Concentración de bupivacaína y preservación de fuerza de cuádriceps en bloqueo femoral para artroplastía total de rodilla / Bupivacaine concentration and quadriceps strength preservation in femoral nerve block for total

INTRODUCTION: The commonly used concentrations of local anesthetics (LA) for femoral nerve block (FNB) cause a significant decrease in the quadriceps strength (QS), limiting physiotherapy and determining a risk factor for patient's falls. The use of more dilute solutions could determine the preservation of motor function without impairing analgesia. METHODS: Five patients scheduled for total knee arthroplasty (TKA) received a preoperative FNB with 20 mL of bupivacaine in decreasing concentrations (0.0875%, 0.075%, 0.0625%, 0.050%, 0.0375%). Sensory block to cold in the anterior knee region, QS, surface electromyography (SEMG) of vastus lateralis (VL), vastus medialis (VM) and rectus femoris (RF) plus were recorded before and 30 minutes after the blockage. Posteriorly, the clinical data of 20 patients who underwent TKA and received a continuous femoral nerve block (CFNB) with bupivacaine in the most dilute concentration that granted sensory blockade and significantly preserved the QS in the previous analysis were retrospectively analyzed. Postoperative pain at 24 and 48 hours, morphine consumption at 24 hours, the ability to successfully perform physiotherapy on the first postoperative day (POD) and reports of falls were rescued from the patients' files. Finally, seventy-five patients that underwent TKA during 2018 who received a CFNB with a similar dilution, but using levobupivacaine, were also retrospectively analyzed. Postoperative pain, need for advanced rescue analgesia, ability to perform physiotherapy, CFNB related complications and reports of patients falls during the first 72 hours post-surgery were obtained. RESULTS: Biomechanical study: of the 5 concentrations analyzed, either 0.050% or 0.0375% bupivacaine were adequate producing sensory block and preserving 94% and 100% of the basal QS, respectively. With both concentrations, the SEMG showed a similar range of activation with respect to baseline values. Bupivacaine case series: Twenty patients undergoing TKA received a 5-8 mL/hr infusion of 0.037% bupivacaine. The average consumption of morphine at 24 hours was 3.9 (3.6) mg. The median [IQR] of dynamic postoperative pain at 24 and 48 hours was 3 [1-4] and 3 [2-5]. All patients had adequate active joint ranges at 24 hours and physiotherapy was not limited by significant motor block. No falls were reported during the stay. Levobupivacaine case series: seventy-five patients undergoing TKA received a 5-8 mL/hr infusion of 0.037% levobupivacaine. The median [IQR] of at rest (R) and dynamic (D) postoperative pain at 24, 48 and 72 hours were R24: 0 [0-3]; D24: 3 [1-5]; R48: 0 [0-2]; D48: 3 [1.5-5]; R72: 0 [0-1]; D72: 3 [1-4]. 21% of patients required adding a PCA mode to the CFNB and a 7% a morphine PCA. On POD 1, 4% of patients were not able to adequately perform rehabilitation. On POD 2 and 3, all patients had adequate active joint ranges and physiotherapy was not limited by significant motor block. There were also no falls during hospitalization. CONCLUSIONS: The use of diluted solutions of bupivacaine and levobupivacaine for CFNB may represent a good alternative for TKA postoperative analgesia while avoiding significant quadriceps paresis. Additional studies are necessary to determine the ideal concentration and administration regimen to then compare with other quadriceps sparing analgesic alternatives.

INTRODUCCIÓN: Las concentraciones habituales de anestésicos locales (AL) utilizadas para el bloqueo del nervio femoral (BNF) provocan una disminución significativa de la fuerza del cuádriceps (FC), limitando la fisioterapia y constituyendo un factor de riesgo de caídas de pacientes. El uso de soluciones más diluidas podría determinar preservación de la función motora sin perjudicar la analgesia. MÉTODOS: Cinco pacientes programados para artroplastía total de rodilla (ATR) recibieron un BNF preoperatorio con 20 mL de bupivacaína en concentraciones decrecientes (0,0875%, 0,075%, 0,0625%, 0,050%, 0,0375%). Se registró la FC, electromiografía de superficie (EMGS) de vasto lateral (VL), vasto medial (VM) y recto femoral (RF) y el bloqueo sensitivo al frío antes y 30 minutos después del bloqueo. Posteriormente, se analizó retrospectivamente 20 casos sometidos a ATR que recibieron un bloqueo continuo del nervio femoral (BCNF) con bupivacaína en la concentración más diluida que otorgó bloqueo sensitivo y preservó significativamente la fuerza basal del cuádriceps durante el análisis anterior. El dolor postoperatorio a las 24 y 48 horas, el consumo de morfina las primeras 24 horas, la capacidad de realizar con éxito la fisioterapia el primer día postoperatorio (DPO) y reporte de caídas fueron rescatados de los expedientes. Por último, también se analizó retrospectivamente un grupo de 75 pacientes sometidos a ATR durante el 2018 y que recibieron un BCNF con una dilución similar, pero de levobupivacaína. Se obtuvieron datos de dolor, requerimientos de rescate analgésico, capacidad de realizar rehabilitación, complicaciones del BCNF y reporte de caídas durante las primeras 72 horas postoperatorias. RESULTADOS: Estudio biomecánico: de las 5 concentraciones analizadas, tanto bupivacaína 0,05% como 0,0375% produjeron adecuado bloqueo sensorial preservando el 94% y el 100% de la FC, respectivamente. Con ambas concentraciones la EMGS mostró similar rango de activación respecto a valores basales. Serie de casos con bupivacaína: veinte pacientes sometidos a ATR recibieron una infusión de bupivacaína 0,037% a 5-8 mL/h. El consumo promedio de morfina a las 24 horas fue 3,9 (3,6) mg. La mediana [RIC] del dolor dinámico postoperatorio a las 24 y 48 horas fue 3 [1-4] y 3 [2-5]. Todos los pacientes tuvieron rangos articulares activos adecuados a las 24 horas y la fisioterapia no fue limitada por bloqueo motor significativo. No se registraron caídas durante la hospitalización. Serie de casos levobupivacaína: setenta y cinco pacientes sometidos a ATR recibieron una infusión de levobupivacaína 0,037% a 5-8 mL/h. La mediana [RIC] de dolor postoperatorio en reposo (R) y dinámico (D) a las 24, 48 y 72 horas fue R24: 0 [0-3]; D24: 3 [1-5]; R48: 0 [0-2]; D48: 3 [1.5-5]; R72: 0 [0-1]; D72: 3 [1-4]. Un 21% requirió agregar modo PCA al BCNF y 7% una PCA de morfina. En DPO 1, un 4% de pacientes no pudo realizar adecuadamente la rehabilitación. En DPO 2 y 3 todos los pacientes tuvieron rangos articulares activos adecuados y fisioterapia no fue limitada por bloqueo motor significativo. Tampoco se registraron caídas durante la hospitalización. CONCLUSIONES: El uso de soluciones diluidas de bupivacaína y levobupivacaína en BCNF podría representar una buena opción para analgesia postoperatoria en ATR evitando la paresia significativa del cuádriceps. Estudios adicionales son necesarios para determinar la concentración y régimen de administración ideal para luego comparar con otras alternativas analgésicas preservantes del cuádriceps.

Analgesic Effect of Continuous Femoral Nerve Block Combined with Parecoxib on Patients Undergoing Total Knee Replacement Surgery / 现代生物医学进展

Objective:To investigate the postoperative analgesia effect of continuous femoral nerve block (CFNB) combined with parecoxib on the patients with Total knee arthroplasty (TKA).Methods:A total of 100 patients,who underwent unilateral TKA in Affiliated Hospital of Guizhou Medical University from January 2015 to December 2016,were selected and randomly divided into study group (n=50) and control group (n=50).After TKA,the patients of two groups were received CFNB,CFNB combined with parecoxib analgesia respectively,analgesic time was 2 days.The visual analogue pain scores (VAS) of the patients of two groups at rest and during exercise and the incidence of postoperative adverse reactions were observed at 6h,12 h,24 h,48 h after operation.The Hospital Special Surgery knee score (HSS) was used to evaluate the joint function of patients in the two groups 1 d before operation and 1 d,2 d,3 d after operation.Results:Resting state VAS and motion state VAS in the study group were significantly lower than those in the control group 6 h,12 h,24 h,and 48 h after operation (P＜0.05).There were no significant differences in the incidence of nausea / vomiting,respiratory depression,catheter related problems,and urinary retention between the two groups (P＞0.05).There was no significant difference in HSS score between the two groups 1 d before operation(P＞0.05).The HSS scores of the patients in the two groups 1 d,2 d,3 d after operation were significantly higher than those 1d before operation,and the HSS scores of the patients in the study group were significantly higher than those in the control group (P＜0.05).Conclusion:CFNB combined with parecoxib has the advantages of good analgesic effect and safety for postoperative analgesia of the patients undergoing TKA,which is good for the patients' early knee joint function exercise and is worthy of clinical promotion.

Effects of parecoxib sodium combined with continuous femoral nerve block on the balance of Th1/Th2 in elderly patients after total knee arthroplasty / 临床麻醉学杂志

Objective To study the effects of parecoxib sodium combined with continuous femoral nerve block on the balance of Th1/Th2 in elderly patients after total knee arthroplasty. Methods Fifty elderly patients,33 males and 1 7 females,aged 65 to 80 years,with ASA Ⅰ or Ⅱtreated with total knee arthroplasty were randomly divided into two groups (n =25 each):parecoxib sodium combined with continuous femoral nerve block group (group A)and parecoxib sodium com-bined with intravenous analgesia group (group B).Quick induce laryngeal mask anesthesia and intra-venous parecoxib sodium 40 mg at 30 min before skin incision were adopted in both groups.After the first 8 h,parecoxib sodium of 40 mg was intravenously injected again.The patients in group A re-ceived femoral nerve puncture and continuous electronic analgesia pump.The patients in group B re-ceived postoperative intravenous electronic analgesia pump.Visual analogue score(VAS)during rest and movement at 6,12,24,36,48 h after operation,side effects in two groups were recorded,venous blood samples were taken before anesthesia (T0 ),at the end of operation (T1 ),and 24 h(T2 ),48 h (T3 ),72 h (T4 )after operation for determination of plasma IFN-γ,IL-10 and cortisol (Cor). Results The values of VAS were significantly lower in group A compared with group B in rest at 6, 12 h after operation,the values of VAS were significantly lower in group A compared with group B in moving at every time points after surgery (P <0.05 ).The plasma Cor concentrations were signifi-cantly increased at T1-T3 compared with baseline value at T0 in two groups(P <0.05 ).The plasma Cor concentrations in group A were significantly decreased compared with group B at T1-T3 (P <0.05).The plasma IFN-γconcentrations were significantly lower at T2 and T3 compared with baseline value at T0 in group A,the plasma IFN-γ concentrations were significantly lower at T2-T4 compared with baseline value at T0 in group B (P <0.05),the plasma IFN-γ concentrations were significantly increased in group A compared with group B at T2-T4 (P <0.05 ).The plasma IL-10 concentrations were significantly increased compared with baseline value at T1-T4 in two groups (P < 0.05 ),the plasma IL-10 concentrations were significantly decreased in group A compared with group B at T1-T4 (P <0.05).Compared with group B,the incidence of postoperative nausea,vomiting and pruritus in group A was lowered significantly (P <0.05).Conclusion Parecoxib sodium combined with continu-ous femoral nerve block on postoperative pain in elderly patients after total knee arthroplasty can a-chieve good effect of postoperative analgesia and fewer complications, lower cortisol secretion, slowing down the decrease of IFN-γ secretion and the increase of IL-10 secretion.This method could effectively protect the immune function of patients undergoing arthroplasty.

Ultrasound and nerve stimulator guided continuous femoral nerve block analgesia after total knee arthroplasty: a multicenter randomized controlled study / Bloqueio contínuo do nervo femoral guiado por ultrassom e estimulador de nervo para analgesia após artroplastia total de joelho: estudo multicêntrico, randomizado e controlado / Bloqueo continuo del nervio femoral guiado por ultrasonido y estimulador de nervio para analgesia posterior a la artroplastia total de rodilla: estudio multicéntrico, aleatorizado y controlado

BACKGROUND AND OBJECTIVES: Postoperative analgesia is crucial for early functional excise after total knee arthroplasty. To investigate the clinical efficacy of ultrasound and nerve stimulator guided continuous femoral nerve block analgesia after total knee arthroplasty. METHODS: 46 patients with ASA grade I-III who underwent total knee arthroplasty received postoperative analgesia from October 2012 to January 2013. In 22 patients, ultrasound and nerve stimulator guided continuous femoral nerve block were performed for analgesia (CFNB group); in 24 patients, epidural analgesia was done (PCEA group). The analgesic effects, side effects, articular recovery and complications were compared between two groups. RESULTS: At 6 h and 12 h after surgery, the knee pain score (VAS score) during functional tests after active exercise and after passive excise in CFNB were significantly reduced when compared with PCEA group. The amount of parecoxib used in CFNB patients was significantly reduced when compared with PCEA group. At 48 h after surgery, the muscle strength grade in CFNB group was significantly higher, and the time to ambulatory activity was shorter than those in PCEA group. The incidence of nausea and vomiting in CFNB patients was significantly reduced when compared with PCEA group. CONCLUSION: Ultrasound and nerve stimulator guided continuous femoral nerve block provide better analgesia at 6 h and 12 h, demonstrated by RVAS and PVAS. The amount of parecoxib also reduces, the incidence of nausea and vomiting decreased, the influence on muscle strength is compromised and patients can perform ambulatory activity under this condition. .

JUSTIFICATIVA E OBJETIVOS: Analgesia pós-operatória é fundamental para o exercício funcional precoce logo após a artroplastia total de joelho. O objetivo foi investigar a eficácia clínica do bloqueio contínuo do nervo femoral guiado por ultrassom e estimulador de nervo em analgesia após artroplastia total do joelho. MÉTODOS: Receberam analgesia pós-operatória, de outubro de 2012 a janeiro de 2013, 46 pacientes, estado físico ASA I-III, submetidos à artroplastia total de joelho. Em 22 pacientes, o bloqueio femoral contínuo foi guiado por ultrassom e estimulador de nervo para analgesia (grupo BFC); em 24 pacientes, analgesia foi administrada por via epidural (grupo ACP). Os efeitos analgésicos, efeitos colaterais, a recuperação articular e as complicações foram comparados entre os dois grupos. RESULTADOS: Às seis e 12 horas após a cirurgia, os escores de dor no joelho (escore EVA) durante os testes funcionais após exercício ativo e passivo foram significativamente menores no grupo BFC do que no grupo ACP. A quantidade usada de parecoxib nos pacientes do grupo BFC foi significativamente menor em comparação com o grupo ACP. Quarenta e oito horas após a cirurgia, o grau de força muscular no grupo BFC foi significativamente maior e o tempo de atividade ambulatória foi menor do que no grupo ACP. A incidência de náusea e vômito em pacientes do grupo BFC foi significativamente menor em comparação com o grupo ACP. CONCLUSÃO: O bloqueio femoral contínuo guiado por ultrassom e estimulador do nervo proporcionou melhor analgesia às seis e 12 horas, demonstrada por EVA-R e EVA-P. A quantidade de parecoxib também foi menor, a incidência de náusea e vômito diminuiu, a influência sobre a força muscular é comprometida e os pacientes podem fazer atividade ambulatorial sob essa condição. .

JUSTIFICACIÓN Y OBJETIVOS: La analgesia postoperatoria es fundamental para el ejercicio funcional precoz posteriormente a la artroplastia total de rodilla. El objetivo fue investigar la eficacia clínica del bloqueo continuo del nervio femoral guiado por ultrasonido y estimulador de nervio en analgesia después de la artroplastia total de la rodilla. MÉTODOS: Cuarenta y seis pacientes, con estado físico ASA I-III, sometidos a artroplastia total de rodilla recibieron analgesia postoperatoria de octubre de 2012 a enero de 2013. En 22 pacientes, el bloqueo femoral continuo fue guiado por ultrasonido y estimulador de nervio para analgesia (grupo BFC); en 24 pacientes, la analgesia fue administrada por vía epidural (grupo ACP). Los efectos analgésicos, efectos colaterales, recuperación articular y las complicaciones fueron comparados entre los 2 grupos. RESULTADOS: A las 6 y 12 h después de la operación, las puntuaciones de dolor en la rodilla (puntuación EVA) durante los test funcionales después del ejercicio activo y pasivo fueron significativamente menores en el grupo BFC que en el grupo ACP. La cantidad usada de parecoxib en los pacientes del grupo BFC fue significativamente menor en comparación con el grupo ACP. Cuarenta y ocho horas después de la operación, el grado de fuerza muscular en el grupo BFC fue significativamente mayor y el tiempo de actividad ambulatoria fue menor que en el grupo ACP. La incidencia de náuseas y vómitos en pacientes del grupo BFC fue significativamente menor en comparación con el grupo ACP. CONCLUSIÓN: El bloqueo femoral continuo guiado por ultrasonido y estimulador del nervio proporcionaron una mejor analgesia a las 6 y 12 horas, lo que quedó demostrado por EVA-R y EVA-P. La cantidad de parecoxib también fue menor, la incidencia de náuseas y vómito disminuyó, la influencia sobre la fuerza muscular está comprometida y los pacientes pueden realizar una actividad ambulatoria bajo esa condición. .

Effect of continuous femoral nerve block versus patient controlled intravenous analgesia on rehabilitation following total knee arthroplasty / 中华创伤杂志

Objective To compare the effect of continuous femoral nerve block (CFNB) with patient controlled intravenous analgesia (PCIA) on pain relief,rehabilitation efficacy,satisfaction degree following total knee arthroplasty (TKA) in an attempt to find a safe and effective analgesia at the stage of rehabilitation.Methods The records of 116 patients undergone unilateral TKA for osteoarthritis or rheumatoid arthritis of the knee were evaluated.The patients with preoperative American Society of Anesthesiology (ASA) score of 1 to 3 were randomized into CFNB group (58 cases) and PCIA group (58 cases) according to the random number table.Both operations were performed under ultrasound guidance.Postoperative visual analogue score (VAS),knee function,incidence of adverse reaction,and satisfaction degree were compared between the two groups.Results Regardless of the score at postoperative 4 and 12 hours,VAS between CFNB and PCIA groups revealed significant differences at postoperative 24 [(3.2±1.1)pointsvs (4.1 ±1.5)points],48 [(3.4±1.2)pointsvs (4.1 ±1.0) points] and 72 hours [(3.3 ± 1.2) points vs (4.0 ± 1.1) points] (all P ＜ 0.05).Time to achieve knee rehabilitation training objectives like straight leg raise,walking with crutches,and passive bending to 90° were similar between the two groups.Both groups achieved comparable knee function status with respect to Hospital for Special Surgery (HSS) score,Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score,and maximal knee flexion angle at postoperative 3 months.Postoperative nausea and vomit were significantly more frequent in PCIA group (24％) than in CFNB group (14％) (all P ＜O.05),but patients in both groups were satisfactory.Conclusion Ultrasound guided CFNB is an effective analgesic method during the early stage of TKA,for it can control pain,accelerate rehabilitation training and function recovery,reduce adverse reaction as well as improve patients' satisfaction.

Comparison of analgesic effect of ultrasound-guided continuous femoral nerve block after total knee ath-roplasty / 临床麻醉学杂志

Objective To observe the analgesic effect of ultrasound-guided and nerve stimulator after artificial total knee athroplasty(TKA).Methods Forty elective cases receiving TKA under gen-eral anesthesia were randomly allocated into the ultrasound group (group C)and stimulator group (group S).The time for nerve block,onset time and complications were recorded in both groups. Results Compared to group S,the time for nerve block and onset time was significantly shortened in group C (P <0.05).There was no statistical difference in times of pressing analgesic pump and VAS score in postoperative 48 h.One patient suffered from nerve injury and two underwent vascular dam-age and hematoma in group S,while no complication was found in group C.Conclusion Compared to nerve stimulator,ultrasound-guided continuous femoral nerve block(CFNB)may reduce nerve block time and onset time and decrease complications,so that to increase safety of CFNB.

Effect of continuous femoral nerve block and epidural analgesia on rehabilitation after total knee arthroplasty surgery / 中国矫形外科杂志

[Objective]To compare the effects of continuous femoral nerve block(CFNB) and epidural analgesia(CEA) on rehabilitation after total knee arthroplasty(TKA) surgery. [Methods]Fifty patients undergoing unilateral TKA surgery were randomly divided into group CFNB(n=25) and group CEA(n=25).All patients were received unilateral spinal anesthesia with 0.5% dicaine and given analgesia with 0.2 % ropivacaine with 1ug/ml sufentanil.VAS pain scores during rest and continuous passive movement(CPM) at each time point was recorded.Other parameter such as the angle of initiative flections,blood loss at 6 h post operation,the concentration of serum hemoglobin at 24 h,48 h and side effect were recorded.[Results]The VAS pain scores during test had no significant difference between two groups.The VAS scores of CPM at 24 h and 48 h in group CFNB were obvious lower(3.68?0.93 and 3.93?0.78) than those in group CEA.The initiative flections were similar at 12 and 24 hours after operation.The concentration of hemoglobin at 6 h after operation was lower than that before operation.After reinfusion it was increased but did not reach the level before operation.The incidence of side effects was not noted in both groups.[Conclusion]After TKA surgery,the continuous femoral nerve block can provide better pain relief.No adverse impact on rehabilitation movement of operated legs or blood loss and has less side effect.Therefore,it should be considered an alternative analgesia method after TKA.