3-in-1 Block with Bupivacaine VS Bupivacaine Plus Dexamethasone in Acute Pain Control for Patients Undergoing Hip Nailing Surgery: A Double Blind Randomized Controlled Trial

Background: Femoral 3-in-1 block is one of the most effective methods in cases of hip nailing surgery because of its ease, low cost, and fewer complications. This study aims to evaluate the effect of adding dexamethasone to peripheral nerve block solution.Methods: Forty-four ASA (I,II & III) patients aged between 50-80 years, scheduled for elective hip-nailing surgery who met inclusion and exclusion criteria were enrolled in this double blind randomized controlled trial. Patients were allocated into two groups randomly; at the end of the surgery, femoral 3-in-1 nerve block was performed with 40 ml of bupivacaine 0.25% solution with or without 8 mg dexamethasone. Pain score was measured for 24 hours.Results: We found no significant difference in pain intensity scores until hour 0.5 and the scores were below 1. Thereafter, the VAS scores increased, yet it remained below 3 in the first 12 postoperative hours. Morphine was administered during hours 12-24 in both groups, when VAS scores reached to about 4. The total amount of morphine consumption was a little lower in the case group, although the difference was not statistically significant. Conclusion: Adding dexamethasone to bupivacaine 0.25% for 3-in-1 block has no more benefit than bupivacaine 0.25% alone for acute postoperative pain management after elective hip nailing surgery

Bloqueo 3 en 1 para analgesia en pacientes con fractura de cadera / Three-in-one block for analgesia in patients with hip fracture

Se realizó una intervención terapéutica en 81 adultos mayores con fractura de cadera, operados de urgencia en el Hospital Clinicoquirúrgico Docente Dr Ambrosio Grillo Portuondo de Santiago de Cuba, de enero del 2008 a igual mes del 2009, con vistas a determinar la efectividad del bloqueo 3 en 1 para aliviar el dolor en el período preoperatorio. Los pacientes fueron asignados aleatoriamente a 2 grupos de tratamiento: el de estudio (n=39), a cuyos integrantes se les aplicó el bloqueo 3 en 1 con bupivacaina a 0,5 por ciento, y el de control (n=42), al cual se le trató con metamizol por vía intramuscular (600 mg cada 8 horas). Utilizando una escala analógica visual, se midió el dolor al inicio del tratamiento, pasados 30 y 60 minutos, y cada 4 horas hasta completar 12. Se obtuvo un predominio del grupo etario de 60-79 años (51,2 por ciento) y el sexo femenino (58,0 por ciento), así como una disminución de la dolencia en el estado de reposo con el uso de ambos procedimientos terapéuticos. Igualmente, se logró alivio adecuado del dolor en los que recibieron bloqueo 3 en 1, de los cuales solo 5,1 por ciento requirió analgesia de rescate, de modo que esta técnica resultó efectiva para alcanzar el resultado deseado.

A therapeutic intervention was conducted in 81 older adults with hip fracture, who underwent emergency operation in Dr Ambrosio Grillo Portuondo Teaching Clinical Surgical Hospital of Santiago de Cuba, from January 2008 to January 2009 in order to determine the effectiveness of the 3-in-1 block for pain relief in the preoperative period. Patients were randomly assigned to two treatment groups: study group (n=39) in whom 3-in-1 block with 0.5 percent bupivacaine was administered, and control group (n=42), which was treated intramuscularly with metamizole (600 mg every 8 hours). Using a visual analogical scale pain was measured at the beginning of the treatment, after 30 and 60 minutes, and every 4 hours to complete 12. A prevalence of 60-79 (51.2 percent ) age group and female sex (58.0 percent ) was found, as well as a reduction of the disease at rest with both therapeutic procedures. Also, adequate pain relief was achieved in those that received 3-in-1 block, of them only 5.1% required rescue analgesia, so that this technique was effective to achieve the desired effect.

Optimizing the dose of intrathecal morphine when combined with continuous 3-in-1 nerve block after total knee replacement / 대한마취과학회지

BACKGROUND: Continuous femoral 3-in-1 block alone is insufficient for the treatment of severe pain after total knee replacement (TKR). Intrathecal (IT) morphine provides effective postoperative analgesia but may result in many side effects. The optimal dose of spinal morphine when combined with continuous 3-in-1 block after TKR is not known. METHODS: Patients were randomized to receive IT morphine in five groups (n = 20 per group): 1) 0.0 mg, 2) 0.05 mg, 3) 0.1 mg, 4) 0.15 mg, and 5) 0.2 mg. All patients received continuous 3-in-1 block performed with 20 ml of 0.25% bupivacaine, followed by a continuous infusion of 0.125% bupivacaine at the rate of 2 ml/h plus PCA boluses of 1 ml with a lockout of 10 minutes. The intensity of pain at rest and on movement of the knee was assessed by using a visual analog scale for the first two postoperative days. RESULTS: All treatment groups produced effective pain relief and decreased cumulative femoral PCA bolus use of 0.125% bupivacaine compared with control, respectively (P < 0.05); however, there were no significant differences among the treatment groups. The incidence of vomiting was significantly more frequent with 0.1-0.2 mg IT morphine groups compared with control, respectively (P < 0.05). The rate of administration of antipruritic medication was increased as IT morphine dose increased (P < 0.05). CONCLUSIONS: Use of 0.05 mg IT morphine would appear to provide the optimal balance between pain relief and adverse effects following TKR.

The Effect of Intrathecal Morphine Added to Continuous Femoral 3-in-1 Nerve Block for Analgesia after Total Knee Replacement / 대한마취과학회지

BACKGROUND: Most of the patients who received a 3-in-1 nerve block for analgesia after total knee replacement (TKR) complained of pain in the back of the knee. We investigated the value of an intrathecal (IT) morphine in patients receiving continuous 3-in-1 nerve block with a PCA technique for pain control after unilateral TKR. METHODS: Group 1 (n = 20) received spinal anesthesia with IT fentanyl 10microgram. Group 2 (n = 20) received spinal anesthesia with IT morphine 0.1 mg. All patients received continuous 3-in-1 nerve block performed with 20 ml of 0.25% bupivacaine with epinephrine 1 : 200000, followed by a continuous infusion of 0.125% bupivacaine at the rate of 2 ml/h plus PCA boluses of 1 ml with a lockout of 10 min. The intensity of pain at rest and on movement was assessed by the patients using a visual analog scale (VAS) for the first 2 postoperative days. RESULTS: Patients in Group 2 reported significantly lower VAS pain scores at rest than those in Group 1 for the first 1 day (P < 0.05). Cumulative PCA bolus use of 0.125% bupivacaine in Group 2 was significantly lower than those in Group 1 for the first 2 days (P < 0.05). The incidences of pruritus in Groups 1 and 2 were 0 and 50%, respectively (P < 0.01). CONCLUSIONS: We determined that the addition of IT morphine 0.1 mg to continuous femoral 3-in-1 nerve block improves postoperative analgesia after TKR.

Comparison of Continuous Three-in-One Block and Intravenous Patient-Controlled Analgesia for Postoperative Pain after Total Knee Replacement / 대한마취과학회지

BACKGROUND: Severe postoperative pain can delay knee rehabilitation and prolong the duration of convalescence after a total knee replacement (TKR). This study compared a continuous 3-in-1 block using a patient-controlled analgesia (PCA) technique and IV PCA for analgesia after a unilateral TKR. METHODS: Forty patients scheduled for an elective TKR under spinal anesthesia were randomly divided into two groups. Group 1 received an IV PCA with butorphanol and ketorolac. Group 2 received a continuous 3-in-1 block performed with 20 ml of 0.25% bupivacaine and epinephrine 1 : 200,000, followed by a continuous infusion of 0.125% bupivacaine through a femoral catheter at a rate of 2 ml/h plus 1 ml PCA boluses of a lockout time of 10 min. The level of pain was assessed at rest and during continuous passive motion using a visual analog scale (VAS). The VAS pain scores, nausea and vomiting were recorded in the postanesthetic care unit, at 6 PM on the day of operation, and at 8 AM and 6 PM on postoperative days 1 and 2, respectively. The duration of surgery, anesthesia time, blood loss, and hospital stay were compared. RESULTS: The patients in Group 2 reported lower VAS pain scores than those in Group 1 (P < 0.05). The duration of surgery, nausea and vomiting, blood loss, and hospital stay were similar in the two groups except for the anesthesia time. CONCLUSIONS: A continuous 3-in-1 block with a PCA technique provides better pain relief than IV PCA with butorphanol and ketorolac after TKR.