Comparison of Pain Scores and Medication Usage Between Three Pain Control Strategies for Pediatric Anterior Cruciate Ligament Surgery

Abstract

Introduction Assessment and management of postoperative pain in the pediatric population after anterior cruciate ligament (ACL) surgery can be challenging; the optimal approach to pain control remains controversial. Recent studies show that use of intraoperative nerve blocks may reduce the need for opioids to control pain in the postoperative period. However, it is unclear which block type is most beneficial in the pediatric outpatient setting. This study compared effectiveness of pain control among three different pain management strategies. Methods We retrospectively reviewed charts of patients aged 12-17 years who received an elective ACL reconstruction between 2013 and 2017. The three groups were femoral nerve block, combined femoral and sciatic block, and intraarticular injection of bupivacaine (n = 50 per group). The primary variable was postoperative pain scores (visual analog scale 1-10) in the postanesthesia care unit (PACU). Results Less than 50% of patients in the combined nerve block group had opioids intraoperatively or in the PACU compared with nearly 100% of patients in the other two groups (p < 0.0001). Also, for patients receiving opioids, the total intraoperative morphine equivalents and PACU pain scores (all patients) were significantly less in the combined block group (p < 0.001). For patients receiving opioids in the PACU, the total morphine equivalents were significantly higher in the intraarticular injection group compared with the nerve block groups (p < 0.0001). Conclusion Patients in the combined femoral and sciatic nerve block group had significantly better pain scores in the PACU with less cumulative morphine equivalent consumption compared with the femoral nerve block group and the intraarticular injection group.

Local Infiltration Analgesia Versus Femoral Nerve Block for Pain Control in Anterior Cruciate Ligament Reconstruction: A Systematic Review With Meta-analysis

“…Of the 10 included studies, 8 11 , 12 , 14 , 20 – 22 , 28 , 39 were RCTs, and the other 2 were comparative studies that were designed prospectively 17 and retrospectively 30 ( Appendix Table A1 ). A total of 400 knees and 388 knees with LIA and FNB, respectively, were included.…”

“…Pain on VAS was evaluated at 2, 4, 8, 12, 24, and 48 hours after ACLR comparing LIA (intra-articular or periarticular injection) with FNB in included studies. At 2 hours after ACLR, 6 studies (439 patients) 11 , 12 , 20 , 21 , 30 , 39 reported VAS pain scores comparing the 2 groups, showing that the pooled MD was significantly improved in FNB compared with LIA (MD, 8.19 [95% CI, 0.75 to 15.63]; P = .03). Of the 6 studies, 5 11 , 20 , 21 , 30 , 39 reported intra-articular injection comparing FNB, showing significantly improved VAS in FNB versus intra-articular injection (MD, 8.86 [95% CI, 0.46 to 17.26]; P = .04) ( Figure 2 ).…”

Analgesia para cirugía pediátrica ambulatoria

“…En reparación de ligamento cruzado anterior, Lisgelia et al, demostraron que el bloqueo combinado femoral+ciático es mejor que el bloqueo femoral único y la infiltración intraarticular con bupivacaína, recibiendo menos opioides en el intraoperatorio (48% vs 100% vs 98%, p < 0,0001) y posoperatorio (28% vs 92% vs 96% p < 0,0001). Además, disminuyó scores de dolor (1,5 ± 2,0 vs 4,5 ± 2,0 vs 2,8 ± 1,8, p = 0,0013) [26]. Dado el riesgo de bloqueo motor de los bloqueos de nervio femoral o ciático, se han empezado a usar bloqueos más bajos y selectivos como bloqueo del canal obturador para cirugía de rodilla o nervio ciático o poplíteo para cirugía de pie [15], [17].…”

Bloqueos Regionales en Cirugía Pediátrica Ambulatoria

“…Por ejemplo, un estudio comparó tres opciones de bloqueos analgésicos: bloqueo femoral, infiltración intra-articular con anestésico local y la combinación de bloqueo femoral con bloqueo ciático. En el grupo de pacientes con bloqueo femoral asociado a bloqueo ciático, menos del 50% requirió uso de opioides en el perioperatorio y quienes lo necesitaron, lo hicieron en dosis menores e intensidad del dolor menor (medido con EVA) que los pacientes de los otros grupos (46). Similares resultados se obtuvieron en otro estudio en que todos los pacientes recibían un bloqueo femoral continuo, pero en uno de los grupos se combinó con bloqueo ciático único.…”