Michel Fallaha | PubMed Health

PubMed2006

A multimodal analgesia protocol for total knee arthroplasty. A randomized, controlled study.

BACKGROUND: Although numerous methods of postoperative analgesia have been investigated in an attempt to improve pain control after total knee arthroplasty, parenteral narcotics still play a major role in postoperative pain management. Local anesthetics have the advantage of blocking pain conduction at its origin and minimizing the systemic side effects associated with postoperative narcotic use. This study was performed to evaluate the benefits and safety of a multimodal analgesia protocol that included periarticular injection of large doses of local anesthetics in patients undergoing total knee arthroplasty. METHODS: We compared morphine consumption during the first twenty-four hours after unilateral total knee arthroplasty in forty-two patients who had been randomized to receive either (1) a perioperative infiltration mixture, consisting principally of local anesthetic, and self-administered morphine or (2) self-administered morphine only. Narcotics consumption, pain control, medication-related side effects, plasma levels of the local anesthetic (ropivacaine), and postoperative rehabilitation were monitored. RESULTS: Although there was high satisfaction and good pain control in both groups, morphine consumption was significantly lower in the local analgesia group than it was in the control group (28.8 +/- 17.4 mg compared with 50.3 +/- 25.4 mg twenty-four hours after surgery, and 46.7 +/- 19.4 mg compared with 68.6 +/- 38.6 mg forty hours after surgery). Both groups achieved a similar amount of knee flexion on the fifth postoperative day. Over the five-day period after the procedure, the patients in the local analgesia group reported a total of 2.6 +/- 3.9 hours of nausea compared with 7.1 +/- 12.2 hours in the control group. No complications related to the infiltration of the local anesthetic were observed, and all plasma concentrations of the local anesthetic were below the toxic range. CONCLUSIONS: This multimodal perioperative analgesia protocol that included infiltration of a local anesthetic offered improved pain control and minimal side effects to patients undergoing total knee arthroplasty. Our study also confirmed the safety of the protocol.

Analgesia, Patient-Controlled↗

PubMed2004

The posterior lumbar plexus (psoas compartment) block and the three-in-one femoral nerve block provide similar postoperative analgesia after total knee replacement.

PURPOSE: To compare the efficacy of a continuous posterior lumbar plexus (PSOAS) block to a continuous three-in-one femoral nerve (FEM) block in patients undergoing primary total knee replacement (TKR). METHODS: Sixty patients were randomly allocated to receive iv patient-controlled morphine analgesia (PCA), PCA plus a continuous FEM block with 30 mL ropivacaine 0.5% and epinephrine 1:200,000 bolus followed by an infusion of ropivacaine 0.2% at 12 mL.hr(-1) for 48 hr, or PCA plus a continuous PSOAS block with the same bolus and infusion regimen as the FEM group. Postoperative morphine consumption, verbal analogue scale pain scores at rest and during physiotherapy, and evidence of sensory and motor blockades were noted. RESULTS: Both regional techniques significantly reduced 48 hr morphine consumption (FEM 37.3 +/- 34.7 mg, P = 0.0002; PSOAS 36.1 +/- 25.8 mg, P < 0.0001) compared to PCA (72.2 +/- 26.6 mg). Pain scores at rest, six and 24 hr after TKR were lower in the FEM and PSOAS groups compared to the PCA group (P < 0.0001). Although sensory and motor blockades of the obturator nerve were achieved more often in the PSOAS group than in the FEM group (P < 0.0001), morphine consumption and pain scores did not differ between the two groups. CONCLUSION: Both continuous PSOAS block and continuous three-in-one FEM block provided better analgesia than PCA but no differences were seen between the two regional techniques.

Adult↗