Femoral Nerve Block Research Articles

Usefulness of ultrasonography guided femoral and lateral femoral cutaneous nerve blocks in providing analgesia before giving spinal anaesthesia in patients undergoing surgery for intertrochanteric fracture of femur: A randomized clinical trial.

It is challenging to give the patient position for subarachnoid block (SAB) as intertrochanteric (IT) fracture of the femur produces intolerable pain. In this study, we have analyzed the usefulness of combined ultrasonography (USG)-guided femoral nerve block (FNB) and lateral femoral cutaneous nerve block (LFCNB) to reduce the fracture pain before performing SAB. A prospective, randomized, comparative study was conducted on 60 American society of anesthesiologists (ASA) grade I and II patients (18-80 years) scheduled for elective IT fracture surgery. Group A (n = 30) patients received USG-guided FNB and LFCNB using 0.75% ropivacaine before SAB. Group B patients (n = 30) received SAB only. All the patients received SAB (3 mL of 0.5% bupivacaine) by an anesthesiologist blinded to the patient groups. The patients were observed for quality of patient positioning for SAB, perioperative visual analog scale (VAS) scores, time to administration of SAB, and duration of analgesia and motor blockade. Statistical analysis was done by Student's t-test and Chi-square test. Baseline VAS score (T1) was similar in both the groups. Mean T2 (VAS score just before SAB) in group-A (3.2 ± 0.98) was lower compared to group-B (8.23 ± 0.7) with P < 0.0001. The quality of patient positioning in group-A was good to optimal but in group-B, it was satisfactory to not satisfactory. Group-A had longer mean duration of analgesia 804 ± 114.28 minutes with P value < 0.0001 than group-B in which it was 200 ± 28.77 min. Backache was significant in group-B with P value of 0.038 compared to group-A. USG-guided FNB and LFCNB can be used as an effective supplementation to SAB in patients undergoing surgery for IT fracture of the femur as it reduces fracture site pain, provides good patient positioning during SAB, and prolongs postoperative analgesia.

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.

Assessment of xenon-induced depth of hypnosis according to Kugler’s scale in elderly and senile patients undergoing knee replacement surgery: a prospective open-label cohort study

INTRODUCTION. Anesthesia with xenon is characterized by stable hemodynamic parameters, cardio- and neuroprotection preferable in elderly. Assessment of the depth of hypnosis remains challenging. The Kugler classification based on electroencephalogram has been suggested for such assessment. OBJECTIVES. To assess the feasibility of Kugler scale for objective assessment of the depth of hypnosis induced by xenon alone or in combination with narcotics and regional anesthesia during knee arthroplasty in elderly. MATERIALS AND METHODS. The study included 57 patients divided into 2 groups. In group 1, general anesthesia with xenon was performed, fentanyl and femoral nerve block were used for pain control. In group 2, xenon anesthesia was performed in combination with femoral and sciatic nerve block. The depth of hypnosis was monitored using EEG and matched with the Kugler scale. Also, the bispectral index (BIS) was recorded. RESULTS. At xenon concentration of 40 %, the depth of hypnosis reached D2 stage in group 1 and D1 in group 2 patients, while at 55 % and above it was D2 in both groups. Fentanyl increased the δ-rhythm by 19.08 %, which corresponded to reduction in the effective xenon concentration by 20 %. A correlation between δ-rhythm decrease and BIS was seen in groups 1 (r = –0.78; R2 = 60 %) and 2 (r = –0.61; R2 = 37 %). The differences could be related to the use of fentanyl in group 1. The intergroup difference between the reduction of BIS was not significant. CONCLUSIONS. In elderly patients undergoing knee arthroplasty under combined anesthesia, stage D2 according to Kugler scale (proportion of δ-rhythm more than 50 %) is achieved at xenon concentration of 55 % without narcotics and at concentration of 40 % with fentanyl. The diminished correlation between δ-rhythm and BIS in group 2 and no difference in decrease of BIS suggests that BIS is less accurate for determining the depth of hypnosis during xenon monoanesthesia.

Dexmedetomidine as an Adjuvant to 0.25% Bupivacaine in Ultrasound Guided Femoral Nerve Block for Preoperative Positioning and Postoperative Analgesia in Patients Undergoing Elective Surgery for Fracture Shaft of Femur.

Background:Femur fracture causes excruciating pain and surgical repair is recommended. To obtain satisfactory patient co-operation in the perioperative period, various analgesics have been used. Femoral nerve block (FNB) provides an excellent alternative for analgesia in the perioperative period. Dexmedetomidine of up to 2 μg.kg−1 has been used in FNB as adjuvants in lower limb surgeries.Aims:The aim was to study the effect of addition of Dexmedetomidine to Bupivacaine in FNB on the comfort of positioning for subarachnoid block (SAB) and postoperative analgesia.Materials and Methods:Prospective, randomized, double-blind design was followed. Seventy American Society of Anesthesiologist I and II patients aged 18–70 years of either gender were randomly allocated into Group B (20 mL 0.25% Bupivacaine + 2 mL Normal Saline) and Group BD (received 20 mL 0.25% Bupivacaine + Dexmedetomidine 2 μg.kg−1 diluted to 2 mL) for FNB. Numerical rating scale (NRS) was recorded before and after FNB and comfort of positioning graded. After 10 min, subarachnoid block (SAB) was administered. NRS was recorded postoperatively until 24 h.Results:The comfort of positioning improved in both the groups after FNB but was statistically not significant when compared among the groups (P = 0.7). Duration of postoperative analgesia was significantly higher in the Group BD (741 min ± 97 min) compared to the Group B (440 min ± 45 min) (P = 0.001) and was statistically significant.Conclusion:FNB improved the comfort of positioning for SAB, but the addition of Dexmedetomidine did not have any added advantages with respect to comfort of positioning. However, the addition of Dexmedetomidine significantly increased the duration of postoperative analgesia with minimal hemodynamic changes.

Effectiveness of Femoral Nerve Block Versus Intravenous Nalbuphine in Positioning of Patients with Intertrochanteric Fractures for Spinal Anaesthesia: A Randomised Clinical Study

Introduction: Femoral fracture is a common entity in all age groups. It is more common in elderly, and is a painful condition. Various modalities like peripheral nerve blocks, intravenous opioids can mitigate the pain associated with it which is deterrent to ideal patient positioning for spinal anaesthesia. Aim: To compare the effectiveness of Femoral Nerve Block (FNB) versus Intravenous Nalbuphine (IVN) in positioning of patients with intertrochanteric fracture for spinal anaesthesia. Materials and Methods: A randomised clinical study was conducted in 70 patients of American Society of Anesthesiologists (ASA) physical status I and II, with intertrochanteric fractures posted for surgery under Subarachnoid block. Group IVN received intravenous Nalbuphine at dose of 0.1 mg/kg, and Group FNB received femoral nerve block with 20 mL of 0.2% Ropivacaine 15 minutes, prior to positioning of patients for Subarachnoid block. The ease of patient positioning was assessed by the pain relief observed during positioning for spinal anaesthesia, and by means of anesthesiologist satisfaction score. Time taken to position the patients during spinal anesthesia, and patient satisfaction scores were also measured. Independent ‘t’ test and Mann-Whitney U tests were used for the analysis. Results: The Visual Analogue Scale (VAS) score achieved during positioning of patients for subarachnoid block was significantly better in FNB (3.87±0.99), as compared to IVN (5.09 ±1.23). No significant differences were observed between both the groups regarding anesthesiologist’s satisfaction score, (p=0.11). Time taken for positioning of patients for spinal anaesthesia in seconds (p=0.69), and patient satisfaction score (p=0.08) were also comparable between both groups of patients. Conclusion: FNB is more effective for positioning of patients of intertrochanteric fractures for spinal anaesthesia. Although either of the techniques can be adopted for improving patient care, FNB may have an edge over IVN.

Dexmedetomidine Combined with Femoral Nerve Block Provides Effective Analgesia Similar to Femoral Nerve Combined with Sciatic Nerve Block in Patients Undergoing Total Knee Arthroplasty: A Randomized Controlled Study.

BackgroundTotal knee arthroplasty (TKA) is a severe traumatic procedure, and femoral nerve block (FNB) combined with a sciatic nerve block (SNB) is widely used in TKA. However, injury of the sciatic nerve is clinically reported. Dexmedetomidine (DEX) could reduce stress and inflammation, as well as improve pain in TKA. This study aims to observe the analgesic impact of DEX combined with FNB in TKA.MethodsEighty-eight patients undergoing TKA were included and randomly divided into two groups: DF group (FNB combined with DEX 0.6μg/kg before surgery, followed by DEX 0.2–0.4μg/kg/h until articular closure) and SF group (FNB combined with SNB). Each nerve was blocked with 0.375% ropivacaine 20mL, and all patients received general anesthesia routinely. The primary endpoint was the pain visual analog scale (VAS) score during activities at postoperative 24 hours.ResultsThere was no statistical difference in the pain VAS scores at any time point. The mean duration of analgesia for patients with rescue analgesic requests was comparable between the two groups: 25.4 ± 6.3 hours in the DF group vs 24.8 ± 6.4 hours in the SF group (two-sample t-test, p=0.738). The total dose of sufentanil was similar between groups (P=0.355). The maintenance dose of propofol and dose of rescue analgesics were comparable (all P>0.05). There were no statistical differences in the incidence of adverse events. However, the time to extubate in the DF group was significantly longer than those in the SF group (P<0.001).ConclusionDEX combined with FNB could provide effective analgesia similar to SNB combined with FNB in TKA.Clinical Trial RegistrationThe trial was registered at the Chinese Clinical Trial Registry on November 17, 2019 (identifier: ChiCTR1900027552).

Ultrasound-guided femoral nerve block and intravenous fentanyl in pain management of the patients with hip fracture: a prospective, randomized, single blinded clinical trial.

Proximal femoral fracture is a painful condition. Pain alleviation is a treatment cornerstone to both comfort the patient and reduce adverse effects. This study aimed to evaluate and compare ultrasound-guided femoral nerve block and intravenous fentanyl administration in relieving the pain of patients with hip fractures. The present interventional clinical trial was conducted on 40 patients referred to Shahid-Bahonar Hospital with unilateral isolated proximal femur fracture and American Society of Anesthesiologists I and II. The patients were randomly divided into two groups: intravenous fentanyl and ultrasound-guided femoral nerve block for pain management. Pain severity was assessed by a numerical rating scale before and after the intervention in both groups and the groups were then compared. Forty patients were enrolled in to study; 27 (67.5%) were male. There was no significant difference in demographic variables between the two groups. Fourteen (35%) were older than 80 years. Pain significantly decreased three scores compared to the pre-intervention level in both groups (95% confidence interval, 2-4). This was slightly higher in the femoral nerve block group. The largest strength of association for age and numerical rating scale of pain was found in the differences between the pre-intervention and after-intervention in femoral nerve block group (r=-0.775, P < 0.001). We found similar pain severity between the two groups. Considering the possible side effects of fentanyl, an ultrasound-guided femoral nerve block shows may provide safer pain control and may be particularly suitable for patients with opioid dependence.

Between Heaven and Hell: Experiences of Preoperative Pain and Pain Management among Older Patients with Hip Fracture.

IntroductionAmong older adults, hip fracture is a common and serious consequence of a fall. Preoperative pain is common and often severe among patients with hip fracture. Opioids are usually used but have many side effects. One alternative is a femoral nerve block, which has been shown to reduce pain and lower the need for opioids. However, to our knowledge no study has explored qualitatively how patients with hip fracture experience treatment with femoral nerve block.ObjectiveThe aim of this study was to explore experiences of preoperative pain and pain management among older patients with hip fracture who had received a femoral nerve block.MethodA qualitative design with semi-structured interviews (n = 23) conducted 2–6 days after surgery. Inclusion criteria were Swedish-speaking patients aged 70 years or older with hip fracture admitted to the orthopedic ward, treated with femoral nerve block before nursing actions. Data were analyzed with qualitative content analysis.ResultsOur result revealed one theme, hovering between heaven and hell, with five subthemes: how the pain was described – no pain, to worst pain and everything in between; they were dealing with pain in their own way; felt dependent on staff´s willingness to relieve pain; pain management could be lifesaving and a near-death experience; and how they experienced memory loss with respect to the pain and pain management.ConclusionThe experience of pain and pain management was described as hovering between heaven and hell. We conclude that independent of which pain management given, staff should have an individualized pain mangement approach towards the patient in order to achieve well managed pain.

Effectiveness of Periarticular Cocktail Injection in Pain Management of Patients Undergoing Total Knee Arthroplasty

Introduction: Total knee arthroplasty is a procedure that can improve quality of life, and it is performed in increasing numbers every year because of the increase in the elderly population due to improved medical technology. However, the problem is that patients avoid this operation because of postoperative pain, which affects patient satisfaction and delays recovery and rehabilitation. There are many modalities to improve operative pain control, such as femoral nerve blocks, epidural anaesthesia, and periarticular injections. These modalities have been shown to reduce post-operative pain and increase patient satisfaction. Periarticular injection was reported to have good efficacy in controlling pain, cost-effectiveness, a few side effects, and ease of use. This method can be used by every surgeon without further training, unlike techniques like epidural anaesthesia or femoral nerve blocks, which require experience and further training. Material and Methods: The study was conducted in the Department of Orthopaedics at SCB Medical College &amp; Hospital, Cuttack, Odisha. All the IPD patients who got admitted to the Dept. of Orthopaedics were taken as the study subject total of 30 cases were selected during study period out of which 15 were cases and 15 controls. Observation and Discussion: In Group A, R/L TKA was done in 3/12 patients and in Group B, R/L TKA was done in 8/7. All the Group A patients experienced less pain than the baseline parameters(p&lt;0.05) following TKA. Post-operative evaluation of Range of motion in between 2 Groups there was significant difference in between the two Groups A and B as it was comparatively more in POD1, POD2, POD3, POD7, DOD AND 3 months after follow up in Cocktail Group A. Knee Society Score in POD3 was found to be 100 and 90 in Group A and Group B respectively. Conclusion: This study has several strengths. First, it is a well powered, randomized study. Second, we included follow-up beyond the initial hospitalization. Third, the injection medications we used are available through any hospital pharmacy and are easily administered during the surgical procedure, so our findings could be generalized for any joint reconstruction surgeon. Keywords: Total knee replacement, Periarticular injection, Pain management

Anterior cruciate ligament reconstruction with ultrasound-guided femoral nerve block does not adversely affect knee extensor strength beyond that seen with intravenous patient-controlled analgesia at 3 and 6 months postoperatively

BackgroundThis study aimed to investigate the effect of anterior cruciate ligament (ACL) reconstruction with an ultrasound-guided femoral nerve block (FNB) on knee extensor strength weakness 3 and 6 months, and graft rupture in the 1 year following ACL reconstruction. MethodsOne hundred and seven patients who underwent ACL reconstruction were included in this retrospective study. The patients were divided into two groups stratified by the method of postoperative pain management. The FNB group included 66 patients, and there were 41 patients in the intravenous patient-controlled analgesia (iv-PCA) group. The isokinetic peak torque of knee flexor and extensor was measured preoperative, 3 and 6 months after ACL reconstruction. Muscle strength measurements were performed using the BIODEX dynamometer at a velocity of 60°/s and 180°/s. Peak torque of knee extensor and flexor strength, estimated pre-injury capacity (EPIC), body weight ratio (BW), and graft rupture incidence were compared between the two groups. ResultsThere were no statistically significant differences in the knee extensor and flexor strength for all items at 3 and 6 months after ACL reconstruction. There was also not a statistically significant difference in the graft rupture incidence between the two groups: FNB group was two patients, 3.0% vs. iv-PCA group was one patient, 2.4% (p = 0.86). ConclusionACL reconstruction with ultrasound-guided FNB does not affect knee extensor strength at 6 months, nor graft rupture at 1 year postoperatively.

Femoral Nerve Anesthesia in Hostile Environments (Mountains)

Traumatic injuries associated with adventure sports activities occur in hostile environment. The Femoral nerve anesthesia (FNA) outside of the hospital settings has been demonstrated but not in hostile environment. So, the objective of this study was to determine the feasibility of FNA for these very painful traumatized patients on the accident site and during their extraction-evacuation by helicoper. This prospective observational study was enrolled a convenience sample of 11 patients (4 women, 7 men) with closed fractures femurs. FNA was performed on all participants and 3 situations were defined (Impossible, Difficult if more than 1 attempt, Easy to perform). Pain evaluated using visual analog scale (VAS) (0-10) measured at the following time point: Rescue team arrival (T0), Ten minutes after FNA (T10), at Reduction of fracture (T Reduction) and during helicopter Evacuation (T Evacuation). The median age of the participants was aged 40 +/- 18 years. The accidents which occurred were 7 Skiing, 2 moutaineering, 1 snowshoeing, 1 parapliding. 11 FNA performed with 5 fascia iliaca blocks, 6 femoral nerve blocks. 82% blocks were technically easy and 18% difficult. Pain evaluation showed an average VAS of 7,5 (7-8) at T0, 1,1 (0-2) at T10, 0,45 (0-1) at T Reduction, 0,36 (0-1) at T Evacuation. All the pathologies were treated with reduction and immobilization. Helicopter evacuations were conducted without incident in a calm atmosphere and with excellent patient cooperation. In final, FNA performed in difficult environment is feasible, effective, and reproducible in extreme conditions. There is no limitation due to hostile terrain. FNA techniques used must simple and fast but performed by trained physicians who are technical experts in order achieve a successful outcome in difficult terrain.

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.

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.

Femoral Nerve Blockade During Endovenous Ablation of Great Saphenous Vein Decreases Pain but does not have an Impact on the Use of Opioids During the Procedure

Femoral Nerve Blockade During Endovenous Ablation of Great Saphenous Vein Decreases Pain but does not have an Impact on the Use of Opioids During the Procedure

Peripheral Nerve Block Compared to Intra-Articular Injection for Post-Operative Pain Control in Total Ankle Arthroplasty: A Randomized, Controlled, and Non-Inferiority Trial

Category:Ankle Arthritis; Ankle; OtherIntroduction/Purpose:Ankle arthritis is associated with debilitating pain and chronic disability. Total ankle arthroplasty (TAA) is increasingly performed to treat end-stage arthritis resulting in favorable clinical outcomes. Peripheral nerve blocks (PNB) are widely used for post-operative pain management; however, PNB can lead to post-operative neuropathic complications. Intra- articular injections (IAI) have been widely reported as an alternative to PNB in total knee arthroplasty, resulting in lower post- operative narcotic consumption and accelerated functional recovery. Little information exists on patient outcomes following IAI in TAA. The purpose of this study was to assess the effectiveness and tolerability of IAI compared to PNB for pain control, measured by oral morphine milligram equivalents (MME) and a Visual Analogue Pain Scale (VAS), following TAA.Methods:We conducted a prospective, randomized, non-inferiority study involving 51 opioid naïve adults undergoing primary, unilateral TAA. Participants were randomized to IAI joint cocktail containing anesthetic and steroid at the completion of the TAA (n=26), injected in four joint capsule locations, or PNB (n=25). PNB included a single popliteal fossa block of the sciatic nerve and adductor canal block of the distal femoral nerve. Primary outcomes were mean difference in oral post-operative MME, via inpatient record and patient daily narcotic diaries, and post-operative pain measured by the VAS (0-100mm) at 24 hours and 2 weeks post-TAA. IAI was considered non-inferior to PNB if mean difference in consumption of narcotics was less than 30 MME (24 hour) and 75 MME (2 weeks), and the mean difference in pain was less than 15mm on the VAS using the upper limit of one- sided 95% confidence intervals (UCI) for increase in MME and VAS scores.Results:There were 39 patients with complete data. Mean oral MME in 24 hours was 50.4 (sd = 38.1) in the IAI group (n=22) versus 52.9 (sd = 48.1) in PNB (n=17) with -2.4 MME mean difference (UCI 20.8). Mean VAS at 24 hours was 25.6 (sd = 25.1) in IAI compared to 25.4 (sd = 29.2) in PNB. Mean difference in VAS at 24 hours was 0.22 (UCI 14.9). Mean two week post- VAS was 13.3 (sd = 17.2) in IAI compared to 15.1 (sd = 21.2) for PNB with mean difference of -1.8 (UCI 8.5). All demonstrate non- inferiority. At two week post- IAI reported 384.6 MME (sd = 491.0) and PNB 319.2 (sd = 323.7) with 65.5 MME difference (UCI 303.6), not supporting non-inferiority.Conclusion:IAI is non-inferior to PNB in the first 24 hours after TAA as measured by oral narcotic consumption and patient-self reported pain. At two week post-TAA, IAI resulted in non-inferior pain scores; however, non-inferiority was not confirmed for oral narcotic consumption due to the high variability in documented use. This study suggests IAI is effective for controlling immediate post-operative pain without introducing the neuropathic complications associated with PNB.

The effect of low concentration femoral and sciatic nerve block with dexamethason for post operative pain management in lower limb surgery

The effect of low concentration femoral and sciatic nerve block with dexamethason for post operative pain management in lower limb surgery

Additional Peripheral Nerve Block to Periarticular Injection Has No Benefit for Patients Undergoing TKA: A Factorial Propensity Score-Matched Analysis Comparing Four Multimodal Analgesic Techniques.

Controversy remains over what and how many analgesic techniques are required as the most effective multimodal pain regimen in total knee arthroplasty (TKA). This study aimed to evaluate the effect of additional analgesic methods combined with periarticular injection (PAI) analgesia for TKA. Using retrospective cohort data, patients undergoing TKA with spinal anesthesia and PAI were divided into 4 groups. Group A (control) comprised 66 patients; group B (73 patients) had additional adductor canal block; group C (70 patients) obtained additional femoral nerve block, and group D (73 patients) received additional adductor canal block and intrathecal morphine. Propensity score matching was applied to compare visual analog scale (VAS) for pain intensity, cumulative morphine use (CMU), knee flexion angle, straight leg raise, length of hospital stay, and postoperative nausea and vomiting. There was no significant difference regarding VAS and morphine use, when either group B or C was compared with group A. Group D had significantly lower VAS than groups A, B, and C during the first 24hours after surgery and required significantly less CMU than groups A and B. However, the pain score of group D increased afterward, with significantly longer length of hospital stay than groups A and B. There was no difference in straight leg raise among the groups. Additional peripheral nerve block to PAI provides no benefit for patients undergoing TKA. Adjuvant intrathecal morphine could significantly reduce the VAS and CMU in the acute postoperative period; however, rebound pain with prolonged hospital stays was observed.

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.

Comparison of ultrasound-guided femoral + anterior sciatic nerve block and genicular nerve block for postoperative pain in total knee arthroplasty

Purpose: This study aimed to compare the effectiveness of ultrasound-guided femoral and anterior sciatic (FAS) nerve blocks and genicular (G) nerve blocks as preventive analgesia methods after total knee arthroplasty.&#x0D; Materials and Methods: Fifty patients, aged 55–80 years were divided into two groups preoperatively. Patients in the FAS group (n=25) received 20 mL solutions (10 mL 0.5% bupivacaine, 1 mL [4 mg] dexamethasone, and 9 mL saline) in both femoral and sciatic blocks. Patients in the G group (n=25) received 5 mL solutions (2 mL 0.5% bupivacaine, 1 mL [4 mg] dexamethasone, and 2 mL saline) for each nerve. Patients were assessed 24 h postoperatively, and pain scores, time to first analgesic requirement, total analgesic dose, and postoperative complications during the first 24 h were recorded.&#x0D; Results: VAS scores at postoperative 0, 1, and 6 h and the total amount of tramadol consumed 24 h were lower in the FAS group than in the G group. There was no requirement for additional analgesia in the first 24 h in the FAS group; however, 9 patients required additional analgesia in the G group. &#x0D; Conclusion: USG FAS nerve blocks were superior to the genicular nerve blocks in TKA. Additionally, the genicular block doesn’t cause motor block. A genicular block can be considered as an alternative with this regard.

Comparison of Peng Block versus Ficb in Hip Surgeries, A Randomised Control Study

Background: Hip surgeries are among the common surgeries performed in orthopaedics especially in geriatric age group. A recent anatomical study on hip innervation led to the identification of relevant landmarks to target the hip articular branches of femoral nerve and accessory obturator nerve making Pericapsular nerve group (PENG) block popular. However there are other commonly performed blocks for hip surgeries including Fascia Iliaca block, 3 in 1 block, Femoral nerve block. This study is aimed at comparing the efficacy of Pericapsular nerve group (PENG) block and Fascia Iliaca Block (FICB) in terms of post operative analgesia. Aims and objectives: To compare the efficacy of post- operative analgesia in Pericapsular nerve group (PENG) block and Fascia Iliaca block in hip surgeries. Material and Methods: Total 90 patients scheduled for hip surgeries under combined spinal epidural anesthesia were selected for the study. In 30 patients ,ultrasound guided PENG block was given, in other 30 ultrasound guided Suprainguinal Fascia Iliaca block was given and other 30 patients were used as control group in the post operative period and duration of analgesia was assessed by numeric rating scale (NRS) and visual analogue scores ( VAS ) Results: In our study of 90 patients posted for hip surgeries, PENG block showed better results in terms of reduction in pain scores, time of first analgesia requirement and quantity of rescue analgesics used in the post operative period. Conclusion: The newer PENG block is better than Fascia Iliaca block in hip surgeries in delaying post opioid consumption, its associated side effects and delirium especially in geriatric patients.