Comparison of continuous femoral nerve block (CFNB/SA) and continuous femoral nerve block with mini-dose spinal morphine (CFNB/SAMO) for postoperative analgesia after total knee arthroplasty (TKA): a randomized controlled study

Petchara Sundarathiti, Jadesadha Thammasakulsiri, Supawadee Supboon, Supalak Sakdanuwatwong, Molruedee Piangjai, Petchara Sundarathiti, Jadesadha Thammasakulsiri, Supawadee Supboon, Supalak Sakdanuwatwong, Molruedee Piangjai

Abstract

Background: Unsatisfactory analgesia for major knee surgery with femoral nerve block (FNB) alone was reported and the additional benefit of sciatic block to continuous femoral nerve block (CFNB) was not conclusive. The aim of the present study was to find the benefit of the additional mini-dose spinal morphine (0.035 mg) to CFNB for postoperative pain control and to compare their associated side effects after total knee arthroplasty (TKA).

Methods: After written informed consent and with Institutional Ethics Committee approval, 68 American Society of Anesthesiologists (ASA) Physical Status I-III patients scheduled for elective unilateral TKA under spinal anesthesia (SA) were included in the present prospective, randomized controlled study. The patients were allocated into two groups. CFNB was placed in all patients by the inguinal paravascular approach with 20 ml of 0.25 % levobupivacaine. Group I (named CFNB/SA group), SA was administered with 2.8 ml levobupivacaine and Group II (named CFNB/SAMO group), SA with 2.8 ml levobupivacaine plus morphine 0.035 mg. At Post Anesthesia Care Unit (PACU), pain and other adverse effects were recorded. Pain was assessed by visual analog scale (VAS) 0-10. Tramadol 50 mg intravenous (IV) was given if the VAS > 4. In the ward, all patients were maintained by continuous femoral infusion of 0.125 % levobupivacaine rate 7 ml/hr and then reduced to 5 ml/hr if VAS ≤3.

Results: Patient's demographics data in each group were not different. At post-operative (PO) 12-24 h, the VAS scores were significantly lesser in the CFNB/SAMO group. Cumulative tramadol IV requirement for PO48h were also significantly lesser in the CFNB/SAMO group. Nausea, vomiting and numbness were significantly greater in the CFNB/SAMO group during early postoperative period (PO1-6 h).

Conclusion: Though in some patients CFNB was inadequate, a mini-dose of intrathecal morphine (0.035 mg) in addition to CFNB was found to be effective with minimal side effects.

Trial registration: Thai Clinical Trial Registry (identifier: TCTR20150609003 , date of registration: 6 June 2015).

Keywords: Continuous femoral nerve block (CFNB); Levobupivacaine; Mini-dose spinal morphine; Postoperative analgesia; Total knee arthroplasty (TKA).

Figures

Fig. 1
Fig. 1
CONSORT 2010 Flow diagram
Fig. 2
Fig. 2
Cumulative tramadol IV requirement for PO48h
Fig. 3
Fig. 3
Incidence of nausea/vomiting

References

    1. Capdevila X, Barthelet Y, Biboulet P, Ryckwaert Y, Rubenovitch J, d'Athis F. Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery. Anesthesiology. 1999;91(1):8–15. doi: 10.1097/00000542-199907000-00006.
    1. Singelyn FJ, Deyaert M, Joris D, Pendeville E, Gouverneur JM. 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. Anesth Analg. 1998;87(1):88–92.
    1. Wang H, Boctor B, Verner J. The effect of single-injection femoral nerve block on rehabilitation and length of hospital stay after total knee replacement. Reg Anesth Pain Med. 2002;27(2):139–44.
    1. Bonica J. Postoperative pain. In: Bonica J, editor. The Management of Pain. 2. Philadelphia: Lea & Febiger; 1990. pp. 461–80.
    1. Pang WW, Hsu TC, Tung CC, Hung CP, Chang DP, Huang MH. Is total knee replacement more painful than total hip replacement? Acta Anaesthesiol Sin. 2000;38(3):143–8.
    1. Fowler SJ, Symons J, Sabato S, Myles PS. Epidural analgesia compared with peripheral nerve blockade after major knee surgery: a systematic review and meta-analysis of randomized trials. Br J Anaesth. 2008;100(2):154–64. doi: 10.1093/bja/aem373.
    1. Sundarathiti P, Ruananukul N, Channum T, Kitkunasathean C, Mantay A, Thammasakulsiri J, et al. A comparison of continuous femoral nerve block (CFNB) and continuous epidural infusion (CEI) in postoperative analgesia and knee rehabilitation after total knee arthroplasty (TKA) J Med Assoc Thai. 2009;92(3):328–34.
    1. Bauer MC, Pogatzki-Zahn EM, Zahn PK. Regional analgesia techniques for total knee replacement. Curr Opin Anaesthesiol. 2014;27:501–6. doi: 10.1097/ACO.0000000000000115.
    1. Pöpping DM, Zahn PK, Van Aken HK, et al. Effectiveness and safety of postoperative pain management: a survey of 18 925 consecutive patients between 1998 and 2006 (2nd revision): a database analysis of prospectively raised data. Br J Anaesth. 2008;101:832–40. doi: 10.1093/bja/aen300.
    1. Abdallah FW, Brull R. Is sciatic nerve block advantageous when combined with femoral nerve block for postoperative analgesia following total knee arthroplasty? Reg Anesth Pain Med. 2011;36:493Y498. doi: 10.1097/AAP.0b013e318228d5d4.
    1. Tierney E, Lewis G, Hurtig JB, Johnson D. Femoral nerve block with bupivacaine 0.25% for postoperative analgesia after open knee surgery. Can J Anaesth. 1987;34(5):455–8. doi: 10.1007/BF03014348.
    1. Weber A, Fournier R, Van Gessel E, Gamulin Z. Sciatic nerve block and the improvement of femoral nerve block analgesia after total knee replacement. Eur J Anaesthesiol. 2002;19(11):834–6. doi: 10.1097/00003643-200211000-00012.
    1. Mansour NY, Bennetts FE. An observational study of combined continuous lumbar plexus and single-shot sciatic nerve blocks for post-knee surgery analgesia. Reg Anesth. 1996;21(4):287–91.
    1. Chelly JE, Greger J, Gebhard R, Coupe K, Clyburn TA, Buckle R, et al. Continuous femoral blocks improve recovery and outcome of patients undergoing total knee arthroplasty. J Arthroplasty. 2001;16(4):436–45. doi: 10.1054/arth.2001.23622.
    1. Joshi GP. Multimodal analgesia techniques for ambulatory surgery. Int Anesthesiol Clin. 2005;43(3):197–204. doi: 10.1097/01.aia.0000166336.69251.dd.
    1. Maheshwari AV, Boutary M, Yun AG, Sirianni LE, Dorr LD. Multimodal analgesia without routine parenteral narcotics for total hip arthroplasty. Clin Orthop Relat Res. 2006;453:231–8. doi: 10.1097/01.blo.0000246545.72445.c4.
    1. Parvataneni HK, Shah VP, Howard H, Cole N, Ranawat AS, Ranawat CS. Controlling pain after total hip and knee arthroplasty using a multimodal protocol with local periarticular injections: a prospective randomized study. J Arthroplasty. 2007;22(6 Suppl 2):33–8. doi: 10.1016/j.arth.2007.03.034.
    1. Peters CL, Shirley B, Erickson J. The effect of a new multimodal perioperative anesthetic regimen on postoperative pain, side effects, rehabilitation, and length of hospital stay after total joint arthroplasty. J Arthroplasty. 2006;21(6 Suppl 2):132–8. doi: 10.1016/j.arth.2006.04.017.
    1. Wang JK, Nauss LA, Thomas JE. Pain relief by intrathecally applied morphine in man. Anesthesiology. 1979;50(2):149–51. doi: 10.1097/00000542-197902000-00013.
    1. Chinachoti T1, Nilrat P, Samarnpiboonphol P. Nausea, vomiting and pruritus induced by intrathecal morphine. J Med Assoc Thai. 2013;96(5):589–94.
    1. Suksompong S, Pongpayuha P, Lertpaitoonpan W, von Bormann B, Phanchaipetch T, Sanansilp V. Low-dose spinal morphine for post-thoracotomy pain: a prospective randomized study. J Cardiothorac Vasc Anesth. 2013;27:417–22. doi: 10.1053/j.jvca.2012.12.003.
    1. Kalso E. Effects of intrathecal morphine, injected with bupivacaine, on pain after orthopaedic surgery. Br J Anaesth. 1983;55(5):415–22. doi: 10.1093/bja/55.5.415.
    1. Kirson LE, Goldman JM, Slover RB. Low-dose intrathecal morphine for postoperative pain control in patients undergoing transurethral resection of the prostate. Anesthesiology. 1989;71(2):192–5. doi: 10.1097/00000542-198908000-00004.
    1. Ilfeld BM. Continuous peripheral nerve blocks: a review of the published evidence. Anesth Analg. 2011;113:904–25. doi: 10.1213/ANE.0b013e3182285e01.

Source: PubMed

Sponsorit ja yhteistyökumppanit

Sairaudet

Huumeiden interventiot

3
Tilaa