FEWER NURSING INTERVENTIONS AND LOWER SYMPTOMS FREQUENCY AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION WITH NERVE BLOCK ANALGESIA

Abstract

S284 INTRODUCTION: In this study, we examined outpatients undergoing anterior cruciate ligament reconstruction (ACLR), and the influence of various anesthesia clinical pathways (with and without femoral nerve block analgesia) on the incidence of pain and postoperative nausea and vomiting (PONV). We also tabulated the number of nursing interventions required for these common postoperative symptoms. Our hypothesis was that anesthetics incorporating a femoral nerve block led to less postoperative pain and regional anesthetics led to less PONV than did general anesthesia. METHODS: We queried our institution's database for 701 ACLR patients over 3 years (from July 1995 through June 1998). Based on the patient's medical record, we tabulated the number of required nursing interventions throughout recovery for pain, nausea, and vomiting. We considered the number of postoperative nursing interventions a quality indicator of the intraoperative anesthetic delivered, with respect to the anesthesia care team's management of the anesthetic process consistent with goals of the anesthesia clinical pathway. The incidence of pain, PONV, and the number of required nursing interventions were the dependent variables. The specific anesthesia techniques (and/or clinical pathways used) were the independent variables. One-way analysis of variance (ANOVA) was used to identify differences in required nursing interventions; differences between specific groups were determined using the Bonferroni adjustment for multiple comparisons. The independent-sample t-test was used for pairwise comparisons, when appropriate. Binomial variables (the incidence of pain and PONV) were analyzed using the chi-squared test. For all statistical tests, P < 0.05 was considered significant. RESULTS: All patient data entered into the ACLR database were subject to this analysis. The incidence of pain and PONV after general anesthesia (GA) was 61% and 37%, respectively. Combined regional anesthesia (RA) and GA (CRG) significantly reduced the incidence of pain to 30% (P<0.001), but did not lead to a significant reduction in the incidence of PONV (35%). RA (without GA) led to lower incidences of pain (19%, P=0.007) and PONV (14%, P<0.001) than did combined GA-RA. RA designed to include prolonged femoral nerve block analgesia led to a lower incidence of postoperative pain (13%) than did RA without prolonged femoral nerve block analgesia (27%, P=0.002). There were no significant differences in the incidence of PONV based on the presence or absence of femoral nerve block analgesia superimposed upon an intraoperative regional anesthetic. GA led to the most postoperative nursing interventions (2.5 +/- 0.4), while both RA and combined GA-RA led to significantly fewer interventions than did GA. The difference in the number of interventions for RA (0.7 +/- 0.3) and CGR (1.0 +/- 0.3) was not significant. DISCUSSION: This study examined a complex and painful outpatient procedure (arthroscopic ACLR) and found that a standardized GA technique (in 1996-1997) led to equally unacceptable outcomes as did a non-standardized GA technique (in 1995-1996) in historical controls. Only when the femoral nerve block was added to these GA techniques did the incidence of pain improve. Our shift of intraoperative care from GA to RA, from 1995-96 to 1997-98, led to a lower incidence of inhospital PONV. Intraoperative RA with femoral nerve block analgesia has led to less pain (but no less postoperative PONV) than RA without femoral nerve block analgesia.