who experienced transient anesthesia of the brachial plexus, no side effect was noted in any group. We conclude that combined deep and superficial cervical plexus block is an effective technique to alleviate pain during and immediately after thyroidectomy.

The safety and efficacy of extended thromboprophylaxis with fondaparinux after major orthopedic surgery of the lower limb with or without a neuraxial or deep peripheral nerve catheter: The EXPERT study

BACKGROUND:The benefit-risk ratio of extended fondaparinux therapy has not been assessed in patients undergoing major lower limb joint arthroplasty. Few data on the concomitant use of fondaparinux and continuous neuraxial or deep peripheral nerve blockade are available. We performed a prospective intervention study in patients undergoing major orthopedic surgery primarily designed to assess the efficacy of fondaparinux when drug administration was withheld for 48 h to permit removal of a neuraxial or deep peripheral nerve catheter. The safety and efficacy of extended fondaparinux therapy for the prevention of venous thromboembolism were also evaluated. METHODS:Patients received a daily subcutaneous injection of 2.5 mg fondaparinux for 3 to 5 wk postoperatively. In patients with a neuraxial or deep peripheral nerve catheter, the catheter was removed 36 h after the last fondaparinux dose. The next fondaparinux dose was administered 12 h after catheter removal. The primary end points were symptomatic venous thromboembolism and major bleeding up to 4–6 wk after surgery. RESULTS:We recruited 5704 patients. A neuraxial or deep peripheral nerve catheter was inserted in 1553 (27%) patients and 78 (1.4%) patients, respectively. The rate of venous thromboembolism was 1.0% (54 of 5387). There was no difference between patients without (1.1%) or with (0.8%) a catheter (the upper limit of the 95% confidence interval of the odds ratio, 1.49, being below the predetermined noninferiority margin of 1.75). The incidence of major bleeding was 0.8% (42 of 5382). No neuraxial or perineural hematoma was reported. CONCLUSIONS:Once-daily subcutaneous injection of 2.5 mg fondaparinux given for 3 to 5 wk was effective and safe for prevention of venous thromboembolism after major orthopedic surgery. Temporary discontinuation of fondaparinux for 48 h permitted safe removal of a neuraxial or deep peripheral nerve catheter without decreasing thromboprophylatic efficacy.

Ultrasound- or Nerve Stimulation-Guided Wrist Blocks for Carpal Tunnel Release: A Randomized Prospective Comparative Study

Background and Objectives: We hypothesized that ultrasound‐guided wrist blocks may be faster to perform, and may increase success rate, compared with nerve stimulation‐guided wrist blocks. Methods: Sixty patients undergoing ambulatory endoscopic carpal tunnel release were randomly allocated to receive median and ulnar nerve blocks using either sensory‐motor nerve stimulation (n = 30) or ultrasound guidance (n = 30). Four mL of mepivacaine 1.5% was injected around each nerve. Performance time and onset time of complete sensory block were assessed. Results: Median time to perform both median (ultrasound, 55 [48‐60] vs. nerve stimulation, 100 [65‐150] seconds, P = .002) and ulnar (ultrasound, 57 [50‐70] vs. nerve stimulation, 80 [60‐105] seconds, P = .02) nerve blocks were significantly shorter in the ultrasound group. Onset time of complete sensory block in the median (ultrasound, 370 [278‐459] vs. nerve stimulation, 254 [230‐300] seconds, P = .02) and ulnar (ultrasound, 367 [296‐420] vs. nerve stimulation, 241 [210‐300] seconds, P = .01) nerve areas were shorter in the nerve stimulation group. The success rate was 93% in both groups. Conclusions: This randomized prospective study demonstrates that ultrasound‐guided wrist nerve blocks are as efficient as those performed with nerve stimulation.