Journal of Anesthesia & Surgery

ISSN: 2473-2184

Impact Factor: 0.643

VOLUME: 2 ISSUE: 2

Page No: 108-115

Epidural analgesia compared with femoral nerve block for postoperative pain therapy after total knee arthroplasty – a matched pair analysis


Co-Authors

Johannes Jauch, Thomas Schilling, Dominik Brammen, Uwe Ebmeyer, Siegfried Kropf, Thomas Hachenberg, Alf Kozian,

Citation

Alf Kozian, Epidural analgesia compared with femoral nerve block for postoperative pain therapy after total knee arthroplasty

Abstract

Background: Combined epidural analgesia (EA) and patient controlled analgesia (PCA) for postoperative pain control after total knee arthroplasty (TKA) is well established. Previous studies demonstrated the effectiveness of femoral nerve block (FNB) in combination with PCA. This study compares clinical efficiency and adverse events of pain therapy of an established (EA+PCA) and a modified (FNB+PCA) protocol.

Methods: A retrospective, single-center cohort study analyzing TKA patients after subarachnoid anesthesia. Matched pair analysis was performed using filters for American Society of Anesthesiologists (ASA) classification, age, gender, height, weight, comorbidities and prior use of analgesics. Surgical technique and postoperative medication protocol were similar in both groups. Primary outcome was postoperative pain on movement assessed by a visual analog scale (VAS) and use of analgesics within 72 hours after surgery. Secondary, incidence of adverse events (postoperative nausea and vomiting, pruritus, urinary retention and hypotension) was examined.

Results: From a total of 846 patients, 104 matched pairs were built and analyzed within 72 hours after surgery. Mean VAS scores were similar in patients receiving EA+PCA (2.7 ± 1.1) or FNB+PCA (2.8 ± 1.2). Supplemental opioid administration was higher in EA+PCA patients. Hypotension was more frequent in EA+PCA as in FNB+PCA patients (36 % vs. 12 %). Combined adverse events were more frequent in EA+PCA as in FNB+PCA patients (75 % vs. 58 %).

Conclusions: Both FNB+PCA and EA+PCA results in equivalent degrees of analgesia after TKA. Converting an established mode of pain therapy to a modified protocol may decrease incidence of adverse events rather than improve quality of analgesia.

 

Key words: analgesia, epidural analgesia, femoral nerve block, postoperative pain, total knee arthroplasty

References

  1. Capdevila, X., et al., Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery. Anesthesiology, 1999. 91(1): p. 8-15. PMid:10422923

    View Article      PubMed/NCBI     
  2. Mistraletti, G., et al., Comparison of analgesic methods for total knee arthroplasty: metabolic effect of exogenous glucose. Reg Anesth Pain Med, 2006. 31(3): p. 260-9.

    View Article           
  3. Sakai, N., et al., Continuous femoral versus epidural block for attainment of 120 degrees knee flexion after total knee arthroplasty: a randomized controlled trial. J Arthroplasty, 2013. 28(5): p. 807-14. PMid:23434107

    View Article      PubMed/NCBI     
  4. Nishio, S., et al., Comparison of Continuous Femoral Nerve Block, Caudal Epidural Block, and Intravenous Patient-controlled Analgesia in Pain Control After Total Hip Arthroplasty: A Prospective Randomized Study. Orthop Rev (Pavia), 2014. 6(1): p. 5138. Mid:24744837 PMCid:PMC3980153

    View Article           
  5. Paul, J.E., et al., Femoral nerve block improves analgesia outcomes after total knee arthroplasty: a meta-analysis of randomized controlled trials. Anesthesiology, 2010. 113(5): p. 1144-62. PMid:20966667

    View Article      PubMed/NCBI     
  6. Puolakka, R., et al., Technical aspects and postoperative sequelae of spinal and epidural anesthesia: a prospective study of 3,230 orthopedic patients. Reg Anesth Pain Med, 2000. 25(5): p. 488-97.

    View Article           
  7. Singelyn, F.J., et al., 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): p. 88-92. PMid:9661552

    PubMed/NCBI     
  8. Barrington, M.J., et al., Continuous femoral nerve blockade or epidural analgesia after total knee replacement: a prospective randomized controlled trial. Anesth Analg, 2005. 101(6): p. 1824-9. PMid:16301267

    View Article      PubMed/NCBI     
  9. Cots, F., et al., Patient classification systems and hospital costs of care for knee replacement in 10 European countries. Health Econ, 2012. 21 Suppl 2: p. 116-28. PMid:22815117

    View Article      PubMed/NCBI     
  10. Kurtz, S.M., et al., Impact of the economic downturn on total joint replacement demand in the United States: updated projections to 2021. J Bone Joint Surg Am, 2014. 96(8): p. 624-30. PMid:24740658

    View Article      PubMed/NCBI     
  11. Pabinger, C. and A. Geissler, Utilization rates of hip arthroplasty in OECD countries. Osteoarthritis Cartilage, 2014. 22(6): p. 734-41. PMid:24780823

    View Article      PubMed/NCBI     
  12. Pabinger, C., H. Lothaller, and A. Geissler, Utilization rates of knee-arthroplasty in OECD countries. Osteoarthritis Cartilage, 2015. 23(10): p. 1664-73. PMid:26028142

    View Article      PubMed/NCBI     
  13. Robertsson, O., et al., Knee arthroplasty in Denmark, Norway and Sweden. A pilot study from the Nordic Arthroplasty Register Association. Acta Orthop, 2010. 81(1): p. 82-9. PMid:20180723 PMCid:PMC2856209

    View Article      PubMed/NCBI     
  14. Schafer, T., et al., Trends and geographical variation of primary hip and knee joint replacement in Germany. Osteoarthritis Cartilage, 2013. 21(2): p. 279-88. PMid:23220558

    View Article      PubMed/NCBI     
  15. Choi, P.T., et al., Epidural analgesia for pain relief following hip or knee replacement. Cochrane Database Syst Rev, 2003(3): p. CD003071.

    View Article           
  16. Hunt, L.P., et al., 45-day mortality after 467,779 knee replacements for osteoarthritis from the National Joint Registry for England and Wales: an observational study. Lancet, 2014. 384(9952): p. 1429-36. 60540-7

    View Article           
  17. Liddle, A.D., et al., Adverse outcomes after total and unicompartmental knee replacement in 101,330 matched patients: a study of data from the National Joint Registry for England and Wales. Lancet, 2014. 384(9952): p. 1437-45. 60419-0

    View Article           
  18. Murphy, P.M., et al., Optimizing the dose of intrathecal morphine in older patients undergoing hip arthroplasty. Anesth Analg, 2003. 97(6): p. 1709-15. PMid:14633547

    View Article      PubMed/NCBI     
  19. Jage, J., et al., [Postoperative pain therapy with piritramide and metamizole. A randomized study in 120 patients with intravenous on-demand analgesia after abdominal surgery.]. Schmerz, 1990. 4(1): p. 29-36. PMid:18415211

    View Article      PubMed/NCBI     
  20. Plante, A., E. Ro, and J.R. Rowbottom, Hemodynamic and related challenges: monitoring and regulation in the postoperative period. Anesthesiol Clin, 2012. 30(3): p. 527-54. PMid:22989593

    View Article      PubMed/NCBI     
  21. Walsh, M., et al., Relationship between intraoperative mean arterial pressure and clinical outcomes after noncardiac surgery: toward an empirical definition of hypotension. Anesthesiology, 2013. 119(3): p. 507-15. PMid:23835589

    View Article      PubMed/NCBI     
  22. Davies, P. and H. Howells, Hypotension following combined spinal epidural anaesthesia. Anaesthesia, 2003. 58(9): p. 932. PMid:12911396

    View Article      PubMed/NCBI     
  23. Hopf, H.B., R. Schlaghecke, and J. Peters, Sympathetic neural blockade by thoracic epidural anesthesia suppresses renin release in response to arterial hypotension. Anesthesiology, 1994. 80(5): p. 992-9. PMid:8017664

    View Article      PubMed/NCBI     
  24. Quinlan, D.J. and B.I. Eriksson, Novel oral anticoagulants for thromboprophylaxis after orthopaedic surgery. Best Pract Res Clin Haematol, 2013. 26(2): p. 171-82. PMid:23953905

    View Article      PubMed/NCBI     
  25. Davies, A.F., et al., Epidural infusion or combined femoral and sciatic nerve blocks as perioperative analgesia for knee arthroplasty. Br J Anaesth, 2004. 93(3): p. 368-74. PMid:15247111

    View Article      PubMed/NCBI     
  26. Cook, T.M., 201 combined spinal-epidurals for anaesthesia using a separate needle technique. Eur J Anaesthesiol, 2004. 21(9): p. 679-83. PMid:15595578

    PubMed/NCBI     
  27. Abou Hammoud, H., et al., Intravenous morphine titration in immediate postoperative pain management: population kinetic-pharmacodynamic and logistic regression analysis. Pain, 2009. 144(1-2): p. 139-46. PMid:19435651

    View Article      PubMed/NCBI     
  28. Bouillon, T., et al., Population pharmacokinetics of piritramide in surgical patients. Anesthesiology, 1999. 90(1): p. 7-15. PMid:9915307

    View Article      PubMed/NCBI     

Journal Recent Articles