Major Complications Associated with Femoral Nerve Catheters for Knee Arthroplasty

129

Background Two of the more common methods of pain management after TKA are peripheral nerve blocks and intraarticular/periarticular injections. However, we are not aware of any study directly comparing the commonly used combination of a continuous femoral block given with a single-shot sciatic block with that of a periarticular injection after TKA. Questions/purposes This randomized clinical trial compared a combined femoral and sciatic nerve block with periarticular injection as part of a multimodal pain protocol after total knee arthroplasty with respect to (1) pain; (2) narcotic use; (3) quadriceps function and length of stay; and (4) peripheral nerve complications. Methods One hundred sixty patients completed randomization into two treatment arms: (1) peripheral nerve blocks (PNB; n = 79) with an indwelling femoral nerve catheter and a single shot sciatic block; or (2) periarticular injection (PAI; n = 81) using ropivacaine, epinephrine, ketorolac, and morphine. All patients received standardized general anesthesia and oral medications. The primary outcome was postoperative pain, on a 0 to 10 scale, measured on the afternoon of postoperative day 1 (POD 1). Secondary outcomes were narcotic use, quadriceps function, length of stay, and peripheral nerve complications. Results Mean pain scores on the afternoon of POD 1 were not different between groups (PNB group: 2.9 [SD 2.4]; PAI group: 3.0 [SD 2.2]; 95% confidence interval, À0.8 to 0.6; p = 0.76). Mean pain scores taken at three times points on POD 1 were also similar between groups. Hospital length of stay was shorter for the PAI group (2.44 days [SD 0.65] versus 2.84 days [SD 1.34] for the PNB group; p = 0.02). Narcotic consumption was higher the day of surgery for the PAI group (PAI group: 11.7 mg morphine equivalents [SD 13

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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The Chitranjan Ranawat Award: Periarticular Injections and Femoral & Sciatic Blocks Provide Similar Pain Relief After TKA: A Randomized Clinical Trial

Spangehl

Clarke

Hentz

et al. 2015

129

“…Epidural analgesia, while effective at controlling postoperative pain, has undesirable side effects, including nausea, hypotension, pruritis, somnolence, dizziness, and respiratory depression [5]. Likewise, femoral nerve blockade (FNB) has been associated with poor early postoperative ambulatory ability and the risk of in-hospital falls [7,9,12]. As a result, alternative methods of analgesia are being sought and there has been increasing support for the inclusion of peri-or intraarticular local anesthetics in the multimodal pain regimen after TKA.…”

Section: Introductionmentioning

confidence: 99%

Intraarticular Analgesia Versus Epidural Plus Femoral Nerve Block After TKA: A Randomized, Double-blind Trial

Reinhardt

Duggal

Umunna

et al. 2014

Background Pain management after TKA remains challenging and the efficacy of continuously infused intraarticular anesthetics remains a controversial topic.Questions/purposes We compared the side effect profile, analgesic efficacy, and functional recovery between patients receiving a continuous intraarticular infusion of ropivacaine and patients receiving an epidural plus femoral nerve block (FNB) after TKA. Methods Ninety-four patients undergoing unilateral TKA were prospectively randomized to receive a spinal-epidural analgesic infusion plus a single-injection FNB or a spinal anesthetic plus a continuous postoperative intraarticular infusion of 0.2% ropivacaine. All patients were blinded to their treatment with placebo saline catheters. Blinded coinvestigators collected data concerning side effect profiles (nausea, hypotension), analgesic efficacy (VAS pain scores, narcotic usage), and functional recovery (timed up and go test, quadriceps strength, WOMAC scores, Knee Society scores, early postoperative ambulatory ability, in-hospital falls). All complications and adverse events were recorded. Results The frequency of nausea and hypertension was not different between the study groups. During the first 12 and 24 postoperative hours, the mean maximum VAS pain scores were higher in the ropivacaine group than in the epidural group (first 12 hours: 3.93 versus 1.14, respectively, p \ 0.0001; 12-24 hours: 3.52 versus 1.93, respectively, p = 0.008). After 24 hours, pain scores were similar between groups. Narcotic consumption was significantly higher in the ropivacaine group on the day of surgery, but overall in-hospital narcotic usage was similar between groups. There were no clinically important differences in functional recovery between groups at any time point, but patients in the epidural group were more likely to have knee buckling (32.7% versus 6.7%, p = 0.002) and delayed ambulation (16.3% versus 0.0%, p = 0.006) than patients in the ropivacaine group, though not in-hospital falls. No infections occurred in either group, and the frequency of complications was not different between groups.

“…These postoperative falls represent a major source of potential morbidity for the patient, as well as regulatory and financial liability for the institution; therefore, substantial resources have been expended to understand which patients are at risk for falling and when these falls occur [2,4,10,12,15,16]. Numerous factors associated with falls have been identified, some of which are intrinsic to the patient, such as age and cognitive impairment, while other factors are related to the procedures and treatments that they undergo, such as medication side effects and muscle weakness from peripheral nerve blocks [3,9,10,13,17]. External factors may also play a role, including room design, bed height, and staff-to-patient ratios [19,20].…”

Section: Introductionmentioning

confidence: 99%

Preoperative Patient Education Reduces In-hospital Falls After Total Knee Arthroplasty

Clarke

Timm

Goldberg

et al. 2012

Background Inpatient hospital falls after orthopaedic surgery represent a major problem, with rates of about one to three falls per 1000 patient days. These falls result in substantial morbidity for the patient and liability for the institution. Questions/purposes We determined whether preoperative patient education reduced the rate of in-hospital falls after primary TKA and documented the circumstances and the injuries resulting from the falls. Patients and MethodsWe reviewed data from all 244 patients who underwent primary TKA at a single institution between March and November 2009. Seventytwo patients of one surgeon were enrolled in a preoperative nurse-led education program. This group was compared with a control group of 172 patients who concurrently underwent TKA at the same institution but did not receive preoperative education. Results More control patients had in-hospital falls than those in the education group: seven (one of whom had two falls) of 172 (4%) versus none of 72 (0%), respectively.