Continuous Femoral Nerve Block Research Articles

Adductor Canal Block versus Femoral Nerve Block in Total Knee Arthroplasty: Network Meta-Analysis.

The quality of postoperative analgesia in total knee arthroplasty is crucial for patient recovery, rehabilitation and hospital stay duration. In line with the above, а single-shot adductor canal block has been considered as surpassing method over continuous femoral nerve block. However, continuous adductor canal block and single-shot femoral nerve block 'kept overboard' the discussion. This study aims to compare the effectiveness of various types of adductor and femoral nerve blocks on clinically relevant outcomes in patients following total knee arthroplasty. A systematic review and network meta-analysis were conducted following 'PRISMA-NMA' and Cochrane Handbook guidelines. Eligibility criteria included randomized trials and, where these were lacking for a comparison, non-randomized studies involving adults undergoing primary total knee arthroplasty, comparing single-shot adductor canal block, continuous adductor canal block, single-shot femoral nerve block, and continuous femoral nerve block. A total of 36 studies involving 3308 patients were included. Single-shot adductor canal block showed higher pain scores and opioid consumption but better functional recovery at 24-h compared to continuous femoral nerve block. However, this trend vanishes by the 48-h assessment post-surgery. Continuous adductor canal block had higher opioid consumption but better functional recovery and shorter hospital stay compared to continuous femoral nerve block. Single-shot adductor canal block showed higher pain scores but comparable opioid consumption and functional recovery to continuous adductor canal block. The shift from continuous femoral nerve block to single-shot adductor canal block as the preferred method for pain relief after total knee arthroplasty may be premature. While the latter improves mobility, it falls short in pain control and doesn't shorten hospital stays. Continuous adductor canal block shows promise but is currently underappreciated, and single-shot femoral nerve block is often overshadowed by other techniques in regional anesthesia. Further high-quality, multicenter randomized controlled trials are needed to validate these findings.

The Efficacy of the Combination of Continuous Femoral Nerve Block and Intravenous Parecoxib on Rehabilitation in Patients Undergoing Total Knee Arthroplasty: A Double-Blind, Randomized Clinical Trial.

The optimal strategy for the management of postoperative pain after total knee arthroplasty (TKA) remains challenging, while its treatment is crucial to increase patients' outcomes. This study aimed to investigate the effects of parecoxib as add-on therapy, in a standard postoperative pain management protocol, represented by the continuous femoral nervous block. We studied its influence on rehabilitation indices and pain scoresin patients undergoing TKA. This is a single-center, prospective, double-blind, randomized, placebo-controlled trial. All patients were operated with the use of subarachnoid anesthesia, and divided into two groups for postoperative analgesia. Both groups received a continuous femoral nerve block. One of the groups received intravenous parecoxib, while the other received a placebo. The primary investigated outcome was the range of motion (ROM). Recordings were noted at different times postoperatively. Bromage score (BS), visual analogscale (VAS), and the State-Trait Anxiety Inventory (STAI) were also studied. A total of 90 patients were included and analyzed. ROM was significantly better (p<0.001) and pain scores were significantly lower (p=0.007) in the parecoxib group. No statistically significant difference was found with regardto BS between the two groups. A significant correlation was found between ROM and VAS pain scores at 12 hours (p=0.02), while ROM was inversely correlated with STAI postoperatively. The use of intravenous parecoxib is effective in improving rehabilitation indices and provides decreased postoperative pain scores after TKA.

Sufentanil Improves the Analgesia Effect of Continuous Femoral Nerve Block After Total Knee Arthroplasty

Sufentanil Improves the Analgesia Effect of Continuous Femoral Nerve Block After Total Knee Arthroplasty

Comparison of the Efficacy of Continuous Femoral Nerve Block with Epidural Analgesia for Postoperative Pain Relief after Unilateral Total Knee Replacement

Background: By identifying the most effective and safe approach to postoperative pain management, we can enhance patient recovery, improve their quality of life, and optimize healthcare resource utilization. Objective: Comparison of the Efficacy of Continuous Femoral Nerve Block with Epidural Analgesia for Postoperative Pain Relief after Unilateral Total Knee Rep. Method: The study was conducted as a randomized controlled trial at Tertiary Hospital in Dhaka. Sixty patients, consisting of 12 males and 48 females, between the ages of 40 and 90 years, were enrolled in the study. These patients were scheduled to undergo unilateral total knee replacement (TKR) for osteoarthritis and fell under American Society of Anesthesiologists (ASA) physical status classes I and II. The inclusion criteria required patients to weigh between 50 and 99 kg and have the ability to fully understand and respond to the numeric rating scale (NRS). Exclusion criteria comprised patients with ASA physical status class ≥3, those on chronic opiate therapy, individuals with allergies to local anesthetics or equipment materials, or those with neuromuscular disease. Ethical approval was obtained, and the patients were divided into two groups: group A received epidural analgesia, while group B received a femoral nerve block for postoperative pain management. Pain assessments were conducted using the NRS at six, 12, and 24 hours postoperatively, and data were collected for analysis. Results: During the study, in group A (Epidural) and Group B (Femoral nerve block) mean age was 69.45 ± 7.34 and 65.45 ± 7.34 years. Mean Preoperative knee extension between two groups was Group A (Epidural): 9.05 ± 4.38 and Group B (Femoral nerve block): 7.76 ± 4.14. The results showed a significant difference for NRS scoring at six hours and 12 hours. Patients who were in group A and were given Epidural postop for pain management showed better results and lower values for NRS and needed fewer extra boluses for their .....

A comparative study between continuous epidural analgesia, ultrasound guided continuous femoral nerve block (CFNB), and ultrasound guided continuous adductor canal block (ACB) for post-operative pain management after total knee replacement (TKR)

BackgroundTotal knee replacement (TKR) is considered a prevailing cause of severe postoperative pain and discomfort among orthopedic surgeries, limiting postoperative ambulation that is important for regaining joint function. Despite being the gold standard, epidural analgesia can be accompanied by diverse complications delaying postoperative ambulation and discharge from hospital. Continuous femoral nerve block (CFNB) and continuous adductor canal block (ACB) are reliable and efficacious regional anaesthesia techniques allowing better control of postoperative pain. This study purposed to compare epidural analgesia, continuous femoral nerve block & continuous adductor canal block regarding postoperative analgesia & incidence of postoperative complications.The aim of this study is to estimate the efficacy of epidural analgesia, continuous femoral nerve block & continuous adductor canal block regarding postoperative pain control following total knee replacement and the rate of incidence of associated postoperative complications.This is a prospective randomized controlled study where sixty patients were randomized into three equal groups, patients in group A received epidural analgesia, patients in group B received continuous femoral nerve block while patients in group C received continuous adductor canal block with postoperative continuous infusion of 0.125% bupivacaine with fentanyl 2µg/ml in the three groups at a rate of 5 ml/hr. VAS score was assessed for 48 hours post-operatively and complications were recorded.ResultsEpidural analgesia was superior to CFNB and ACB regarding postoperative pain control using visual analogue scale and postoperative pain control. CFNB and ACB are superior to epidural analgesia regarding postoperative ambulation and postoperative complications.ConclusionsContinuous epidural analgesia provides superior analgesia following total knee replacement than femoral nerve block and adductor canal block, with relatively more adverse effects like pruritus, post operative nausea, and vomiting (PONV). Both CFNB and ADB are good alternatives with fewer systemic side effects.Trial registrationClinicalTrials.gov Identifier: NCT 05249478.

Continuous femoral nerve block enhances outcome of spinal anaesthesia in preventing perioperative cardiac complications in patients with cardiac risk

ABSTRACT Background Elevated brain natriuretic peptide (BNP) is crucial to detect perioperative adverse cardiovascular events in patients with cardiac risk, even at low elevation of BNP level or when myocardial necrosis has not been already established. This study aims to compare between two anaesthesia methods in preventing perioperative myocardial infarction for patients having cardiac risk undergoing total knee arthroplasty (TKA). Patients and methods Fifty adult patients planned for TKA with risk factors as ischemic heart disease, diabetics, hypertensive, heavy smokers or body mass index ≥ 35 were categorized randomly into two groups. Group (S): received spinal anaesthesia followed by continuous ultrasound guided femoral nerve block once spinal motor blockade had been resolved. Group (G): received combined general and lumber epidural anaesthesia. BNP, cardiac troponins, pain severity, analgesic consumption, patients’ satisfaction and adverse cardiac events were observed preoperatively and extended to 2 days postoperatively. Results Baseline readings of BNP and cardiac troponins were comparable in both members. At 24 and 48 hours postoperatively, it decreased significantly in group S compared to group G. Mean Visual analogue score was significantly lower in group S comparative to group G at all times except at 40 and 48 hours postoperatively. Morphine utilization was significantly lower in group S. Patients in group S were significantly more satisfied than those in group G. Conclusions The use of spinal anaesthesia with continuous femoral nerve block can reduce the prevalence of perioperative myocardial infarction in patients with cardiac risk undergoing TKA.

Sublingual Sufentanil Tablet System (SSTS-Zalviso®) for Postoperative Analgesia after Orthopedic Surgery: A Retrospective Study.

The aim of this study is to compare sublingual sufentanil and the administration device for its delivery (SSST-Zalviso®) with the traditional strategies used for the control of postoperative pain to establish if there is an actual benefit for the patient and healthcare personnel. A retrospective study was conducted to compare the efficacy of SSTS in the management of postoperative pain after orthopedic surgery between October 2018 and June 2020. We analyzed 50 patients who underwent a total knee arthroplasty (TKA). The control group consisted of 21 patients who underwent TKA and during the hospitalized recovery received a continuous femoral nerve block (cFNB). The statistical study was conducted with a level of significance p = 0.05 using "U" test, Mann-Whitney, to verify if patients had a better control of pain and fewer calls for rescue analgesia. Patients involved in the study showed a significant reduction in pain intensity with the use of SSTS in the 24 h following surgery (p = 0.0568), also a drastic drop of the calls for rescue analgesia (p &lt; 0.0001) reduces the number of calls for its control. This study demonstrates how SSTS might reduce pain intensity in the first 24 h after surgery and reduce the number of calls for its control, indicating better analgesic coverage and implying reduced interventions from healthcare personnel. This could allow a redistribution of resources and a reduction in the use of analgesic drugs in wards where the SSTS is used.

Network meta-analysis of the analgesic effectiveness of regional anaesthesia techniques for anterior cruciate ligament reconstruction.

Anterior cruciate ligament reconstruction can cause moderate to severe acute postoperative pain. Despite advances in our understanding of knee innervation, consensus regarding the most effective regional anaesthesia techniques for this surgical population is lacking. This network meta-analysis compared effectiveness of regional anaesthesia techniques used to provide analgesia for anterior cruciate ligament reconstruction. Randomised trials examining regional anaesthesia techniques for analgesia following anterior cruciate ligament reconstruction were sought. The primary outcome was opioid consumption during the first 24 h postoperatively. Secondary outcomes were: rest pain at 0, 6, 12 and 24 h; area under the curve of pain over 24 h; and opioid-related adverse effects and functional recovery. Network meta-analysis was conducted using a frequentist approach. A total of 57 trials (4069 patients) investigating femoral nerve block, sciatic nerve block, adductor canal block, local anaesthetic infiltration, graft-donor site infiltration and systemic analgesia alone (control) were included. For opioid consumption, all regional anaesthesia techniques were superior to systemic analgesia alone, but differences between regional techniques were not significant. Single-injection femoral nerve block combined with sciatic nerve block had the highest p value probability for reducing postoperative opioid consumption and area under the curve for pain severity over 24 h (78% and 90%, respectively). Continuous femoral nerve block had the highest probability (87%) of reducing opioid-related adverse effects, while local infiltration analgesia had the highest probability (88%) of optimising functional recovery. In contrast, systemic analgesia, local infiltration analgesia and adductor canal block were each poor performers across all analgesic outcomes. Regional anaesthesia techniques that target both the femoral and sciatic nerve distributions, namely a combination of single-injection nerve blocks, provide the most consistent analgesic benefits for anterior cruciate ligament reconstruction compared with all other techniques but will most likely impair postoperative function. Importantly, adductor canal block, local infiltration analgesia and systemic analgesia alone each perform poorly for acute pain management following anterior cruciate ligament reconstruction.

Pain levels and patient comfort after lower limb arthroplasty comparing i.v. patient-controlled analgesia, continuous peripheral nerve block and neuraxial analgesia: a retrospective cohort analysis of clinical routine data

BackgroundInsufficient pain control after lower limb arthroplasty results in delayed recovery and increased risk for pain chronicization. The ideal kind of analgesia is still discussed controversially. We conducted a retrospective analysis of single-center routine data from a German university hospital, including patients receiving either total hip (THA) or knee arthroplasty (TKA).MethodsAll patients received general anesthesia. Patients undergoing THA received either continuous epidural ropivacaine infusion (0.133%, Epi) or patient-controlled analgesia (PCA) with the Wurzburg Pain Drip (tramadol, metamizole and droperidol, WPD) or with piritramide (Pir). After TKA, patients received either continuous femoral nerve block (ropivacaine 0.2%, PNB) or Pir.ResultsThe analyzed cohort comprised 769 cases. Use of WPD after THA (n = 333) resulted in significantly reduced Numeric Rating Scale (NRS) values at rest, compared to Epi (n = 48) and Pir (n = 72) (.75 [IQR 1.14] vs. 1.17 [1.5], p = .02 vs. 1.47 [1.33], p < .0001) as well as maximum NRS scores (2.4 [1.7] vs. 3.29 [1.94], p < .001 vs. 3.32 [1.76], p < .0001). Positive feedback during follow-up visits was significantly increased in patients with a WPD PCA (p < .0001), while negative feedback (senso-motoric weakness/technical problems/nausea/dizziness/constipation) was particularly increased in Epi patients and lowest in those with WPD (p < .0001). After TKA, Pir (n = 131) resulted in significantly reduced NRS values at rest, compared to PNB (n = 185) (1.4 [1.4] vs. 1.6 [1.68], p = .02). Positive feedback was increased in patients with a Pir PCA in comparison with PNB (p = .04), while negative feedback was increased in PNB patients (p = .04). Overall, WPD presented with the lowest rate of any complications (8.7%), followed by Pir (20.2%), PNB (27.6%) and Epi (31.3%) (p < .001).ConclusionsIn the assessed population, the use of a WPD PCA after THA offered better pain control and patient comfort in comparison with continuous epidural or piritramide-based analgesia. After TKA, the use of a Pir PCA provided superior analgesia and a lower complication rate compared to continuous PNB.

Comparison of the Efficacy of Continuous Femoral Nerve Block With Epidural Analgesia for Postoperative Pain Relief After Unilateral Total Knee Replacement.

IntroductionWith recent developments in postoperative pain management after total knee replacement (TKR), the continuous femoral nerve block is becoming a common practice. The purpose of this study was to compare a femoral nerve block with time-tested epidural analgesia in a tertiary care setup in a developing country.MethodologyA randomized control trial took place at Shifa International Hospital (SIH), Islamabad, Pakistan. Sixty patients, aged 40 to 90 years old, 12 males and 48 females, who were undergoing unilateral TKR for osteoarthritis in American Society of Anesthesiologists (ASA) physical status classes I and II, weighing between 50 and 99 kg, and fully able to understand and respond to the numeric rating scale (NRS) were included in the study. While patients belonging to ASA physical status class ≥3, with chronic opiate therapy, having allergies to local anesthetics or equipment material, or with neuromuscular disease, were excluded from the study. Ethical approval was obtained, and patients were divided into two groups, with group A given epidural and group B given a femoral nerve block for pain management postop. Data were collected. The pain was recorded using the NRS at six, 12, and 24 hours postop.ResultsThe results for six hours and 12 hours were found to be significant. Patients in group A had a lower NRS rating postop as compared to group B and required a lesser amount of additional boluses for pain management. ConclusionThe femoral nerve block is inferior to epidural analgesia for pain management after unilateral TKR in the first 24 hours, with a greater need for extra boluses to relieve pain.

Effectiveness of continuous femoral nerve block for pain relief after total knee arthroplasty: comparison with epidural patient-controlled analgesia and periarticular injection

ObjectiveTo compare the clinical outcomes among three analgesic techniques, continuous femoral nerve block (CFNB), epidural patient-controlled analgesia (EPCA) and periarticular injection (PAI), in patients undergoing total knee arthroplasty (TKA).MethodsThis retrospective case–control study enrolled patients that underwent TKA. Visual analogue scale (VAS) pain scores, sleep disturbance, additional opioid consumption and incidence of opioid-related side-effects were assessed.ResultsA total of 120 patients were categorized into three groups: EPCA (group A, n = 40), PAI (group B, n = 40) and CFNB (group C, n = 40). Group C had significantly lower VAS pain scores than groups A and B at 8, 12 and 24 h after TKA. There were no significant differences in VAS pain scores among the three groups from 48 h after TKA. Sleep quality on the first day after surgery was significantly better in group C than in groups A and B. Additional opioid consumption was significantly lower in the group C than in the groups A and B. Group C showed a lower rate of opioid-related side-effects than groups A and B.ConclusionCFNB was a more effective additional analgesic technique than EPCA or PAI for acute postoperative pain control within 24 h of TKA.

A Comparative Study of Ultrasound-Guided Continuous Adductor Canal Block With Ultrasound-Guided Continuous Femoral Nerve Block in Unilateral Total Knee Arthroplasty for Limb Mobilization and Analgesic Efficacy.

BackgroundTotal knee joint replacement surgery is associated with severe postoperative pain and is amenable to regional anesthesia techniques for pain control. Femoral nerve block (FNB) provides effective analgesia after total knee arthroplasty (TKA) but has been associated with delayed ambulation due to quadriceps muscle weakness. Adductor canal block (ACB) may be a promising alternative, with less effect on the quadriceps muscle and comparable analgesic efficacy. We evaluated the effectiveness, safety, and patient satisfaction of continuous ACB augmented with infiltration between the popliteal artery and capsule of the knee (iPACK) block and compared them with those of continuous FNB amplified with iPACK block in preventing postoperative pain among patients undergoing unilateral total knee replacement (TKR) surgeries.MethodologyAccording to a computer-generated sequence from September 2019 to June 2020, 50 American Society of Anesthesiologists grades I-III patients aged between 35 and 75 years who underwent unilateral TKR surgery were randomized into two equal groups, namely, ACB and FNB. The Timed Up and Go (TUG) and 10-minute walk tests were used to detect early ambulation (impact on quadriceps muscle). The secondary goal was to evaluate and compare opioid consumption and analgesic efficacy between the groups measured using a numeric rating scale (NRS). The demographic characteristics, technical difficulty, efficiency, safety, and comfort were compared between the two groups.ResultsDuring the postoperative period, patients in the ACB group could perform all TUG tests significantly faster than those in the FNB group. The mean get-up time in the ACB group was 39.08 ± 5.53 seconds, whereas that in the FNB group was 44.92 ± 7.10 seconds (p < 0.01). The 3-m walk time was 123.16 ± 15.90 seconds in the ACB group and 134.68 ± 13.13 seconds in the FNB group (p < 0.01). The 10-m walk time was 221.24 ± 18.82 seconds in the ACB group and 245.24 ± 21.68 seconds in the FNB group (p < 0.001). No significant difference was observed in NRS scores between the groups after the first 24 hours. The number of opioids available for consumption in both groups was equivalent.ConclusionsACB when augmented with an iPACK block is a good alternative to FNB for unilateral TKR surgeries. ACB may promote early ambulation without a reduction in analgesia when compared with FNB.

Reduction of leakage from insertion site during continuous femoral nerve block with catheter-through-needle versus catheter-over-needle technique for postoperative analgesia after total knee arthroplasty: a randomized controlled trial

BackgroundContinuous femoral nerve block (CFNB) is a common procedure used for postoperative analgesia in total knee arthroplasty. Continuous nerve block using a conventional needle (catheter-through-needle/CTN) is complicated by leakage of the anesthetic from the catheter insertion site. A different type of needle (catheter-over-needle/ CON) is now available, which is believed to reduce leakage as the diameter of the catheter is larger than that of the needle. The purpose of this study was to compare the incidence of leakage from the catheter insertion site during CFNB while using CTN and CON for postoperative analgesia after total knee arthroplasty (TKA).MethodsThis prospective, randomized, single-blinded controlled study included 60 patients who were scheduled for TKA at our facility between May 2016 and November 2017. Patients were randomly allocated to the CTN or CON groups. All patients in both groups received CFNB and sciatic nerve block for postoperative analgesia. The administration of 0.16% levobupivacaine mixed with 6 mg of indigo carmine (a dye added to easily identify leakage) was started at 6 ml/h at the end of surgery. The primary outcome was the incidence of leakage from the catheter insertion site. We further investigated the degree of leakage, the incidence of catheter migration, pain scores using the numerical rating scale at 48 h postoperatively, and the number of days until the operated knee could be flexed 120 degrees postoperatively in both groups.ResultsThe CON group had a significantly lower incidence and degree of leakage from the catheter insertion site. There were no significant differences in other measurement outcomes.ConclusionsUse of CON reduces the incidence of leakage from the catheter insertion site during CFNB in the use of postoperative analgesia for total knee arthroplasty. Future research is needed to determine additional benefits of using CON related to decreased leakage.Trial registrationThe study was registered in the University Hospital Medical Information Network (UMIN) Clinical Trials Registry (UMIN000021537), prospectively registered on 18 March 2016.

Continuous Femoral Nerve Block Reduces the Need for Manipulation Following Total Knee Arthroplasty.

Background:Peripheral nerve blocks improve both pain control and functional outcomes following total knee arthroplasty (TKA). However, few studies have examined the effects of different peripheral nerve block protocols on postoperative range of motion. The present study assessed the impact of a single-shot femoral nerve block (SFNB) versus continuous femoral nerve block (CFNB) on postoperative range of motion and the need for subsequent manipulation following TKA.Methods:We retrospective reviewed patient charts to identify patients who had undergone primary elective unilateral TKA by 2 surgeons at a high-volume orthopaedic specialty hospital over a 3-year period. A total of 1,091 patients received either SFNB or CFNB and were included in the data analysis. Identical surgical techniques, postoperative oral analgesic regimens, and rehabilitation protocols were used for all patients. Patients with <90° of flexion at 6 weeks postoperatively underwent closed manipulation under anesthesia (MUA).Results:Overall, 608 patients (55.7%) received CFNB and 483 patients (44.3%) received SFNB. Overall, 94 patients (8.6%) required postoperative manipulation for stiffness, including 36 (5.9%) in the CFNB group and 58 (12%) in the SFNB group. The 50% reduction in the need for manipulation in the CFNB group was independent of primary surgeon (p > 0.05). No significant differences were observed between the groups in terms of postoperative range of motion, either at the time of discharge or at 6 weeks postoperatively. A history of knee surgery, decreased preoperative range of motion, and decreased range of motion at the time of discharge were significantly associated with the need for further MUA (p = 0.0002, p < 0.0001, and p < 0.0001, respectively).Conclusions:Despite similar final postoperative range of motion between patients in both groups, our results suggest that CFNB may be superior to SFNB for reducing the need for postoperative manipulation after primary TKA. Furthermore, a history of ipsilateral knee surgery, decreased preoperative range of motion, and decreased range of motion at the time of discharge were identified as independent risk factors for postoperative stiffness requiring MUA after primary TKA.Level of Evidence:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effect of Preoperative Continuous Femoral Nerve Block in Ease of Administration of Spinal Anaesthesia for Fracture Neck of Femur Stabilisation: A Case-control Study

Introduction: Subarachnoid block remains the anaesthesia modality of choice for surgical fixation of femur. Extreme fracture pain makes ideal positioning for spinal anaesthesia difficult. Preoperative continuous femoral block can provide analgesia for such patients. Aim: To evaluate the effect of continuous femoral nerve block in ease of administration of spinal anaesthesia for fracture neck of femur stabilisation. Materials and Methods: This was a prospective case-control study conducted at the Government Medical College, Kozhikode, Kerala, India from September 2020 to September 2021. Total of 86 adult patients posted for fracture femur neck stabilisation were selected and divided into two groups- group 1 and group 2. Patients in group 1, were administered ultrasound guided continuous femoral nerve block with 0.2% ropivacaine (15 mL) followed by subarachnoid block and group 2 patients were administered subarachnoid block without prior femoral nerve block. Parameters observed included were VAS score while positioning for spinal anaesthesia, ease of palpating interspinous space, time required to perform spinal anaesthesia, number of attempts required to achieve dural puncture, patient satisfaction score as well as haemodynamic and respiratory changes while positioning for subarachnoid block. Results: Group 1 patients had significantly lower VAS scores while positioning for spinal anaesthesia (4.2±1.8 in group 1 as compared to 6.3±1.2 in group 2, p-value=0.001). There was a significant difference in the number of attempts required for dural puncture (1.3±0.4 in group 1 as compared to 1.8±0.6 in group 2, p-value=0.04) and total performance time for spinal anaesthesia (2.2±0.4 min in group 1 as compared to 3.3±0.9 in group 2, p-value=0.02) between 2 groups. Patient satisfaction scores were significantly higher in group 1 compared to group 2 (9.3±0.6 in group 1 as compared to 6.5±0.5, p-value &lt;0.001). Both groups were comparable in terms of ease of palpating inter spinous space, haemodynamic and respiratory changes during positioning for subarachnoid block. Conclusion: Preoperative administration of continuous femoral nerve block provides better conditions for performing subarachnoid block in fracture neck of femur surgeries by reducing the pain while positioning.

Perioperative anesthetic challenges in Alkaptonuria patient with comorbid conditions

Dear Editor, Alkaptonuria (AKU) is a rare autosomal-recessive inborn error of tyrosine metabolism which is a progressive debilitating disease and symptomatic around 30 years of age. In AKU, patient lacks enzyme required to breakdown homogentisic acid and on exposure to air complains of “black nappies.” Deposition of the onchronosis pigment in the large joints and spine causes joint destruction. In addition, there is involvement of airway, respiratory, renal, cardiac and coagulation system.[1] A 56-year-old man with AKU, G6PD deficiency, hypothyroidism, and hypertension, was scheduled for unilateral total knee arthroplasty. He was receiving levo-thyroxine 50 μg and amlodipine 5 μg once a day (OD). Over a span of 13 years the patient underwent multiple surgeries including lumbar thoracic, cervical fixation and, open cholecystectomy under general anesthesia. Neurological examination revealed hyperreflexia and spasticity in the lower limbs with decreased sensation over S1 dermatome. Airway examination revealed mouth opening of 5 cm, thyromental distance of 5.5 cm, limited neck extension (<10°), and a Mallampati class IV. Rest all investigations were normal. Patient was kept nil per oral prior to surgery and amlodipine and levo-thyroxine on the day of surgery. In the operating theatre, an 18 G intravenous line was secured, mandatory monitoring was attached and a difficult airway cart was kept ready. Patient was asked to self-position on the operation table. Following pre-oxygenation, IV fentanyl 2 μg/kg and propofol 2 mg/kg were administered. After loss of eyelash reflex, a check laryngoscopy was done with video-laryngoscope C-MAC® (Karl Storz, Germany) using a D-Blade which revealed a POGO of 75% with a granular deposit over the left posterior arytenoid, which adequate glottic chink. Vecuronium bromide 0.1 mg/kg was administered and trachea was intubated with 8.5 mm ID. Anesthesia was maintained with nitrous in oxygen, propofol infusion at 50-100 μg/kg/min, and intermittent boluses of vecuronium. At the end of surgery, an ultrasound-guided continuous femoral nerve block with 0.2% ropivacaine 15 ml bolus was performed followed by infusion of ropivacaine 0.2% with fentanyl 2 μg/ml. The surgery lasted for 2 h and vitals were stable during the entire period. 1.5 L of crystalloids were infused. Muscle paralysis was reversed. Black discolouration of heat and moisture exchanger as seen in this patient [Figure 1]. Trachea was extubated and the patient had an uneventful postoperative period.Figure 1: Black discolouration of heat and moisture exchanger in this patientCaring for a patient with AKU ochronosis with multiple comorbidities is challenging. Deposition of HGA in the cartilage of the airway and respiratory system can result in glottic stenosis leading to difficult airway management.[2] HGA deposits also make the dura and the arachnoid membrane vulnerable, therefore central neuraxial techniques were not preferred in the present case.[3] Drug-related precautions were observed for G6PD deficiency.[4] The learning points in this case is the preparedness for anticipated difficult airway, multimodal analgesia and good coordination with orthopedic team for perioperative management. Use of VL with shorter learning curve has changed the management in patients with difficult airway.[56] Since there is no approved treatment for AKU, with every repeated surgery these patients have progressively increasing anaesthetic challenges necessitating meticulous anesthetic management. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Taylor’s Approach to Rescue: A Case of Undiagnosed Alkaptonuria Undergoing Bilateral Total Knee Replacement

Alkaptonuria is a rare inherited autosomal recessive metabolic disorder due to the deficiency of homogentisic acid oxidase resulting in accumulation of homogentisic acid in collagen and cartilaginous tissue resulting in stiffening of joints, spine and involving other systems which pose challenges to anaesthesiologist in providing anaesthesia. Here we present a patient with undiagnosed alkaptonuria who was posted for bilateral total knee replacement. Since these patients usually have reduced intervertebral spaces, neuraxial anaesthesia was difficult with classic approach. Taylor’s approach was used for neuraxial anaesthesia and, post-operative analgesia was achieved with continuous femoral nerve block with catheter placement.

Continuous Lumbar Plexus Block under the Guidance of the "Shamrock Method" Ultrasound: Analgesic Effects and Hemodynamic Effects after Total Knee Arthroplasty in Elderly Patients.

Objective To explore the effect of continuous lumbar plexus block guided by the “Shamrock method” on postoperative analgesia and hemodynamics in elderly patients after total knee arthroplasty (TKA). Methods From January 2020 to December 2020 in our hospital, 98 patients who underwent TKA were selected. Using the random number table method, the patients were divided into two groups: a continuous lumbar plexus block group (group L), with 49 patients, and a continuous femoral nerve block group (group F), with 49 patients. The onset time and maintenance time of motor and sensory nerve blocks in patients were recorded. A visual analogue scale (VAS) was applied to assess the pain severity at 6, 12, 24, and 48 h after the operation. The VAS score (FVAS) was applied to evaluate the pain severity of the patients during 24 and 48 h after the operation and knee joint functional exercise. The levels of hemodynamic indexes such as heart rate, mean arterial pressure, and oxyhemoglobin saturation and the levels of hemorheological indexes such as plasma viscosity, high and low whole blood shear viscosity, fibrinogen, and hematocrit were detected and compared between the two groups immediately after the operation and at 12 h and 48 h after the operation, respectively. The incidence of adverse reactions induced by anesthesia was counted. Results The onset time of motor and sensory nerve blocks in group L was lower than that in group F, and the maintenance time was higher than that in group F (P < 0.05). The VAS scores of 6, 12, 24, and 48 h after operation in group L were significantly lower than those in group F (P < 0.05). The FVAS scores of group L at 24 and 48 h after operation were significantly lower than those of group F (P < 0.05). The heart rates of the patients in the two groups were higher at 12 h and 48 h after operation than those immediately after operation (P < 0.05). The heart rates at 12 h and 48 h after operation in group L were lower than those in group F (P < 0.05). The plasma viscosity, high whole blood shear viscosity, and low whole blood shear viscosity in the group L at 12 h and 48 h after operation were lower than those in group F (P < 0.05). There was no significant difference in the incidence of local anesthetic poisoning, nausea, vomiting, urinary retention, pruritus, and other adverse reactions between the two groups (P > 0.05). Conclusion The “Shamrock method” ultrasound-guided continuous lumbar plexus block in elderly patients after TKA has good analgesic effect, stable hemodynamics, little influence on hemorheology, and good safety. It is of great value to enhance the surgical effect and promote postoperative rehabilitation.

Continuous Femoral Nerve Blockade versus Continuous Epidural Analgesia for Postoperative Pain Relief in Knee Surgeries

Abstract Background The progression of osteoarthritis is characteristically slow, occurring over several years or decades. Over this period, the patient can become less and less active and thus more susceptible to morbidities related to decreasing physical activity (including potential weight gain). Early in the disease process, the joints may appear normal. However, the patient’s gait may be antalgic if weight-bearing joints are involved. Objective Compare the benefits of continuous femoral nerve block (CFNB) with those of continuous epidural analgesia CEPA for postoperative pain management after Knee surgeries. Methods This study is a randomized controlled clinical trial was conducted in Ain Shams University Hospitals after obtaining approval from the Research Ethical Committee of Ain Shams University during a period of three months. Patients undergoing primary unilateral TKA for osteoarthritis, were recruited at least one day prior to the scheduled surgery, male and female patients. Results There was significant difference in terms of pain scoring between continuous femoral nerve block (CFNB) and continuous epidural analgesia (CEA) in the first 6 hours, 12 hours, 24 hours, 48 hours, 72 hours but non significant difference in incidence of side effects Conclusion Our study showed that CEA had optimal analgesia and pain control than CFNB in management of post operative pain after total knee replacement.

Effects of the addition of dexamethasone on postoperative analgesia after anterior cruciate ligament reconstruction surgery under quadruple nerve blocks

BackgroundAnterior cruciate ligament (ACL) reconstruction is an invasive surgical procedure for the knee. Quadruple nerve blocks including continuous femoral nerve block and single-injection sciatic, obturator, and lateral femoral cutaneous nerve blocks can provide effective intraoperative anesthesia and analgesia in the early postoperative period. However, severe pain often appears after the effect of single-injection nerve blocks resolves and that is why we conducted two studies. The first study was to determine whether dexamethasone administered along with local anesthetic for sciatic nerve block could prolong the duration of analgesia in patients given quadruple nerve blocks, including continuous femoral nerve block, for ACL reconstruction using a hamstring tendon autograft. The second study was designed to evaluate any difference in effects from dexamethasone administered perineurally versus intravenously.MethodsPatients undergoing unilateral arthroscopic ACL reconstruction using a hamstring tendon autograft were enrolled into two studies. The first study was prospectively conducted to see if dexamethasone 4 mg could prolong the duration of analgesia when administered perineurally to the subgluteal sciatic nerve with 0.5% ropivacaine. In the second study, we retrospectively evaluated the effects of intravenous dexamethasone 4 mg as compared with those of perineural dexamethasone to the sciatic nerve block and effects with no dexamethasone.ResultsIn the first study, perineural dexamethasone prolonged the duration of analgesia by 9.5 h (median duration: 22.5 and 13.0 h with and without perineural dexamethasone, respectively, P = 0.011). In the second study, the duration of analgesia was similarly prolonged for intravenous and perineural dexamethasone compared with no dexamethasone.ConclusionPerineural dexamethasone administered along with local anesthetic for single sciatic nerve block prolonged the duration of analgesia of quadruple nerve blocks for ACL reconstruction, however the effects were not different from those of intravenous dexamethasone.Trial registrationThe protocols of both studies were approved by the Institutional Review Board of Shimane University Hospital, Japan (study number 2821 and 3390 for study 1 and study 2, respectively). Study 1 was registered in University Hospital Medical Information Network Clinical Trials Registry (UMIN000028930). Study 2, which was a retrospective study, was not registered.