Peripheral nerve blocks versus general anesthesia for total knee replacement in elderly patients on the postoperative quality of recovery

JunLe Liu, WeiXiu Yuan, XiaoLin Wang, Colin F Royse, MaoWei Gong, Ying Zhao, Hong Zhang, JunLe Liu, WeiXiu Yuan, XiaoLin Wang, Colin F Royse, MaoWei Gong, Ying Zhao, Hong Zhang

Abstract

Background: Both peripheral nerve blocks with sedation or general anesthesia can be used for total knee replacement surgery.

Objectives: We compared these anesthetic techniques on the postoperative quality of recovery early in elderly patients.

Materials and methods: In our study, 213 patients who were ≥65 years old and undergoing total knee replacement were randomized to peripheral nerve blocks (PNBs) - lumbar plexus and sciatic - with propofol sedation, or general anesthesia with combined propofol and remifentanil. Blocks were performed using nerve stimulation and 0.35% ropivacaine. All patients received postoperative multimodal analgesia. Postoperative recovery was assessed at 15 minutes, 40 minutes, 1 day, 3 days, and 7 days after surgery, with the Postoperative Quality of Recovery Scale, in physiological, nociceptive, emotive, modified activities of daily living, modified cognitive, and overall patient perspective domains.

Results: Intraoperative blood pressure and heart rate were more stable with PNBs (P<0.001). The recovery was better with PNBs in physiological (P<0.001), emotive (depression and anxiety) (P<0.001), nociceptive (pain and nausea) (P<0.001), modified cognitive (P<0.001), and all domains recovery (P<0.001), but not in activities of daily living (P=0.181). Intraoperative drugs and the postoperative sulfentanil requirement of the PNBs group were lower (all P<0.001). Differences were greatest early after surgery with equivalence by 1 week. Satisfaction was high and not different between groups (P=0.059).

Conclusion: Lumbar plexus and sciatic blocks with sedation facilitates faster postoperative recovery than general anesthesia, but not at 1 week after total knee replacement in patients who were 65 years or older. The trial has been registered at ClinicalTrials.gov. (NCT01871012).

Keywords: general anesthesia; knee replacement; nerve block; perioperative care.

Figures

Figure 1
Figure 1
Flow chart showing patient enrollment, randomization, follow-up, and analysis. Abbreviations: GA, general anesthesia; PNBs, peripheral nerve blocks.
Figure 2
Figure 2
Intraoperative systolic blood pressure and heart rate variation between the PNBs group (■) and the GA group (○). Notes: (A) intraoperative systolic blood pressure; (B) intraoperative heart rate. Abbreviations: GA, general anesthesia; PNBs, peripheral nerve blocks; SBP, systolic blood pressure; HR, heart rate; BL, baseline (performed up to 1–4 days presurgery); OR, operation room; induction, anesthetic induction; skin incision, operation begin; end, end of surgery.
Figure 3
Figure 3
Postoperative recovery variation of the domains over time between the PNBs group (■) and the GA group (○). Notes: The domains include (A) physiology, (B) modified ADL, (C) emotive, (D) nociceptive, (E) modified cognitive, and (F) all domains recovery. Abbreviations: GA, general anesthesia; PNBs, peripheral nerve blocks; ADL, activities of daily living; BL, baseline; T15, 15 minutes after surgery; T40, 40 minutes after surgery; D1, 1 day after surgery; D3, 3 days after surgery; D7, 7, days after surgery.
Figure 4
Figure 4
Incidence of full recovery between the PNBs group (■) and the GA group (O) in nociceptive and emotive domain. Notes: The nociceptive domain includes (A) pain and (B) nausea. Emotive domain includes (C) anxiety and (D) depression. Zero indicated failure of recovery. The maximum number in each graph denotes full recovery. Abbreviations: GA, general anesthesia; PNBs, peripheral nerve blocks; BL, baseline; T15, 15 minutes after surgery; T40, 40 minutes after surgery, D1, 1 day after surgery; D3, 3 days after surgery; and D7, 7 days after surgery.
Figure 5
Figure 5
Percentage of patients who rated their overall perspective of the operative procedure between the PNBs group (■) and the GA group (○). Notes: The domain includes (A) ADL (eat and dress), (B) clarity of thought, and (C) satisfaction. Also, 100% indicates patients feel “no impact at all”. Abbreviations: GA, general anesthesia; PNBs, peripheral nerve blocks; ADL, activities of daily living; D1, 1 day after surgery; D3, 3 days after surgery; D7, 7 days after surgery.

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Source: PubMed

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