A Prospective, Randomized, Blinded Trial to Compare Continuous Epidural Block and Femoral Nerve Block for Total Knee Arthroplasty

Mitsuharu Kodaka

doi:10.4172/2155-6148.1000410

Abstract

Objective: We conducted a prospective, randomized, and blinded trial to compare the perioperative quality of anesthesia and analgesia for Total Knee Arthroplasty (TKA) using either Epidural Analgesia (EA) or ultrasoundguided continuous Femoral Nerve Block (FNB). Methods: Forty patients scheduled for TKA were randomized to two groups, EA or FNB. The initial local anesthetic doses for EA and FNB blocks were 5 mL and 20 mL 0.5% ropivacaine, respectively. After epidural or femoral nerve sheath catheterization, patients were anesthetized using propofol infusion and air-mixed 40% oxygen. A ProSealTM laryngeal mask airway was inserted and intravenous fentanyl was used as supplementary analgesia if necessary. After surgery, patients in both groups were administered an infusion of 4 mL/h 0.2% ropivacaine and 12.5 μg/h fentanyl via the epidural or femoral nerve catheter. We recorded the total doses of fentanyl administered during surgery, and the extent of postoperative pain using a visual analog scale (VAS) at rest and on movement until the third postoperative day (POD3). Results: The mean doses of fentanyl administered during surgery in the EA and FNB groups were 106.6 ± 45.8 μg and 232.5 ± 84.7 μg, respectively [mean ± standard deviation; p < 0.0001]. Significantly lower VAS pain scores were reported during movement in the EA group on POD1 [EA vs. FNB=23 (0-77) vs. 47 (0-100), p=0.027] and POD2 [43 (0-70) vs. 63 (15-100), p=0.031]. Conclusions: Continuous epidural analgesia requires less fentanyl for TKA than FNB and is more effective for postoperative pain on movement.

Highlights

The number of orthopedic patients receiving epidural anesthesia (EA) has declined because of the increasing use of anticoagulant therapy, such as fondaparinux [1] and edoxaban [2], as prophylaxis against perioperative deep vein thrombosis
We evaluated postoperative nausea and vomiting (PONV: 0=no nausea, 1=nausea only, 2=nausea and vomiting), frequency of Patient-Controlled Analgesia (PCA) bolus and adjuvant analgesic administration, Bromage scale grades on the operated and non-operated sides, and continuous passive motion (CPM) until 3 days had elapsed after Total Knee Arthroplasty (TKA)
There were no significant differences between the two groups at rest on any postoperative days (PODs) in terms of pain scores, adjuvant analgesics, PONV, the Bromage scale, CPM and satisfaction scores (Figure 1, Table 3)

Summary

Introduction

The number of orthopedic patients receiving epidural anesthesia (EA) has declined because of the increasing use of anticoagulant therapy, such as fondaparinux [1] and edoxaban [2], as prophylaxis against perioperative deep vein thrombosis. Ultrasound-guided Femoral Nerve Block (FNB) has been adopted as a safe, reliable analgesic technique for Total Knee Arthroplasty (TKA). The additional precision in location of the nerve sheath afforded by ultrasound has been shown to reduce the volume of local anesthetic needed by 42% compared with FNB guided by nerve stimulation [6]. Two previous studies have compared the postoperative effects of EA and FNB after TKA, the drug combinations and infusion rates in those studies differed from those used in our institution [7, 8]. The efficacy of opioids combined with local anesthetics for peripheral nerve block remains controversial.

Methods

Results

Discussion

Conclusion