Kopp, Sandra

Background: Debate surrounds the issue of whether peripheral nerve blockade or periarticular infiltration (PAI) should be employed within a contemporary, comprehensive multimodal analgesia pathway for total hip arthroplasty. We hypothesized that patients treated with a continuous posterior lumbar plexus block (PNB) would report less pain and consume less opioid medication than those treated with PAI. Methods: This investigator-initiated, independently funded, 3-arm randomized clinical trial (RCT) performed at a single high-volume institution compared postoperative analgesia interventions for elective, unilateral primary total hip arthroplasty: (1) PNB; (2) PAI with ropivacaine, ketorolac, and epinephrine (PAI-R); and (3) PAI with liposomal bupivacaine, ketorolac, and epinephrine (PAI-L) using computerized randomization. The primary outcome was maximum pain during the morning (06:00 to 12:00) of the first postoperative day (POD) on an ascending numeric rating scale (NRS) from 0 to 10. Pairwise treatment comparisons were performed using the rank-sum test, with a p value of <0.017 indicating significance (Bonferroni adjusted). A sample size of 150 provided 80% power to detect a difference of 2.0 NRS units. Results: We included 159 patients (51, 54, and 54 patients in the PNB, PAI-R, and PAI-L groups, respectively). No significant differences were found with respect to the primary end point on the morning of the first POD (median, 3.0, 4.0, and 3.0, respectively; p > 0.033 for all). Opioid consumption was low and did not differ across groups at any intervals. Median maximum pain on POD 1 was 5.0, 5.5, and 4.0, respectively, and was lower for the PAI-L group than for the PAI-R group (p = 0.006). On POD 2, maximum pain (median, 3.5, 5.0, and 3.5, respectively) was lower for the PNB group (p = 0.014) and PAI-L group (p = 0.016) compared with the PAI-R group. The PAI-L group was not significantly different from the PNB group with respect to any outcomes: postoperative opioid use including rescue intravenous opioid medication, length of stay, and hospital adverse events, and 3-month follow-up data including any complication. Conclusions: In this RCT, we found a modest improvement with respect to analgesia in patients receiving PNB compared with those receiving PAI-R, but not compared with those who had PAI-L. Secondary analyses suggested that PNB or PAI-L provides superior postoperative analgesia compared with PAI-R. For primary total hip arthroplasty, a multimodal analgesic regimen including PNB or PAI-L provides opioid-limiting analgesia. Level of Evidence: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Abstract Background Multimodal analgesia is standard practice for total knee arthroplasty; however, the role of regional techniques in improved perioperative outcomes remains unknown. The authors hypothesized that peripheral nerve blockade would result in lower pain scores and opioid consumption than two competing periarticular injection solutions. Methods This three-arm, nonblinded trial randomized 165 adults undergoing unilateral primary total knee arthroplasty to receive (1) femoral catheter plus sciatic nerve blocks, (2) ropivacaine-based periarticular injection, or (3) liposomal bupivacaine-based periarticular injection. Primary outcome was maximal pain during postoperative day 1 (0 to 10, numerical pain rating scale) in intention-to-treat analysis. Additional outcomes included pain scores and opioid consumption for postoperative days 0 to 2 and 3 months. Results One hundred fifty-seven study patients received peripheral nerve block (n = 50), ropivacaine (n = 55), or liposomal bupivacaine (n = 52) and reported median maximal pain scores on postoperative day 1 of 3, 4, and 4.5 and on postoperative day 0 of 1, 4, and 5, respectively (average pain scores for postoperative day 0: 0.6, 1.7, and 2.4 and postoperative day 1: 2.5, 3.5, and 3.7). Postoperative day 1 median maximal pain scores were significantly lower for peripheral nerve blockade compared to liposomal bupivacaine-based periarticular injection ( P = 0.016; Hodges–Lehmann median difference [95% CI] = −1 [−2 to 0]). After postanesthesia care unit discharge, postoperative day 0 median maximal and average pain scores were significantly lower for peripheral nerve block compared to both periarticular injections (ropivacaine: maximal −2 [−3 to −1]; P < 0.001; average −0.8 [−1.3 to −0.2]; P = 0.003; and liposomal bupivacaine: maximal −3 [−4 to −2]; P < 0.001; average −1.4 [−2.0 to −0.8]; P < 0.001). Conclusions Ropivacaine-based periarticular injections provide pain control comparable on postoperative days 1 and 2 to a femoral catheter and single-injection sciatic nerve block. This study did not demonstrate an advantage of liposomal bupivacaine over ropivacaine in periarticular injections for total knee arthroplasty.

BACKGROUND: Objectives were to determine whether the use of ultrasound guidance offers any clinical advantage in the performance of neuraxial or peripheral nerve blocks in children in terms of increasing the success rate or decreasing the rate of complications. METHODS: We searched the following databases to March 2015: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OvidSP), EMBASE (OvidSP), and Scopus (to January 2015). We included all parallel randomized controlled trials that evaluated the effect of ultrasound guidance to perform a regional blockade technique in children. We assessed the selected studies for risk of bias with the Cochrane collaboration tool. We graded the level of evidence for each outcome according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group scale. RESULTS: We included 20 studies (1241 participants). Ultrasound guidance increases the success rate by decreasing the occurrence of a failed block: risk difference −0.11 (95% confidence interval [CI], −0.17 to −0.05); I 2 64%; number needed for additional beneficial outcome for peripheral nerve blocks 6 (95% CI, 5–8). The younger the child, the greater the benefit. From 8 studies (414 participants), pain scores at 1 hour in the postanesthesia care unit were reduced when ultrasound guidance was used; however, the clinical relevance of the difference was unclear (equivalent to −0.2 on a scale from 0 to 10). From 8 studies (358 participants), block duration was longer when ultrasound guidance was used: standardized mean difference (SMD) 1.21 (95% CI, 0.76–1.65: I 2 73%; equivalent to 62 minutes). Here again, younger children benefited the most from ultrasound guidance. Time to perform the procedure was reduced when ultrasound guidance was used for prescanning before a neuraxial block (SMD −1.97; 95% CI, −2.41 to −1.54; I 2 0%; equivalent to 2.4 minutes) or as an out-of-plane technique (SMD −0.68; 95% CI, −0.96 to −0.40; I 2 0%; equivalent to 94 seconds). From 2 studies (122 participants), ultrasound guidance reduced the number of needle passes required to perform the block: SMD −0.90 (95% CI, −1.27 to −0.52; I 2 0%; equivalent to 0.6 needle pass per participant). From 2 studies (204 participants), we could not demonstrate a difference in the incidence of bloody puncture when ultrasound guidance was used for neuraxial blockade, but we found that the number of participants was well below the optimal information size (risk difference −0.07, 95% CI, −0.19 to 0.04). No major complications were reported for any of the 1241 participants. We rated the quality of evidence as high for success, pain scores at 1 hour, block duration, time to perform the block, and number of needle passes. We rated the quality of evidence as low for bloody punctures. CONCLUSIONS: Ultrasound guidance seems advantageous, particularly in young children, for whom it improves the success rate and increases block duration. Additional data are required before conclusions can be drawn on the effect of ultrasound guidance in reducing the rate of bloody puncture.