Effects of adding a combined femoral and sciatic nerve block with levobupivacaine and clonidine to general anaesthesia in femoropopliteal bypass surgery: A randomised, double-blind, controlled trial.

BACKGROUND: Adding a regional block to general anaesthesia can prevent postoperative pain and improve peripheral circulation. OBJECTIVE: To seek improved postoperative analgesia and care due to a long-acting combined femoral and sciatic nerve block in patients undergoing femoropopliteal bypass surgery. DESIGN: A randomised, double-blind, controlled trial. SETTING: Vascular surgery unit of a French university hospital. PATIENTS: Forty-four adults scheduled for bypass surgery under general anaesthesia. INTERVENTION: Patients were allocated to receive either an active nerve block with 20 ml of 0.375% levobupivacaine and clonidine 0.5 µg kg, or a simulated (sham) block only, but with local anaesthesia of the skin, before general anaesthesia. General anaesthesia was standardised with propofol, then sevoflurane and sufentanil adjusted according to clinical need. Postoperative analgesia was standardised with paracetamol 1 g every 6 h, and intravenous morphine, initially titrated in the postanaesthesia care unit and then patient-controlled. Oral analgesics were repeated up to day 3. MAIN OUTCOME MEASURES: The primary outcome was morphine consumption during the first 24 postoperative hours. In a subgroup of postoperative patients distal tissue oxygen saturation was recorded at the lateral side of the blocked calf. RESULTS: Patients in the active group received less intra-operative sufentanil (median dose 25 vs. 41 µg), needed less morphine during the first 24 h (15 vs. 27 mg) and 72 (20 vs. 35 mg) postoperative hours, than in the control group. They also had less pain on movement, but pain at rest, the tissue oxygen saturation and other rehabilitation outcomes were unaffected by the treatment. Tolerance outcomes were also similar between groups. CONCLUSION: Combining the two regional blocks improves the quality of postoperative care in this frail population, probably by reducing the amount of peri-operative opioid. TRIAL REGISTRATION: ClinicalTrials.gov (ref. NCT01785693).

Epidural versus continuous preperitoneal analgesia during fast-track open colorectal surgery: a randomized controlled trial.

BACKGROUND: Effective postoperative analgesia is essential for early rehabilitation after surgery. Continuous wound infiltration (CWI) of local anesthetics has been proposed as an alternative to epidural analgesia (EA) during colorectal surgery. This prospective, double-blind trial compared CWI and EA in patients undergoing elective open colorectal surgery. METHODS: Fifty consecutive patients were randomized to receive EA or CWI for 48 h. In both groups, patients were managed according to Enhanced Recovery After Surgery recommendations. The primary outcome was the dynamic pain score measured during mobilization 24 h after surgery (H24) using a 100-mm verbal numerical scale. Secondary outcomes were time to functional recovery, analgesic technique-related side effects, and length of hospital stay. RESULTS: Median postoperative dynamic pain score was lower in the EA than in the CWI group (10 [interquartile range: 1.6-20] vs. 37 [interquartile range: 30-49], P < 0.001) and remained lower until hospital discharge. The median times to return of gut function and tolerance of a normal, complete diet were shorter in the EA than in the CWI group (P < 0.01 each). Sleep quality was also better in the EA group, but there was no difference in urinary retention rate (P = 0.57). The median length of stay was lower in the EA than in the CWI group (4 [interquartile range: 3.4-5.3] days vs. 5.5 [interquartile range: 4.5-7] days; P = 0.006). CONCLUSION: Within an Enhanced Recovery After Surgery program, EA provided quicker functional recovery than CWI and reduced length of hospital stay after open colorectal surgery.