Opioid-free versus opioid-sparing anaesthesia in ambulatory total hip arthroplasty: a randomised controlled trial.

BACKGROUND: Enhanced recovery after surgery pathways are essential for ambulatory surgery. They usually recommend lower intraoperative opioid use to avoid opioid-related adverse effects. This has led to opioid-sparing anaesthesia (OSA) techniques, with the extreme approach of opioid-free anaesthesia (OFA) mostly with dexmedetomidine. As evidence is lacking in day-case primary total hip arthroplasty, this study was performed to assess the potential benefits in postoperative analgesia of OFA over OSA. METHODS: In this single-centre, prospective, triple blind study, we randomly allocated 80 patients undergoing day-case primary THA under general anaesthesia. Patients received a total intravenous anaesthesia with a laryngeal mask and multimodal analgesic regimen with non-opioid analgesics. The OSA group received low dose of sufentanil, and the OFA group received dexmedetomidine The primary outcome was the opioid consumption in the first 24 h in oral morphine equivalents (OME). RESULTS: There was no difference in median cumulative OME consumption at 24 h between the OSA and OFA groups (12 [0-25] mg vs 16 [0-30] mg, respectively; P=0.7). Pain scores were similar and low in both groups with comparable walking recovery time. Adverse events were sparse and equivalent in both groups except for dizziness, which was more frequent in the OSA group (P<0.05). CONCLUSIONS: In day-case total hip arthoplasty under general anaesthesia, opioid-free anaesthesia and opioid-sparing anaesthesia both provide early recovery and effective postoperative pain relief. When compared with opioid-sparing anaesthesia, opioid-free anaesthesia does not decrease opioid consumption in the first 24 h. These findings do not suggest any significant benefit from complete intraoperative avoidance of opioids. CLINICAL TRIAL REGISTRATION: NCT0507270.

Combined proximal or distal nerve blocks for postoperative analgesia after total knee arthroplasty: a randomised controlled trial.

BACKGROUND: Many regional anaesthetic techniques have been proposed to manage pain after total knee arthroplasty, but the best approach is unclear. We compared opioid consumption in the first 48 h between two different regional anaesthesia strategies in patients undergoing total knee arthroplasty. METHODS: In this single-centre, prospective study, we randomly allocated 90 patients to a combination of IPACK (interspace between popliteal artery and capsule of the posterior knee), triangle femoral and obturator nerve blocks (distal group), or a combination of sciatic, femoral, obturator, and lateral femoral cutaneous nerve blocks (proximal group). All patients received an opioid-sparing general anaesthesia regimen. The primary outcome was opioid consumption in the first 48 h. Secondary outcomes included opioid consumption in the first 24 h and verbal rating pain scores in the first 48 h. RESULTS: There was no difference in median cumulative oral morphine equivalent consumption at 48 h between the distal and the proximal block groups (33 [18-78] mg vs 30 [22-51] mg, respectively; P=0.29). Median oral morphine equivalent consumption at 24 h was higher in the distal group compared with the proximal group (30 [13-59] vs 15 [0-18], respectively; P<0.001). Verbal rating pain scores were lower in the proximal group compared with the distal group on arrival to the postanaesthesia care unit and at 6 and 12 h. CONCLUSIONS: In patients undergoing total knee arthroplasty under total intravenous general anaesthesia with a multimodal analgesia regimen, proximal nerve blocks resulted in improved pain scores in the first 12 h and reduced opioid consumption in the first 24 h when compared with distal nerve blocks. No difference in pain scores or opioid consumption was seen at 48 h. CLINICAL TRIAL REGISTRATION: NCT04499716.

Obturator nerve block does not provide analgesic benefits in total hip arthroplasty under multimodal analgesic regimen: a randomized controlled trial.

BACKGROUND AND OBJECTIVES: Although regional analgesia is considered an important component of optimal pain management, use of peripheral nerve blocks for total hip arthroplasty remains controversial. Since the obturator nerve innervates the anteromedial part of the joint capsule, we hypothesized that an obturator nerve block would decrease the opioid consumption after total hip arthroplasty. METHODS: In this single center, prospective, triple blinded study, we randomly allocated 60 patients undergoing total hip arthroplasty under opioid-sparing total intravenous general anesthesia to a preoperative obturator nerve block or a sham block (placebo group) using 20 mL of ropivacaine 0.2% or saline, respectively. All patients received a multimodal analgesic regimen with non-opioid analgesics including periarticular local infiltration analgesia. The primary outcome was the intravenous opioid consumption in the post-anesthesia care unit. RESULTS: Median (IQR) intravenous oxycodone consumption in the post-anesthesia care unit was 4 (2, 7.5) mg in the obturator nerve block group and 3 (0, 4) mg in the placebo group (p=0.05). There were no differences in pain scores between groups in the first 24 hours except at arrival on the surgical ward with significant higher pain scores in the placebo group (p=0.03). The ability to stand up and walk within 24 hours was comparable between groups as was the time to first walk (180 (90, 720) vs 240 (120, 780) min for the obturator nerve block and placebo groups, respectively; p=0.62). CONCLUSIONS: Obturator nerve block did not improve postoperative opioid consumption after total hip arthroplasty performed under general anesthesia with a multimodal analgesic regimen. TRIAL REGISTRATION NUMBER: NCT04085640.

Total knee arthroplasty under quadruple nerve block with ropivacaine 0.32%: effect of addition of intravenous dexmedetomidine to intravenous dexamethasone on analgesic duration.

BACKGROUND AND OBJECTIVES: Peripheral nerve blocks reduce postoperative pain and enhance recovery after total knee arthroplasty (TKA). This study aims to assess the benefits of addition of intravenous dexmedetomidine (DexM) to intravenous dexamethasone on the analgesic duration of quadruple nerve blocks. METHODS: This double-blind, randomized, controlled trial prospectively enrolled 90 patients scheduled for TKA under quadruple nerve blocks (sciatic, femoral, obturator, and lateral femoral cutaneous nerves blocks) with 70 mL, 0.32% ropivacaine. All patients received systemic dexamethasone 10 mg. Patients were randomized to receive DexM (2 µg/kg, intravenous) or placebo (1:1 ratio). The primary endpoint was the duration of analgesia defined as the time to first request for rescue analgesia (oxycodone). RESULTS: Kaplan-Meier curves for the first analgesic request were similar between groups (log-rank test; p=0.27). Median (IQR) duration of analgesia was similar between placebo (1575 min (1211-1952)) and DexM (1470 min (1263-1700)) groups (p=0.56). Cumulative consumption of oxycodone at the 48th hour was 20 mg (10-30) and 30 mg (20-40) in placebo and DexM groups, respectively (p=0.14). The day after surgery, 93% and 89% of patients were able to walk in placebo and DexM groups, respectively (p=0.46). Intravenous DexM was associated with bradycardia, hypotension and longer recovery room stay (p<0.05 for all comparisons). CONCLUSIONS: In a multimodal analgesic regimen, addition of systemic DexM (2 µg/kg) to systemic dexamethasone does not prolong the analgesic duration of quadruple nerve block with ropivacaine 0.32% after TKA. TRIAL REGISTRATION NUMBER: NCT03834129.

Perineural Versus Systemic Dexamethasone in Front-Foot Surgery Under Ankle Block: A Randomized Double-Blind Study.

BACKGROUND AND OBJECTIVES: Among the different adjuvants, dexamethasone is one of the most accepted to prolong the effect of local anesthetics. This study aims to determine the superiority of perineural over systemic dexamethasone administration after a single-shot ankle block in metatarsal osteotomy. METHODS: We performed a prospective, double-blind, randomized study. A total of 100 patients presenting for metatarsal osteotomy with an ankle block were randomized into 2 groups: 30 mL ropivacaine 0.375% + perineural dexamethasone 4 mg (1 mL) + 2.5 mL of systemic saline solution (PNDex group, n = 50) and 30 mL ropivacaine 0.375% + 1 mL of perineural saline solution + intravenous dexamethasone 10 mg (2.5 mL) (IVDex group, n = 50). The primary end point was the duration of analgesia defined as the time between the performance of the ankle block and the first administration of rescue analgesia with tramadol. RESULTS: Time period to first rescue analgesia with tramadol was similar in the IVDex group and the PNDex group. Data are expressed as mean (SD) or median (range). Duration of analgesia was 23.2 (9.5) hours in the IVDex group and 19 (8.2) hours in the PNDex group (P = 0.4). Consumption of tramadol during the first 48 hours was 0 mg (0-150 mg) in the IVDex group versus 0 mg (0-250 mg) in the PNDex group (P = 0.59). Four (8%) and 12 (24%) patients reported nausea or vomiting in the IVDex group and the PNDex group, respectively (P = 0.03). CONCLUSIONS: In front-foot surgery, perineural and systemic administrations of dexamethasone are equivalent for postoperative pain relief when used as an adjuvant to ropivacaine ankle block. CLINICAL TRIAL REGISTRATION: This study was registered at ClinicalTrials.gov, identifier NCT02904538.

The paramedian technique: a superior initial approach to continuous spinal anesthesia in the elderly.

BACKGROUND: Spinal anesthesia in elderly patients is frequently associated with significant technical difficulties. Thus, we compared the classical midline approach to the paramedian approach to perform continuous spinal anesthesia (CSA). METHODS: We prospectively studied 40 patients aged >75 yr who underwent open surgical repair of a hip fracture. These patients were randomly allocated to one of two groups: Group M: midline approach, and Group PM: paramedian approach. Patients were positioned in the lateral decubitus to receive CSA at L4-5 level. CSA was considered successful if cerebrospinal fluid was obtained through the needle. In case of initial failure in either approach, the same approach was repeated by the same operator. If two attempts were unsuccessful, the other anatomical approach was used by the same operator. If both approaches failed, a staff anesthesiologist performed a final attempt. In case of failure or insufficient block, the patient received general anesthesia. RESULTS: The success rate after the first attempt was 85% (17) for Group PM and 45% (9) for Group M (P = 0.02). All catheters were successfully introduced. No patient required general anesthesia. Vascular puncture after needle puncture was observed in six patients in Group M versus 0 in Group PM (P = 0.03), but none were of clinical consequence. No other clinically significant complications were observed. CONCLUSION: In summary, after the initial attempt, the paramedian approach is associated with an increased success rate, compared with the midline approach, during the performance of CSA in elderly patients.

Eutectic mixture of local anesthetic (EMLA) decreases pain during humeral block placement in nonsedated patients.

BACKGROUND: We evaluated the potential role of an euctectic mixture of local anesthetic (EMLA) cream application before performing midhumeral block. METHODS: Sixty patients undergoing surgery distal to the elbow amenable to a humeral block were prospectively recruited for the study. The patients were randomly allocated to 1 of 3 groups: Group E: topical EMLA cream 60 min before block plus 2 mL IV normal saline 5 min before procedure; Group P: topical sham cream plus 2 mL IV normal saline, and Group S: topical sham cream plus 0.1 microg/kg of sufentanil in 2 mL solution IV. Pain experienced during skin puncture, and overall pain for the whole procedure were rated using a 100-mm visual analog scale (0: no pain to 100: worst pain). RESULTS: Patients in Group E experienced less pain compared with those in Groups P and S (5 +/- 3 mm vs 33 +/- 20 mm and 30 +/- 18 mm, respectively, P < 0.0001). The pain experienced throughout the complete humeral block was more substantial in Group P than in Group E (P = 0.01). CONCLUSION: The patients who received EMLA cream had less pain with needle puncture as well as throughout the performance of humeral block.

The optimal motor response for infraclavicular brachial plexus block.

BACKGROUND: In this prospective study we compared the success of the infraclavicular brachial plexus block using double-stimulation in regard to the second nerve response elicited with neurostimulation. METHODS: Six-hundred-twenty-eight patients undergoing emergency upper limb surgery using infraclavicular brachial plexus block were included in this study. The musculocutaneous nerve was initially blocked and the groups were then evaluated according to the second nerve located, which was radial in 54%, median in 35%, and ulnar in 11% of patients. Blocks were performed using lidocaine 1.5% with 1/400,000 epinephrine 40 mL in all cases. The block was assessed every 5 min for 30 min after completion of the block. RESULTS: The success rate was 96% for the radial response group, 89% for the median response group, and 90% for the ulnar response group (P < 0.05). Time to perform the block and the onset time were not significantly different among groups. No serious complications were observed. CONCLUSION: We conclude that having initially located and blocked the musculocutaneous nerve, subsequent injection on a radial response resulted in a slightly more reliable success rate than injection with an ulnar or median response.

Infraclavicular brachial plexus block versus humeral block in trauma patients: a comparison of patient comfort.

In this prospective randomized study, we compared humeral block (HB) and infraclavicular brachial plexus block (ICB) with pain caused by the block as a primary outcome, assuming that ICB would cause less pain than HB. Patients undergoing emergency upper limb surgery were included in this study and received either ICB (group I, n = 52 patients) or HB (group H, n = 52 patients). Patients were asked to quantify the severity of the pain during the procedure using a visual analog scale from 0 to 100 mm and to identify which of the 4 components of the procedure was most unpleasant (skin transfixion, needle redirection in search of the nerves, local anesthetic injections, or electrical stimulation). The block was assessed every 5 min for 30 min after completion of the block. Overall visual analog scale scores for the block were 35 +/- 27 mm in group H versus 19 +/- 18 mm in group I (P < 0.0011). Electrical stimulation was the most unpleasant part of the block (group H, 29 +/- 15 mm versus group I, 15 +/- 10 mm) (P < 0.019). Time to perform the block was significantly shorter in group I (ICB, 6 +/- 4 min versus HB, 10 +/- 4 min; P < 0.0001). The onset time was 13 +/- 7 min for ICB and 9 +/- 3 min for HB (P < 0.05). No serious complications were observed. In summary, ICB is less painful, compared with HB, with a similar success rate.

Spinal anesthesia using single injection small-dose bupivacaine versus continuous catheter injection techniques for surgical repair of hip fracture in elderly patients.

Aging and disease may make elderly patients particularly susceptible to hypotension during spinal anesthesia. We compared the hemodynamic effect of continuous spinal anesthesia (CSA) and small dose single injection spinal anesthesia (SA) regarding the incidence of hypotension. Seventy-four patients aged >75 yr undergoing surgical repair of hip fracture were randomized into 2 groups of 37 patients each. Group CSA received a continuous spinal anesthetic with a titration of 2.5 mg boluses every 15 min of isobaric bupivacaine, while group SA received a single injection spinal anesthetic with 7.5 mg of isobaric bupivacaine. The overall variations in noninvasive automated arterial blood pressure were not statistically significantly different in the 2 groups at baseline and after CSA or SA (not significant). In the SA group, 68% of patients experienced at least one episode of hypotension (decrease in systolic arterial blood pressure greater than 20% of baseline value) versus 31% of patients in the CSA group (P = 0.005). In the SA group, 51% of patients experienced at least one episode of severe hypotension (decrease in systolic arterial blood pressure more than 30% of baseline value) versus 8% of patients in the CSA group (P < 0.0001). In the CSA group, 4.5 +/- 2 mg of ephedrine was injected versus 11 +/- 2 mg in the SA group (P = 0.005). In the CSA group, 5 mg (2.5-10) of anesthetic solution was required versus 7.5 mg in the SA group (P < 0.0001). We conclude that, in elderly patients undergoing hip fracture repair, CSA provides fewer episodes of hypotension and severe hypotension compared with a single intrathecal injection of 7.5 mg bupivacaine.

[Propofol to facilitate spinal anesthesia in the lateral position in patients with femoral neck fracture]. / Le propofol pour réaliser une rachianesthésie en position latérale chez les victimes d'une fracture du fémur.

PURPOSE: The aim of this study was to assess the feasibility and efficacy of propofol before positioning elderly patients with a femoral neck fracture in the lateral decubitus position, to perform a spinal anesthetic. METHODS: In this prospective and descriptive study, 79 consecutive patients, > 75 yr old, with a femoral neck fracture were included. Propofol, 0.5 mg x kg(-1), was administered. If loss of consciousness was not obtained (Ramsay score < or = 3/6), then additional doses of 0.25 mg x kg(-1) were given until a Ramsay score of 4 or 5 was attained. Then, the patient was turned to the lateral decubitus position, the fractured side up. The efficacy of propofol was assessed by observing a grimace during positioning and asking the patients if they had recall of pain. Hemodynamic data and oxygen saturation were collected. RESULTS: Forty-three patients required a single injection, 34 required two injections and only two patients required three injections. No grimace and no recall of pain were recorded during the study. There was no desaturation (SpO(2) < 92 %), and hypotension, defined as a systolic blood pressure decrease > 30% from baseline, was observed. CONCLUSION: Propofol is a simple and efficacious means of providing comfort while positioning elderly patients with a femoral head fracture before performing spinal anesthesia.

Resident versus staff anesthesiologist performance: coracoid approach to infraclavicular brachial plexus blocks using a double-stimulation technique.

OBJECTIVES: Infraclavicular brachial plexus block with double stimulation (ICB) is a safe technique for upper-limb anesthesia. However, the experience of learning this technique by anesthesiology residents has not been reported. The aim of this study was to compare staff with resident anesthesiologists in the performance of ICB. METHODS: Patients scheduled for orthopedic surgery of the upper limb were included in a prospective, comparative, randomized study and were given ICB by either staff anesthesiologist (Group S, n = 110 patients) or resident anesthesiologist (Group R, n = 110 patients). RESULTS: Time to perform the block was 3.9 minutes (95% confidence interval [CI 95%] = 3.5 to 4.3) for Group S and 5.8 minutes (CI 95% = 5.2 to 6.4) for Group R (P < .05). The onset time was 14.4 minutes (CI 95% = 13.5 to 15.3) for Group S and 15.9 minutes (CI 95% = 14.7 to 17.1) for Group R (P = NS). Success rate was 93% for Group S and 90% for Group R (P = NS). Supplementation was performed in 8 patients in Group S versus 11 patients in Group R (P = NS). No patient needed general anesthesia. One self-limited vascular puncture was made in Group S versus 3 in Group R (P = NS). CONCLUSION: This report determines whether residents can perform this technique with comparable efficiency compared with staff. We conclude that ICB should be taught as part of all resident training programs.

The relationship between bispectral index and endtidal concentration of sevoflurane during anesthesia and recovery in spontaneously ventilating children.

BACKGROUND: Global inverse correlation between BIS (bispectral index) and depth of anesthesia using sevoflurane has been documented in children in several studies under experimental conditions and in steady-state conditions during mechanically controlled ventilation. Because sevoflurane mask anesthesia combined with a peripheral nerve block is widely used in children, we studied the relationship between BIS and endtidal concentration of sevoflurane (PE(sevo)) under these conditions during surgery and emergence. METHODS: In this prospective blinded study of 32 children, the relationship between BIS and PE(sevo) was studied during sevoflurane anesthesia via facemask combined with peripheral nerve block. The intraoperative phase was studied during steady-state conditions (fixed PE(sevo)) and the emergence phase was studied during fast alveolar washout (FAW). BIS and PE(sevo) data fitted using the E(max) model. Coefficients of variation of BIS and PE(sevo) during the two periods were compared. RESULTS: Fit was adequate with the simple E(max) model. Intraoperative variation in BIS was large (28.4%), and larger than at awakening (28.4% vs 8%). At awakening, BIS varied less than PE(sevo) (8% vs 28.5%). No difference was found between children younger and those older than 5 years. CONCLUSIONS: Caution is required for intraoperative titration based on BIS when spontaneous ventilation is maintained because of the wide variability compared with PE(sevo). During emergence using FAW, BIS varied significantly less than PE(sevo), but the clinical relevance of this point could be discussed during anesthesia without tracheal intubation.

[Epidural hematoma after hemorrhagic shock in a parturient]. / Hématome péridural chez une parturiente au décours d'un choc hémorragique.

PURPOSE: Epidural hematoma is a rare but serious complication of epidural anesthesia. We report a case of epidural hematoma, occurring in an obstetric patient after the epidural catheter had been withdrawn accidentally after an episode of hemorrhagic shock leading to a hypocoagulable state. CLINICAL FEATURES: A patient had the epidural catheter inserted during labour when coagulation was normal. She had a postpartum hemorrhage with alteration of coagulation (platelets 16 x 10(-9) x L(-1), thrombin time: 85 sec. Vital signs returned to normal after a general anesthetic, transfusion of blood products, volume repletion and ligation of hypogastric arteries. It was then noticed that the epidural catheter had been withdrawn inadvertently while the patient was hypocoagulable. The patient then developed neurological signs consistent with spinal cord compression due to an epidural hematoma. A hematoma extending from T3 to L5 was diagnosed by magnetic resonance imaging. Because the cord had minimal compression, no specific action was undertaken, other than clinical and radiological follow-up. There were no long-term sequelae. CONCLUSION: In the presence of an epidural hematoma, surgery for emergency cord decompression is usually required. Another option that receives increasing attention is to monitor neurological function, but the indications for this expectant treatment are not well defined.

[Neurostimulation does not increase the success rate of saphenous nerve blocks]. / La neurostimulation n'augmente pas le taux de succes du bloc du nerf saphene.

PURPOSE: To evaluate neurostimulation of motor components of the vastus medialis muscle and the rectus femoris muscle, with a view to blocking the medial sensory fibres of the saphenous nerve. METHOD: First we dissected four femoral trigones, in order to select our puncture point. We were able to observe that, at the flexion crease of the thigh, the different fibers that make up the femoral nerve were clustered together and the saphenous nerve and the vastus medialis nerve had not yet separated from the femoral stem. Secondly, we conducted a prospective clinical study among 71 patients who had undergone surgery on the lower third of the leg with a sciatic block and a saphenous nerve block. The saphenous nerve block was performed using 10 mL of local anesthetic, by puncturing the flexion crease of the thigh in a bid to obtain one of two muscle responses: medial (contraction of the vastus medialis muscle) or anterior (contraction of the rectus femoris muscle and elevation of the patella). RESULTS: There was an overall success rate of 80% with the saphenous nerve block, with no statistical difference existing between the two response types. Average duration for the block to be completed was two minutes and it took an average of 15 min before the anesthesia took effect. No complications were encountered, apart from a puncture of the femoral artery, which was clinically inconsequential. CONCLUSION: Neurostimulation of the vastus medialis muscle has the same effect as neurostimulation of the rectus femoris muscle with respect to anesthesia of the saphenous nerve. Neurostimulation of the medial compartment of the femoral nerve saves local anesthetic, compared to a standard femoral block.

A modified coracoid approach to infraclavicular brachial plexus blocks using a double-stimulation technique in 300 patients.

Infraclavicular brachial plexus block is used less than other techniques of regional anesthesia for upper-limb surgery. We describe a modified coracoid approach to the infraclavicular brachial plexus using a double-stimulation technique and assess its efficacy. Patients undergoing orthopedic surgery of the upper limb were included in this prospective study. The landmarks used were the coracoid process and the clavicle. The needle was inserted in the direction of the top of the axillary fossa (in relation to the axillary artery), with an angle of 45 degrees. Using nerve stimulation, the musculocutaneous nerve was identified first and blocked with 10 mL of 1.5% lidocaine with 1:400,000 epinephrine. The needle was then withdrawn and redirected posteriorly and medially. The radial, ulnar, or median nerve was then blocked. The block was tested every 5 min for 30 min. The overall success rate, i.e., adequate sensory block in the 4 major nerve distributions at 30 min, was 92%, and 6% of the patients required supplementation. Five patients required general anesthesia. No major complications were observed. This modified infraclavicular brachial plexus block using a double-stimulation technique was easy to perform, had frequent success, and was safe in this cohort.