The Efficacy of the Combination of Continuous Femoral Nerve Block and Intravenous Parecoxib on Rehabilitation in Patients Undergoing Total Knee Arthroplasty: A Double-Blind, Randomized Clinical Trial.

BACKGROUND AND AIM: The optimal strategy for the management of postoperative pain after total knee arthroplasty (TKA) remains challenging, while its treatment is crucial to increase patients' outcomes. This study aimed to investigate the effects of parecoxib as add-on therapy, in a standard postoperative pain management protocol, represented by the continuous femoral nervous block. We studied its influence on rehabilitation indices and pain scores in patients undergoing TKA. MATERIAL AND METHODS: This is a single-center, prospective, double-blind, randomized, placebo-controlled trial. All patients were operated with the use of subarachnoid anesthesia, and divided into two groups for postoperative analgesia. Both groups received a continuous femoral nerve block. One of the groups received intravenous parecoxib, while the other received a placebo. The primary investigated outcome was the range of motion (ROM). Recordings were noted at different times postoperatively. Bromage score (BS), visual analog scale (VAS), and the State-Trait Anxiety Inventory (STAI) were also studied. RESULTS: A total of 90 patients were included and analyzed. ROM was significantly better (p<0.001) and pain scores were significantly lower (p=0.007) in the parecoxib group. No statistically significant difference was found with regard to BS between the two groups. A significant correlation was found between ROM and VAS pain scores at 12 hours (p=0.02), while ROM was inversely correlated with STAI postoperatively. CONCLUSIONS: The use of intravenous parecoxib is effective in improving rehabilitation indices and provides decreased postoperative pain scores after TKA.

Análisis retrospectivo de la anestesia regional en la cirugía de cadera: Auditoría clínica / Retrospective analysis of regional anaesthesia in hip surgery: A clinical audit

Introducción: La artroplastia total de cadera es una de las intervenciones quirúrgicas más frecuentes en el contexto hospitalario. Sin embargo, sigue desconociéndose el método ideal para manejar el dolor postoperatorio. Las técnicas de analgesia multimodal basadas en la anestesia regional se encuentran entre las soluciones más prometedoras. Objetivos: El objetivo de este estudio fue evaluar el dolor postoperatorio tras la artroplastia total de cadera, de acuerdo con si se realizaron, o no, bloqueos del nervio periférico (bloqueo femoral, bloqueo de la fascia iliaca y bloqueo del grupo de nervios pericapsulares). Se midió el consumo de morfina intravenosa durante la estancia del paciente en la unidad de cuidados posanestésicos, así como el número de rescates con opioides transcurridas 24 y 48 h de la intervención. Como objetivos secundarios, se establecieron la prevalencia de la lesión nerviosa, la prolongación del bloqueo cuadricipital y el consumo de morfina, de acuerdo con otras variables de interés. Materiales y métodos: En este estudio retrospectivo observacional, se recopilaron datos de la historia clínica digital de 656 pacientes de cirugía traumatológica de abril de 2018 a agosto de 2020, con los criterios de inclusión siguientes: mayores de 18 años, ASA I-III, artroplastia total de cadera primaria con anestesia general o anestesia subaracnoidea (solo con bupivacaína hiperbárica) y uso de levobupivacaína para el bloqueo del nervio periférico. Resultados: Se seleccionó un total de 362 pacientes. La indicación quirúrgica principal fue coxartrosis (61,3%), seguida de fractura de cadera (22,6%). Se realizaron bloqueos del nervio periférico en 169 pacientes (66,3% femoral, 27,7% PENG, y 6% de fascia ilíaca). El consumo medio postoperatorio de opioides en la UCPA fue inferior en los pacientes que recibieron bloqueo PENG (2,2 mg) o femoral (3,27 mg), en comparación con los que no recibieron ninguno de los dos (6,69 mg)...(AU)

Introduction: Total hip arthroplasty is one of the most frequent surgical interventions in the hospital setting. Nonetheless, the ideal method to manage post-operative pain is still unknown. Multimodal analgesia techniques based on regional anaesthesia are amongst the most promising solutions. Objectives: The aim of this study was to evaluate postoperative pain after total hip arthroplasty according to whether peripheral nerve block was performed (femoral block, fascia iliaca block and pericapsular nerve group block). Intravenous morphine consumption during the patient's stay in the post-anaesthesia care unit was measured, as well as the number of opioid rescues at 24 and 48h post intervention. As secondary objectives, the prevalence of nerve injury, prolonged quadricipital block, and morphine consumption were established according to other variables of interest. Materials and methods: In this observational retrospective study, data was collected from the electronic medical record of 656 traumatological surgery patients from April 2018 to August 2020, with the following inclusion criteria: over 18 years old, ASA I-III, primary total hip arthroplasty under general anaesthesia or subarachnoid anaesthesia (only with hyperbaric bupivacaine) and use of levobupivacaine for peripheral nerve block. Results: A total of 362 patients were selected. The main surgical indication was coxarthrosis (61.3%), followed by hip fracture (22.6%). Peripheral nerve blocks were performed on 169 patients (66.3% femoral, 27.7% PENG, and 6.0% fascia iliaca). Mean postoperative opioid consumption in PACU was lower in patients in who received a PENG (2.2 mg) or a femoral (3.27 mg) block, compared to those who received neither (6.69 mg). There were no differences in opioid rescues at 24 and 48h after the procedure...(AU)

Retrospective analysis of regional anaesthesia in hip surgery: A clinical audit.

INTRODUCTION: Total hip arthroplasty is one of the most frequent surgical interventions in the hospital setting. Nonetheless, the ideal method to manage post-operative pain is still unknown. Multimodal analgesia techniques based on regional anaesthesia are amongst the most promising solutions. OBJECTIVES: The aim of this study was to evaluate postoperative pain after total hip arthroplasty according to whether peripheral nerve block was performed (femoral block, fascia iliaca block and pericapsular nerve group block). Intravenous morphine consumption during the patient's stay in the post-anaesthesia care unit was measured, as well as the number of opioid rescues at 24 and 48 h post intervention. As secondary objectives, the prevalence of nerve injury, prolonged quadricipital block, and morphine consumption were established according to other variables of interest. MATERIALS AND METHODS: In this observational retrospective study, data was collected from the electronic medical record of 656 traumatological surgery patients from April 2018 to August 2020, with the following inclusion criteria: over 18 years old, ASA I-III, primary total hip arthroplasty under general anaesthesia or subarachnoid anaesthesia (only with hyperbaric bupivacaine) and use of levobupivacaine for peripheral nerve block. RESULTS: A total of 362 patients were selected. The main surgical indication was coxarthrosis (61.3%), followed by hip fracture (22.6%). Peripheral nerve blocks were performed on 169 patients (66.3% femoral, 27.7% PENG, and 6.0% fascia iliaca). Mean postoperative opioid consumption in PACU was lower in patients in who received a PENG (2.2 mg) or a femoral (3.27 mg) block, compared to those who received neither (6.69 mg). There were no differences in opioid rescues at 24 and 48 h after the procedure. Nerve injury incidence was low (.8%), and not associated with nerve blocks. The incidence of prolonged quadricipital paralysis was also low (1.3%), and was mainly associated with femoral nerve block (75% of cases). CONCLUSIONS: This retrospective study supports the use of regional blocks as opioid-sparing techniques, highlighting their role in rapid functional recovery with no motor impairment.

Femoral nerve inguinal approach versus proximal femoral triangle ap proach for continuous regional analgesia in active rehabilitation after total knee arthroplasty: A prospective, randomised study.

BACKGROUND: A catheter in femoral nerve block (F-Cath) is an effective regional analgesia technique in total knee arthroplasty (TKA) but results in significant quadriceps weakness. The femoral triangle catheter (FTB-Cath) seems to be an interesting alternative. In this study, we aim to demonstrate that the nerve block administration for analgesic purposes via an FTB-Cath results in less quadriceps weakness than via an F-Cath. METHODS: This study included patients scheduled for TKA performed under general anaesthesia. The patients were randomised to receive either an F-Cath or an FTB-Cath. A unique regimen of 0.2% ropivacaine was administrated for 72 h. The primary endpoint was quadriceps strength assessed clinically on postoperative day (POD) 2 by the Manual Muscle Test (MMT) using a motor grading scores (0-5). The secondary endpoints were quadriceps strength measured by a dynamometer, the Timed Up and Go (TUG) test, the 30-m walk test (30MWT) and pain scores. RESULTS: Forty-four patients were analysed (22 in each group). On POD 2, 77.3% of the patients in the FTB-Cath group had MMT scores ≥ 4 and 13.6% in the F-Cath group (p < 0.001). During the first four POD assessments, quadriceps strength evaluated with a dynamometer was less diminished in the FTB-Cath group (p < 0,001). There was no difference between groups regarding pain scores, TUG test results and 30MWT assessment. CONCLUSION: The FTB-Cath provided a better preservation of quadriceps strength than the F-Cath in TKA, with a similar pain relief.

Deep sedation vs femoral block anesthesia: beat-by-beat hemodynamic impact on TAVI procedure.

BACKGROUND: In spite of the increased use of Trans-catheter Aortic Valve Implantation (TAVI) due to the better patient selection, well-trained operators and improved technology, the choice of the best anesthesia regimen remains an open question. In particular, it remains to be clarified whether deep sedation (DS) in spontaneous breathing or femoral local anesthesia (LA) is best. OBJECTIVE: This study compared the hemodynamic variations determined by deep sedation (DS) with spontaneous breathing and local femoral anesthesia (LA) in 2 groups of patients submitted to TAVI with two different kinds of anesthesia, using a beat-by-beat pulse contour method (MostCare®-UP). METHODS: 82 patients with severe aortic stenosis and similar baseline characteristics and indications underwent trans-femoral TAVI: 50 with LA and 32 with DS. All patients were submitted to minimally invasive hemodynamic monitoring. The following parameters were measured: pressure indexes: systolic, diastolic, mean (SysP, DiaP, MAP) and dicrotic (DicP) pressures; flow indexes: cardiac output (CO), stroke volume (SV); ventriculo-arterial coupling indexes (VAC): peripheral arterial elastance (EaP), systemic vascular resistance (SVR); cardiovascular system performance: cardiac cycle efficiency (CCE), dP/dtmax_rad. RESULTS: The TAVI procedure was successful in 89% of patients (VARC-2 criteria) with no difference between the 2 groups. Anesthesia induction determined a higher decrease of pressures in DS than in LA (P<0.01) with no differences in CO. The VAC parameters (EaP, SVR) decreased (P<0.01) in DS with an improvement in CCE (P<0.001); these parameters did not change in LA. The post-TAVI flow and VAC parameters, especially Ea, increased (P<0.05) more significantly in the LA group than in the DS group (P<0.001). Using logistic regression, the occurrence of the post-TAVI aortic regurgitation was correctly associated with the pressure gradient MAP-DicP in 63% of the study population (P=0.033). This association was more effectively detected in the LA group (78%, P=0.011) with a ROC AUC=0.779, than the DS group. CONCLUSION: The use of the pulse contour method to track the fast-hemodynamic changes during the TAVI procedure proved suitable for the aim. As expected, LA and DS induced different pre-TAVI hemodynamic conditions, which influenced the post-TAVI hemodynamic changes. The hemodynamic conditions induced by LA, enabled the occurrence of post-TAVI aortic regurgitation to be detected more effectively.

Eficacia del bloqueo femoral modificado en los pacientes con diagnóstico de fractura de cadera / Effectiveness of modified femoral block in patients with a diagnosis of hip fracture

Introducción: La evidencia demuestra que un inadecuado alivio del dolor preoperatorio tiene consecuencias fisiológicas y psicológicas nocivas en los pacientes, aumenta la morbilidad y la mortalidad. Objetivo: Evaluar la eficacia del bloqueo femoral modificado en los pacientes con el diagnóstico de fractura de cadera. Método: Se realizó un estudio cuasiexperimental en el Hospital Universitario Manuel Ascunce Domenech de la provincia Camagüey, en el periodo correspondiente de enero 2016 hasta enero 2018. Se constituyó el universo con 639 pacientes programados de urgencia y electivo con el diagnóstico de fractura de cadera, a través de un muestreo aleatorio simple de manera automática con el Statistical Package for the Social Sciences (SPSS) Versión 21 para Windows, error aceptable y nivel de confianza del 95 por ciento. Se conformó la muestra por 295 pacientes. Resultados: La mayor parte de los pacientes intervenidos por fractura de cadera están por encima de la quinta década de la vida. Se diagnosticó la fractura extracapsular en 174 pacientes, en la evaluación del dolor a través del Cuestionario de dolor de McGill se constata dolor terrible de 4 con intervalo de confianza (2,00912-6,23110) antes del bloqueo y analgesia después del bloqueo de 1 con intervalo de confianza (0,73102 - 1,48209). Conclusiones: El bloqueo femoral modificado proporcionó analgesia en la totalidad de los casos(AU)

Introduction: Evidence shows that inadequate control of preoperative pain has harmful physiological and psychological consequences in patients, and increases morbidity and mortality. Objective: To evaluate the efficacy of modified femoral block in patients with a diagnosis of hip fracture. Method: A quasi-experimental study was carried out at Manuel Ascunce Domenech University Hospital in Camagüey Province, from January 2016 to January 2018. The study population was made up of 639 emergency and elective surgical patients with the diagnosis of hip fracture of hip, through simple random sampling automatically with the Statistical Package for the Social Sciences (SPSS) Version 21 for Windows, acceptable error and 95% confidence level. The sample was made up of 295 patients. Results: Most of the patients operated on for hip fracture are above their fifth decade of life. Extracapsular fracture was diagnosed in 174 patients. Regarding pain evaluation through McGill's Pain Questionnaire, terrible pain of 4 was perceived, with confidence interval (2.00912-6.23110) before block; and also analgesia of 1 after blockage, with confidence interval (0.73102-1.48209). Conclusions: The modified femoral block provided analgesia in all cases(AU)

Continuous Femoral Catheter for Postoperative Analgesia After Total Knee Arthroplasty.

INTRODUCTION: Postoperative pain management in the total knee replacement (TKR) represent a fundamental step for a positive outcome, allowing rapid mobilization, already on the first day. Further, continuous peripheral nerve block techniques have been reported to allow effective and safe control of acute postoperative pain, ensuring the implementation and completion of an accurate and intensive joint rehabilitation program. AIM: The aim of this study was to assess early mobility and compliance of patients that underwent TKR surgery using the femoral block. METHODS: For the study, all patients that underwent TKR from 2015 to 2018 with ASA score between II-III was evaluated. Patients underwent vital parameters monitoring and were treated initially with midazolam (0.05mg / kg) e.v. combined sciatic block + femoral perineural catheter positioning using a peripheral nerve stimulation-assisted technique. RESULTS: Intraoperatively, satisfactory analgesia was guaranteed in all patients, associated with a complete muscle relaxation of the affected limb. High patient compliance, associated with good control of acute postoperative pain was obtained in the first 24 hours after surgery (VAS 0- 1). The ROM outcomes were good in all rehabilitation stages, managing to reach 90 degrees bending on the seventh day with an average KSS score of 88-90. Patient satisfaction and impact on quality of life were assessed with the SF-36 showing average scores of 78. CONCLUSION: Continuous femoral nerve blocking ensures good postoperative analgesia in TKR allowing an early joint mobilization, a rapid functional recovery of the knee and increasing patient compliance during the post-operative rehabilitation program.

Novel ultrasound-guided lateral approach for femoral nerve block in cats: a pilot study.

OBJECTIVES: The aim of this study was to describe the technique for a novel lateral approach to femoral nerve block in cat cadavers. METHODS: Five feline cadavers were used in our prospective cadaveric experimental study. Ultrasonography was used to identify the anatomy injection site. Both pelvic limbs were injected with a volume (0.1 ml/kg) of methylene blue in each cat. The cadavers were placed in lateral recumbency, with the limb to be blocked positioned uppermost. The transducer was held perpendicular to the most proximal area of the pelvic limb, ventral to the greater trochanter and slightly cranial to the femur. Methylene blue was injected after the localisation of the femoral nerve. Immediately after the injection, the cat was turned and the technique was repeated on the contralateral side. After performing the 'block' in both limbs, the area was dissected bilaterally and the success was evaluated. A positive femoral nerve staining was considered for a coverage of ⩾1 cm. RESULTS: A total of 10 ultrasound-guided femoral nerve injections were performed. Ninety percent (n = 9/10) of the nerves were successfully dyed. CONCLUSIONS AND RELEVANCE: The novel ultrasound-guided lateral approach may be suitable and reproducible for a successful femoral nerve blockade in cats. Further investigations about the clinical usefulness and safety of this femoral nerve block in live cats are required.

Artroscopía de rodilla bajo bloqueos de nervios femoral y ciático en paciente COVID-19 con artritis séptica. Reporte de caso / Knee arthroscopy under femoral and sciatic nerve blocks in a COVID-19 patient with septic arthritis. A case report

Since the start of the COVID-19 pandemic, several anesthetic societies have generated clinical recommendations for the perioperative management of these patients, including the Chilean Society of Anesthesiology. Among these recommendations, the advantages of regional anesthesia have been highlighted. In this article, we report and discuss the case of a 59-year-old patient with diabetes mellitus II, Chronic Arterial Hypertension, Gout, and Stage IV Chronic Renal Failure admitted with a multifocal septic condition characterized by suppurative collections including a large subcutaneous lumbar abscess recently drained. The patient evolved with left knee septic arthritis and was scheduled for arthroscopic irrigation and debridement. As per protocol a SARS-COV2 PCR was tested and resulted positive. It was decided to proceed to surgery under anesthetic ultrasound-guided femoral and sciatic nerve blocks using an adrenalized (2.5 ug/mL) solution of 0.33% Levobupivacaine- 0.66% Lidocaine (15 mL each). Fifteen minutes later, the knee was mobilized passively without pain. Surgery started after 30 minutes. The surgical and anesthetic conditions were described as adequate by the surgeon and the patient, respectively. The postoperative evolution was satisfactory without presenting respiratory symptoms and the patient was discharged 17 days after under oral antibiotic treatment.

Desde el comienzo de la pandemia de COviD-19, varias sociedades de anestesia han generado recomendaciones clínicas para el tratamiento perioperatorio de estos pacientes, incluida la Sociedad Chilena de Anestesiología. Entre estas recomendaciones, se han destacado las ventajas de la anestesia regional. En este artículo, reportamos y discutimos el caso de un paciente de 59 años con diabetes mellitus tipo 2, hipertensión arterial, gota e insuficiencia renal crónica en etapa IV, admitido por una sepsis multifocal caracterizada por colecciones supurativas que incluyen un gran absceso lumbar subcutáneo drenado recientemente. El paciente evolucionó con artritis séptica de rodilla requiriendo de una exploración y aseo artroscópico. Por protocolo perioperatorio COviD-19, se solicitó PCR para SARS-COv2 con un resultado positivo. Se decidió proceder a la cirugía bajo bloqueos anestésicos guiados por ultrasonido de nervios femoral y ciático utilizando una solución adrenalizada (2,5 ug/mL) de levobupivacaína al 0,33% lidocaína al 0,66% (15 mL en cada uno). Quince minutos después, la rodilla se movilizó pasivamente sin dolor. La cirugía se inició tras media hora empleando una ligera sedación con propofol. Las condiciones quirúrgicas y anestésicas fueron descritas como adecuadas por el cirujano y el paciente. Este último evolucionó favorablemente, sin síntomas respiratorios y fue dado de alta 17 días después con tratamiento antibiótico oral.

Ultrasound-guided continuous femoral nerve block: a randomized trial on the influence of femoral nerve catheter orifice configuration (six-hole versus end-hole) on post-operative analgesia after total knee arthroplasty.

BACKGROUND: Multiorifice catheters have been shown to provide superior analgesia and significantly reduce local anesthetic consumption compared with end-hole catheters in epidural studies. This prospective, blinded, randomized study tested the hypothesis that, in continuous femoral nerve block (CFNB) under ultrasound guidance, multiorifice catheter would reduce local anesthetic consumption at 24 h compared with end-hole catheter. METHODS: Eighty adult patients (aged ≥18 years) scheduled to undergo primary total knee arthroplasty under a combination of CFNB, sciatic nerve block and general anesthesia were randomized to CFNB using either a 3-pair micro-hole (Contiplex, BRAUN®, 20G - 400 mm) or an end-hole (Silverstim VYGON®, 20G - 500 mm) catheter. Once the femoral catheter was sited, a bolus of 20 mL lidocaine 1% was injected. An electronic pump then delivered an automated 5 mL bolus of ropivacaine 0.2% hourly, with 10 mL self-administered patient controlled analgesia boluses. RESULTS: There was no inter-group difference in either median number of ropivacaine boluses on demand during the first 24 h (4(2-7) vs. 4(2-8) in six-hole and end-hole groups, respectively; P = 0.832) or median ropivacaine consumption at 48 h (365(295-418) vs. 387(323-466); P = 0.452). No significant differences were recorded between the groups at 24 h regarding median average verbal rate pain scale (2(0-3) vs. 2(0-4); P = 0.486) or morphine consumption (0(0-20) vs. 0(0-20); P = 0.749). Quadriceps muscle strength declined to 7% (0-20) and 10% (0-28) in the six-hole and end-hole groups, respectively, at 24 h after surgery (P = 0.733). CONCLUSIONS: In this superiority trial, catheter orifice configuration did not influence the effectiveness of CFNB in this setting: quality of analgesia was similar, with no reduction in either local anesthetic or morphine consumption, and equivalent postoperative quadriceps weakness. TRIAL REGISTRATION: Retrospectively registered at ( NCT03376178 ). Date: 21 November 2017.

Evaluation of analgesic regimens in total knee arthroplasty, retrospective study.

OBJECTIVE: Analgesic therapies have an immense role in early rehabilitation period after total knee arthroplasty (TKA) and multimodal approaches should be considered as the first choice of treatment. In this retrospective study, the aim was to evaluate the effectiveness of multimodal analgesic therapies for TKA, including femoral nerve block (FNB) and patient controlled analgesia (PCA). METHODS: The data of 79 patients who underwent TKA between January and December 2016 were retrospectively evaluated. In all, 63 patients met the inclusion criteria. Hemodynamic records and Visual Analogue Scale (VAS) pain scores for postoperative 0, 2, 4, 6, 9, and 12 hours were evaluated and patients were separated into 3 groups. Group 1: FNB with 0.25% bupivacaine, Group 2: FNB with 0.166% bupivacaine, and Group 3: No FNB. RESULTS: The average age of the patients was 64.3±14.9 years and average body mass index (BMI) was 32.5±5.3 kg/m2. There was no statistical difference between groups in age, gender, American Society of Anesthesiologists (ASA) classification of physical health scores, BMI, or anesthesia type (p<0.05). When VAS scores at postoperative time intervals were compared, there was a statistically significant difference between Group 1 and Group 2 (p>0.05). When difference between Groups 1 and 3 and Groups 2 and 3 were compared, the difference was statistically significant for VAS 0 (p>0.05). Additional analgesic use was highest in Group 3. CONCLUSION: This study demonstrated that FNB significantly decreases postoperative pain intensity and additional analgesia requirement in patients undergoing TKA. A concentration of 0.166% bupivacaine is as effective as a concentration of 0.25% when used as part of a multimodal analgesia regimen in TKA.

Peri-articular local infiltration analgesia versus femoral nerve block for postoperative pain control following anterior cruciate ligament reconstruction: Prospective, comparative, non-inferiority study.

INTRODUCTION: Femoral nerve block (FNB) is considered as a major advance in anterior cruciate ligament (ACL) reconstruction as it reduces the need for parenteral opioids. However, the incidence of transient or even permanent neurological deficits due to the FNB is estimated at 1.94% after knee surgery. The primary objective of this study was to compare local infiltration analgesia (LIA) to FNB during ACL reconstruction procedures. The study hypothesis was that LIA was not less effective than FNB on early postoperative pain. PATIENTS AND METHODS: A retrospective analysis of data collected prospectively in the FAST cohort included a series of continuous patients who underwent primary repair for isolated ACL with a hamstring graft in 2013-2014. Changes in our anesthesia practices over time allowed us to form three successive groups: Group 1 - FNB, Group 2 - FNB+LIA, Group 3 - LIA only. Ultrasound-guided FNB was done pre-operatively. The LIA was done at the end of the procedure by the surgeon with systematic infiltration of all skin incisions and the hamstring donor site; no intra-articular injections were performed. The primary endpoint was the average early postoperative pain (Days 0-3) described by the patient on a visual analogue scale (0-10). Sample size calculation pointed to 36 subjects being needed per group for a non-inferiority study. RESULTS: The study involved 126 patients: G1=42, G2=38, G3=46. The patients were comparable at enrolment. The average early postoperative pain levels were 3.1±2.4, 2.8±2.0 and 2.5±2.2, respectively (P=0.66). A trend toward higher intake of tramadol was noted in the LIA group on D0 to D3, with a significant trend test on Day 1 (P=0.03) and Day 2 (P=0.02). CONCLUSION: After reconstruction of isolated ACL tears with a hamstring graft, FNB is not more effective than LIA on patients' early postoperative pain. Patients who received a FNB consumed significantly less opioid-like analgesics. LEVEL OF EVIDENCE: III - Prospective, comparative, non-randomized study.

Opioid consumption in total knee arthroplasty patients: a retrospective comparison of adductor canal and femoral nerve continuous infusions in the presence of a sciatic nerve catheter.

OBJECTIVE: To compare opioid consumption among patients who receive a continuous adductor canal block (ACB) versus continuous femoral nerve block (FB) for total knee arthroplasty analgesia in the presence of an intermittent sciatic nerve catheter (iSB). DESIGN: Matched cohort retrospective study. SETTING: Mayo Clinic, Jacksonville, FL. PATIENTS: Ninety patient charts were included in this study: 45 patients with continuous ACB/iSB and 45 with continuous FB/iSB. Patients were matched according to mean preoperative opioid consumption and pain scores, BMI, age, and gender. MEASUREMENTS: The primary outcome of the study was postoperative on-demand opioid consumption on postoperative days 0 (POD 0), 1 (POD 1), and 2 (POD 2). Secondary outcomes included postoperative Visual Analog Scale (VAS) scores for anterior and posterior knee pain, incidence of nausea and pruritus, need for intravenous rescue opioid, and need for catheter bolus by a physician. MAIN RESULTS: On POD 0, mean opioid consumption in milligrams of oral morphine equivalent [mean±SD (95% CI)] was 43.98mg±33.36 (33.96, 54) in the ACB/iSB group vs 38.45mg±30.99 (29.14, 47.76) in the FB/iSB group, respectively (P=.42); on POD 1, 74.96mg±37.23 (63.78, 86.14) vs 72.40mg±62.34 (53.67, 91.13) (P=.81); on POD 2, 28.19mg±17.69 (22.87, 33.51) vs 31.84mg±23.09 (24.90, 38.78) (P=.40). On POD 1, median anterior knee VAS scores at rest were equivalent in both the ACB/iSB and FB/iSB groups (1 vs 1, respectively, P=.46); however, patients in the ACB/iSB group were more likely to have higher anterior knee pain scores with movement (4 vs 1, P=.002). CONCLUSION: In the first 2 days after a total knee arthroplasty, opioid consumption in patients with continuous ACB/iSB was not significantly different from patients receiving continuous FB/iSB. Continuous adductor canal block appears to provide adequate analgesia when compared to continuous femoral blockade.

Dolor posoperatorio en pacientes sometidos a artroscopia de cadera con la técnica dentro-fuera en comparación con la técnica fuera-dentro / Douleur postopératoire chez les patients traités par la technique arthroscopique de dehors en dedans en comparaison avec la technique de dedans en dehors au niveau de la hanche / Postoperative pain in patients undergoing hip arthroscopy with inside-out technique compared with the outside-in technique

Objetivo: comparar el dolor posoperatorio en pacientes sometidos a artroscopia de cadera con la técnica dentro-fuera en comparación con la técnica fuera-dentro. Métodos: se realizó un estudio prospectivo en el que se comparó el dolor posoperatorio en un grupo de pacientes (n = 31) a los que se les realizó artroscopia de cadera mediante la técnica fuera-dentro, con los pacientes (n = 31) a los que se les realizó con la técnica dentro-fuera; ambos grupos de pacientes recibieron la misma analgesia multimodal. Los parámetros principales medidos fueron: la escala visual análoga en diferentes momentos hasta 24 horas después de la operación y la necesidad de opiáceos. Para las variables categóricas se realizó la comparación mediante Chi cuadrado, y para las variables cuantitativas mediante t Student o Mann-Whitney. Se calcularon el OR y el IC 95 por ciento. Para el análisis de los datos se utilizó el programa SPSS versión 21.0 y se consideró un error alfa de 5 por ciento. Resultados: la escala visual análoga posoperatoria fue menor en pacientes con la técnica de fuera-dentro después de 1 hora (diferencia media 1,9 IC 95 por ciento: 0,5 a 3,2, p = 0,01), después de 2 horas (diferencia media 1,29 IC 95 por ciento: 0,3 a 2,2, p = 0,01), y en el momento del alta (diferencia media 0,77 IC 95 por ciento: 0,16 a 1,18; p = 0,01). Sin embargo, 24 horas después del procedimiento, la diferencia no fue significativa (diferencia media 0,4 IC 95 por ciento: 0,02 a 0,84; p = 0,08). Las necesidades de opioides en el posoperatorio fueron significativamente menores en los pacientes con la técnica fuera-dentro ─6,5 por ciento vs. 41,9 por ciento─ (OR crudo 0,09 IC 95 porciento: 0,02 a 0,47; p = 0,004), incluso después de ajustar por edad, sexo y el IMC (OR ajustado 0,09 IC 95 por ciento: 0,016 hasta 0,51, p = 0,006). Conclusiones: los pacientes a los que se les realiza artroscopia de cadera con la técnica fuera-dentro tienen menos dolor posoperatorio y requerimientos de opioides que aquellos a los que se les realiza la técnica dentro-fuera(AU)

Objective: compare postoperative pain in patients undergoing hip arthroscopy with the inside-out technique compared to outside-in technique. Methods: a prospective study was conducted on postoperative pain in a group of patients (n = 31) who underwent hip arthroscopy by outside-in technique, which were compared with patients (n = 31) who received the inside-out technique. Both groups of patients received the same multimodal analgesia. The main parameters were measured: visual analogue scale at different times up to 24 hours after surgery and opioid need. Categorical variables were compared using Chi-square, and quantitative variables using Student t or Mann-Whitney. OR and CI 95 percent were calculated. SPSS version 21.0 was used for data analysis program and an alpha error of 5 percent was considered. Results: postoperative visual analogue scale was lower in patients with outside-in technique after 1 hour (mean difference 1.9, 95 percent CI 0.5 to 3.2, p = 0.01) after 2 hours (mean difference 1.29, 95 percent CI 0.3 to 2.2, p = 0.01) and at discharge (mean difference 0.77, 95 percent CI 0.16 to 1.18; p = 0.01). However, 24 hours after the procedure, the difference was not significant (mean difference 0.4, 95 percent CI 0.02 to 0.84; p = 0.08). Opioid requirements postoperatively were significantly lower in patients with the outside-in technique ─6,5 percent vs. 41.9 percent─ (crude OR 0.09 95 percnt CI 0.02 to 0.47; p = 0.004), even after adjusting age, sex and BMI (adjusted OR 0.09, 95 percent CI: 0.016 to 0.51, p = 0.006). Conclusions: Patients who underwent hip arthroscopy with outside-in technique have less postoperative pain and opioid requirements that those who undergo the inside-out technique(AU)

Objectif: le but de ce travail est de comparer la douleur postopératoire chez des patients opérés par la technique arthroscopique de dedans en dehors avec la technique de dehors en dedans au niveau de la hanche. Méthodes: une étude prospective a été réalisée afin de comparer la douleur postopératoire dans un groupe de patients traités par la technique arthroscopique de dehors en dedans (n = 31) et dans un groupe de patients traités par la technique arthroscopique de dedans en dehors (n = 31) au niveau de la hanche. Tous les deux groupes ont reçu une analgésie multimodale. On a fondamentalement évalué des paramètres tels que l'échelle visuelle analogique (EVA) en différents moments, même 24 heures après l'opération, et le besoin d'opiacés. Pour les variables catégoriques, on a utilisé le test de Chi carré, et pour les variables quantitatives le test du t de Student ou de Mann-Whitney. On a également calculé l'OR et l'IC 95 pourcent. Pour l'analyse des données, on a utilisé le logiciel SPSS v21.0, et une erreur alpha de 5 pourcent a été considérée. Résultats: la valeur EVA en postopératoire a été inférieure chez les patients opérés par la technique de dehors en dedans après 1 h (différence moyenne 1.9 IC 95 pourcent : 0.5 à 3.2, p = 0.01), après 2 h (différence moyenne 1.29 IC 95 pourcent : 0.3 à 2.2, p = 0.01), et à la sortie de l'hôpital (différence moyenne 0,77 IC 95 pourcent : 0.16 à 1.18 ; p = 0.01). Par contre, la différence n'a pas été significative (différence moyenne 0.4 IC 95 pourcent : 0.02 à 0.84 ; p = 0.08) 24 h après le geste opératoire. Le besoin d'opiacés en postopératoire a été significativement inférieur chez les patients traités par la technique de dehors en dedans ─6.5 pourcent vs. 41.9 pourcent─ (OR cru 0.09 IC 95 pourcent : 0.02 à 0.47 ; p = 0.004), même après l'ajustement par âge, sexe et IMC (OR ajusté 0.09 IC 95 pourcent : 0.016 jusqu'à 0.51, p = 0.006). Conclusions: on conclut que les patients traités par la technique arthroscopique de dehors en dedans souffrent moins de douleur postopératoire et n'ont pas besoin d'opiacés que ceux qui ont été traités par la technique arthroscopique de dedans en dehors. Mots clés: arthroscopie de hanche, technique arthroscopique de dehors en dedans, technique arthroscopique de dedans en dehors, blocage fémoral, blocage ilio-facial, analgésie multimodale, douleur postopératoire(AU)

Bloqueos de nervio periférico para el dolor posoperatorio de artroscopia de cadera / Peripheral nerve block for the postoperative pain relief after arthroscopy of the hip

Introducción: el tratamiento del dolor posoperatorio de la artroscopia de cadera es un reto y no se conocen estudios relacionados con su tratamiento basado en bloqueos regionales. Objetivo: Determinar el comportamiento del dolor posoperatorio y la satisfacción de los pacientes tratados por artroscopia de cadera con bloqueo femoral, bloqueo del plexo lumbar o infiltración intraarticular. Métodos: Se revisaron prospectivamente todos los registros anestésicos de 61 pacientes que requirieron artroscopia de cadera bajo anestesia general utilizando bloqueo femoral con 0,3 mL/kg de levobupivacaína al 0,375 %, bloqueo del plexo lumbar con 0,4 mL/kg de levobupivacaína al 0,375 % o infiltración intraarticular con 20 mL de bupivacaína al 0,5 %. Se revisaron los datos de dolor posoperatorio evaluados con escala visual análoga a los 15, 30, 60 y 120 minutos y a las 24 horas; la satisfacción del paciente en el momento del alta hospitalaria y a las 24 horas, el bloqueo motor y sensitivo y la necesidad de morfina en el posoperatorio. Resultados: El grupo tratado con infiltración intraarticular presentó los niveles de dolor más altos en casi todos los momentos evaluados. Comparado con el bloqueo del plexo lumbar, más pacientes del grupo bloqueo femoral presentaron niveles mayores de dolor en casi todos los momentos. De los pacientes del grupo tratado con infiltración intraarticular 55 % recibieron morfina en algún momento del posoperatorio, así como 28,5 % del grupo bloqueo femoral y 15 % del grupo bloqueo del plexo lumbar. El nivel de satisfacción de los pacientes fue alto y similar en los tres grupos. Conclusión: La analgesia posoperatoria para artroscopia de cadera fue mejor con bloqueo del plexo lumbar comparado con el bloqueo femoral o la infiltración intraarticular.

Background: The treatment of postoperative pain after arthroscopy of the hip is a challenge and there are no known studies related to its treatment which have been based on regional block. Objectives:To determine the behaviour of postoperative pain and the satisfaction of the patients who have been treated with arthroscopy of the hip with femoral block, lumbar plexus block or intra-articular infiltration. Methods:All the anaesthetic records of 61 patients that required arthroscopy of the hip under general anaesthesia using femoral block with 0,3 mL/kg of Levobupivacaine 0,375 %, lumbar plexus block with 0,4 mL/kg of Levobupivacaine 0,375 % or intra-articular infiltration with 20 mL of Bupivacaine 0,5 % were checked. The data about postoperative pain which had been assessed with visual analogous scale at the 15, 30, 60 and 120 minutes and at the 24 hours, the satisfaction of the patients at the moment of the discharge from hospital at the 24 hours, the sensitive and motor block and the need to use Morphine in the postoperative phase were also checked. Results:The group of patients that were treated with intra-articular infiltration presented the highest levels of pain in almost all evaluated moments. As compared with the lumbar plexus block, more patients that underwent femoral block presented higher levels of pain in almost all moments. Out of the patients in the group that was treated with intra-articular infiltration, the 55 % received Morphine at any postoperative moment as well as the 28,5 % treated with femoral block and the 15 % who underwent lumbar plexus block. The level of patients´ satisfaction was high and similar in the three groups. Conclusions:Postoperative analgesia for arthroscopy of the hip was better with lumbar plexus block as compared with femoral block or intra-articular infiltration.

Ultrasound-guided nerve blocks in the emergency department.

Peripheral nerve blocks preclude the need for procedural sedation and provide adequate anesthesia during painful procedures. This technique can be performed in the emergency department with the aid of ultrasound imaging to identify target nerves. We describe eight cases of upper and lower extremity nerve blocks performed under ultrasound guidance in the emergency department of the Jai Prakash Narayan Trauma Centre, All India Institute of Medical Sciences, New Delhi. Only two of the patients, both with extensive injuries, required any additional anesthesia during the subsequent procedures and all of them reported significant pain control and muscle relaxation.

Effect of pre-incisional continuous regional block on early and late postoperative conditions in tibial osteotomy and total knee arthroplasty.

BACKGROUND: Postoperative regional anesthesia hastens recovery and reduces the length of hospital stay of orthopedic surgical patients. This study was designed to assess the impact of pre-incisional continuous femoral block on postoperative conditions (POC) of tibial osteotomy and total knee arthroplasty patients. METHODS: After insertion of a femoral catheter under peripheral nerve stimulation control, 111 patients scheduled for total knee arthroplasty or tibial osteotomy were randomized to receive either pre-incisionnal (treatment) or postoperative (control) continuous femoral block. Anesthesia and postoperative management was standardized. An assessor blinded to the randomization process recorded early and late postoperative conditions (POC) which included pain scores, opioid demands, length of stay in Postoperative care unit and patients' satisfaction. RESULTS: Eleven patients were excluded from the final analysis because of catheter disconnection or malfunction. Thus 100 patients (50 in each group) were analyzed for POC. Treatment failed to influence patients overall satisfaction but significantly improved early POC. Subgroup analysis demonstrated that late POC were significantly improved in tibial osteotomy as compared to total knee arthroplasty patients. No complication occurred during the study period. CONCLUSION: Continuous femoral nerve block before surgery significantly improved early postoperative conditions in both surgery while late postoperative conditions were improved only in tibial osteotomy.