The safety of peri-articular local anaesthetic injection for patients undergoing total knee replacement with autologous blood transfusion

Wallace, David; Emmett, Stevan R.; Kang, Keon; Chahal, Gurdip; Hiskens, Richard; Balasubramanian, Sabapathy; McGuinness, K.; Parsons, Helen; Achten, Juul; Costa, Matthew L.

doi:10.1302/0301-620x.94b12.29357

Cited by 11 publications

(5 citation statements)

References 26 publications

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“… 23 Based on pilot data, the standard deviation ( sd ) for VAS for pain was 30 mm. 24 Therefore, to test the null hypothesis of equality of the means of the treatment groups, assuming approximate normality for the VAS, primary outcome data for 264 patients (132 in each arm) were required for 90% power and 5% significance.…”

Section: Methodsmentioning

confidence: 99%

A pragmatic randomised controlled trial comparing the efficacy of a femoral nerve block and periarticular infiltration for early pain relief following total knee arthroplasty

Wall

Sprowson²,

Parsons

et al. 2017

The Bone & Joint Journal

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AimsThe aim of this study was to compare the effectiveness of a femoral nerve block and a periarticular infiltration in the management of early post-operative pain after total knee arthroplasty (TKA).Patients and MethodsA pragmatic, single centre, two arm parallel group, patient blinded, randomised controlled trial was undertaken. All patients due for TKA were eligible. Exclusion criteria included contraindications to the medications involved in the study and patients with a neurological abnormality of the lower limb. Patients received either a femoral nerve block with 75 mg of 0.25% levobupivacaine hydrochloride around the nerve, or periarticular infiltration with 150 mg of 0.25% levobupivacaine hydrochloride, 10 mg morphine sulphate, 30 mg ketorolac trometamol and 0.25 mg of adrenaline all diluted with 0.9% saline to make a volume of 150 ml.ResultsA total of 264 patients were recruited and data from 230 (88%) were available for the primary analysis. Intention-to-treat analysis of the primary outcome measure of a visual analogue score for pain on the first post-operative day, prior to physiotherapy, was similar in both groups. The mean difference was -0.7 (95% confidence interval (CI) -5.9 to 4.5; p = 0.834). The periarticular group used less morphine in the first post-operative day compared with the femoral nerve block group (74%, 95% CI 55 to 99). The femoral nerve block group reported 39 adverse events, of which 27 were serious, in 31 patients and the periarticular group reported 51 adverse events, of which 38 were serious, in 42 patients up to six weeks post-operatively. None of the adverse events were directly attributed to either of the interventions under investigation.Conclusion Periarticular infiltration is a viable and safe alternative to femoral nerve block for the early post-operative relief of pain following TKA.Cite this article: Bone Joint J 2017;99-B:904–11.

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Section: Methodsmentioning

confidence: 99%

A pragmatic randomised controlled trial comparing the efficacy of a femoral nerve block and periarticular infiltration for early pain relief following total knee arthroplasty

Wall

Sprowson²,

Parsons

et al. 2017

The Bone & Joint Journal

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“…Several published reports have demonstrated that plain local anesthetic shed into the prosthetic hip or knee joint following replacement does not lead to toxic serum levels following autotransfusion [19] , [20] , [29] , [30] . Parker et al [19] initially investigated this in 20 patients undergoing TKA who underwent autotransfusion of blood following PAI with ropivacaine.…”

Section: Discussionmentioning

confidence: 99%

“…Only one other study to date assessed bupivacaine, specifically levobupivacaine, and its potential toxicity after autotransfusion of blood following TJA with PAI [30] . Levobupivacaine is an enatomer of bupivacaine that is reported to be less toxic and long lasting [31] .…”

Section: Discussionmentioning

confidence: 99%

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Are reinfusion drains safe to use with periarticular liposomal bupivacaine? An analysis of systemic bupivacaine toxicity

et al. 2018

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BackgroundIntraoperative periarticular injection (PAI) with local anesthetic is an important component of multimodal pain control in total joint arthroplasty (TJA). A potential risk of this practice is serum anesthetic toxicity resulting from the autotransfusion of blood collected from a reinfusion drain. The purpose of this study is to evaluate the levels of bupivacaine in blood collected in an autotransfusion system after use of a PAI in TJA.MethodsIn this prospective study, each TJA patient had an identical PAI consisting of 20 cc of liposomal bupivacaine, 30 cc of 0.25% bupivacaine with epinephrine, and 10 cc of normal saline. An autologous reinfusion drain was utilized in all patients. At 2 and 5 hours postoperatively, blood was collected from the autotransfusion canister and sent to the laboratory to quantify bupivacaine levels. The sums of these levels were compared to the lowest reported serum bupivacaine dose associated with toxicity (1.1 mg/kg).ResultsEleven unilateral TJA patients were enrolled (6 total knee arthroplasties, 5 total hip arthroplasties). The average 2-hour serum bupivacaine level was 2.9 μg (range 0.8-5.6) while the average 5-hour serum bupivacaine level was 4.5 μg (range 0.4-10.0). The average sum of the 2-hour and 5-hour serum bupivacaine level was 5.6 μg (range 0.8-13.6). Each of the 11 patient samples were well below their minimum serum bupivacaine dose toxicity.ConclusionsUse of a reinfusion drain after PAI with liposomal bupivacaine in TJA appears safe, as bupivacaine levels in the autotransfused blood remains well below the reported minimum serum toxic dose.Level of EvidenceIV.

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“…An initial pilot study comparing femoral nerve block and multimodal periarticular infiltration has already been completed in order to help plan and design a full trial with the following null hypothesis. 14 …”

Section: Introductionmentioning

confidence: 99%

Protocol for a single-centre randomised controlled trial of multimodal periarticular anaesthetic infiltration versus single-agent femoral nerve blockade as analgesia for total knee arthroplasty: Perioperative Analgesia for Knee Arthroplasty (PAKA)

et al. 2015

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IntroductionTotal knee arthroplasty (TKA) surgery causes postoperative pain. The use of perioperative injections around the knee containing local anaesthetic, opiates and non-steroidal anti-inflammatory drugs has increased in popularity to manage pain. Theoretical advantages include reduced requirements for analgesia and earlier mobilisation. We propose a single-centre randomised controlled trial of multimodal periarticular anaesthetic infiltration versus femoral nerve anaesthetic blockade as analgesia for TKA. The aim is to determine, in patients undergoing TKA, if there is a difference in patient-reported pain scores on the visual analogue scale (VAS) prior to physiotherapy on day 1 postoperatively between treatment groups.Methods and analysisPatients undergoing a primary unilateral TKA at University Hospitals Coventry and Warwickshire Hospitals will be assessed for eligibility. A total of 264 patients will provide 90% power to detect a difference of 12 mm on the VAS on day 1 postoperatively at the 5% level. The trial will use 1:1 randomisation, stratified by mode of anaesthetic. Primary outcome measure will be the VAS for pain prior to physiotherapy on day 1. Secondary outcome measures include VAS on day 2, total use of opiate analgesia up to 48 h, ordinal pain scores up to 40 min after surgery, independent functional knee physiotherapist assessment on days 1 and 2. Oxford knee Scores (OKS), EuroQol (EQ-5D) and Douleur Neuropathic Pain Scores (DN2) will be recorded at baseline, 6 weeks and 12 months. Adverse events will be recorded up to 12 months. Analysis will investigate differences in VAS on day 1 between the two treatment groups on an intention-to-treat basis. Tests will be two-sided and considered to provide evidence for a significant difference if p values are less than 0.05.Ethics and disseminationNRES Committee West Midlands, 23 September 2013 (ref: 13/WM/0316). The results will be disseminated via peer-reviewed publications and conference presentations.Trial registration numbersISRCTN 60611146 and EUDRACT Number 2013-002439-10 (protocol code number PAKA-33601-AS117013); Pre-results.

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The safety of peri-articular local anaesthetic injection for patients undergoing total knee replacement with autologous blood transfusion

Cited by 11 publications

References 26 publications

A pragmatic randomised controlled trial comparing the efficacy of a femoral nerve block and periarticular infiltration for early pain relief following total knee arthroplasty

A pragmatic randomised controlled trial comparing the efficacy of a femoral nerve block and periarticular infiltration for early pain relief following total knee arthroplasty

Are reinfusion drains safe to use with periarticular liposomal bupivacaine? An analysis of systemic bupivacaine toxicity

Protocol for a single-centre randomised controlled trial of multimodal periarticular anaesthetic infiltration versus single-agent femoral nerve blockade as analgesia for total knee arthroplasty: Perioperative Analgesia for Knee Arthroplasty (PAKA)

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