Does using a femoral nerve block for total knee replacement decrease postoperative delirium?

Sakura Kinjo, Eunjung Lim, Laura P Sands, Kevin J Bozic, Jacqueline M Leung, Sakura Kinjo, Eunjung Lim, Laura P Sands, Kevin J Bozic, Jacqueline M Leung

Abstract

Background: The effect of peripheral nerve blocks on postoperative delirium in older patients has not been studied. Peripheral nerve blocks may reduce the incidence of postoperative opioid use and its side effects such as delirium via opioid-sparing effect.

Methods: A prospective cohort study was conducted in patients who underwent total knee replacement. Baseline cognitive function was assessed using the Telephone Interview for Cognitive Status. Postoperative delirium was measured using the Confusion Assessment Method postoperatively. Incidence of postoperative delirium was compared in two postoperative management groups: femoral nerve block ± patient-controlled analgesia and patient-controlled analgesia only. In addition, pain levels (using numeric rating scales) and opioid use were compared in two groups.

Results: 85 patients were studied. The overall incidence of postoperative delirium either on postoperative day one or day two was 48.1%. Incidence of postoperative delirium in the femoral nerve block group was lower than patient controlled analgesia only group (25% vs. 61%, P = 0.002). However, there was no significant difference between the groups with respect to postoperative pain level or the amount of intravenous opioid use.

Conclusions: Femoral nerve block reduces the incidence of postoperative delirium. These results suggest that a larger randomized control trial is necessary to confirm these preliminary findings.

References

1. 1. Parikh SS, Chung F. Postoperative delirium in the elderly. Anesth Analg. 1995;80:1223–32.
2. 1. Marcantonio ER, Goldman L, Mangione CM, Ludwig LE, Muraca B, Haslauer CM, Donaldson MC, Whittemore AD, Sugarbaker DJ, Poss R. A clinical prediction rule for delirium after elective noncardiac surgery. JAMA. 1994;271:134–9. doi: 10.1001/jama.1994.03510260066030.
3. 1. Edlund A, Lundstrom M, Brannstrom B, Bucht G, Gustafson Y. Delirium before and after operation for femoral neck fracture. J Am Geriatr Soc. 2001;49:1335–40. doi: 10.1046/j.1532-5415.2001.49261.x.
4. 1. Marcantonio ER, Flacker JM, Michaels M, Resnick NM. Delirium is independently associated with poor functional recovery after hip fracture. J Am Geriatr Soc. 2000;48:618–24.
5. 1. Lynch EP, Lazor MA, Gellis JE, Orav J, Goldman L, Marcantonio ER. The impact of postoperative pain on the development of postoperative delirium. Anesth Analg. 1998;86:781–5.
6. 1. Marcantonio ER, Goldman L, Orav EJ, Cook EF, Lee TH. The association of intraoperative factors with the development of postoperative delirium. Am J Med. 1998;105:380–4. doi: 10.1016/S0002-9343(98)00292-7.
7. 1. Rosenberg J, Kehlet H. Postoperative mental confusion-association with postoperative hypoxemia. Surgery. 1993;114:76–81.
8. 1. Vaurio LE, Sands LP, Wang Y, Mullen EA, Leung JM. Postoperative delirium: the importance of pain and pain management. Anesth Analg. 2006;102:1267–73. doi: 10.1213/.
9. 1. Williams-Russo P, Urquhart BL, Sharrock NE, Charlson ME. Post-operative delirium: predictors and prognosis in elderly orthopedic patients. J Am Geriatr Soc. 1992;40:759–67.
10. 1. Leung JM, Sands LP, Paul S, Joseph T, Kinjo S, Tsai T. Does postoperative delirium limit the use of patient-controlled analgesia in older surgical patients? Anesthesiology. 2009;111:625–31. doi: 10.1097/ALN.0b013e3181acf7e6.
11. 1. Gagliese L, Gauthier LR, Macpherson AK, Jovellanos M, Chan VW. Correlates of postoperative pain and intravenous patient-controlled analgesia use in younger and older surgical patients. Pain Med. 2008;9:299–314. doi: 10.1111/j.1526-4637.2008.00426.x.
12. 1. Brandt JSM, Folstein M. The Telephone Interview for Cognitive Status. 18 Neuropsychiatry Neuropsychol Behav Neurol. 1988;1:111–7.
13. 1. Marcantonio ER, Juarez G, Goldman L, Mangione CM, Ludwig LE, Lind L, Katz N, Cook EF, Orav EJ, Lee TH. The relationship of postoperative delirium with psychoactive medications. JAMA. 1994;272:1518–22. doi: 10.1001/jama.1994.03520190064036.
14. 1. de Craen AJ, Heeren TJ, Gussekloo J. Accuracy of the 15-item geriatric depression scale (GDS-15) in a community sample of the oldest old. Int J Geriatr Psychiatry. 2003;18:63–6. doi: 10.1002/gps.773.
15. 1. Bijur PE, Latimer CT, Gallagher EJ. Validation of a verbally administered numerical rating scale of acute pain for use in the emergency department. Acad Emerg Med. 2003;10:390–2. doi: 10.1111/j.1553-2712.2003.tb01355.x.
16. 1. Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113:941–8.
17. 1. Dasgupta M, Dumbrell AC. Preoperative risk assessment for delirium after noncardiac surgery: a systematic review. J Am Geriatr Soc. 2006;54:1578–89. doi: 10.1111/j.1532-5415.2006.00893.x.
18. 1. Gustafson Y, Brannstrom B, Berggren D, Ragnarsson JI, Sigaard J, Bucht G, Reiz S, Norberg A, Winblad B. A geriatric-anesthesiologic program to reduce acute confusional states in elderly patients treated for femoral neck fractures. J Am Geriatr Soc. 1991;39:655–62.
19. 1. Larsen KA, Kelly SE, Stern TA, Bode RH, Price LL, Hunter DJ, Gulczynski D, Bierbaum BE, Sweeney GA, Hoikala KA, Cotter JJ, Potter AW. Administration of olanzapine to prevent postoperative delirium in elderly joint-replacement patients: a randomized, controlled trial. Psychosomatics. 2010;51:409–18.
20. 1. Sieber FE, Zakriya KJ, Gottschalk A, Blute MR, Lee HB, Rosenberg PB, Mears SC. Sedation depth during spinal anesthesia and the development of postoperative delirium in elderly patients undergoing hip fracture repair. Mayo Clin Proc. 2010;85:18–26. doi: 10.4065/mcp.2009.0469.
21. 1. Gamberini M, Bolliger D, Lurati Buse GA, Burkhart CS, Grapow M, Gagneux A, Filipovic M, Seeberger MD, Pargger H, Siegemund M, Carrel T, Seiler WO, Berres M, Strebel SP, Monsch AU, Steiner LA. Rivastigmine for the prevention of postoperative delirium in elderly patients undergoing elective cardiac surgery--a randomized controlled trial. Crit Care Med. 2009;37:1762–8. doi: 10.1097/CCM.0b013e31819da780.
22. 1. Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc. 2001;49:516–22. doi: 10.1046/j.1532-5415.2001.49108.x.
23. 1. Capdevila X, Biboulet P, Morau D, Bernard N, Deschodt J, Lopez S. d'Athis F. Continuous three-in-one block for postoperative pain after lower limb orthopedic surgery: where do the catheters go? Anesth Analg. 2002;94:1001–6. doi: 10.1097/00000539-200204000-00042.

Source: PubMed