Functional recovery after knee arthroplasty with regional analgesia: A systematic review and meta-analysis of randomised controlled trials.

BACKGROUND: Regional analgesia (RA) has been widely evaluated for pain relief after total knee arthroplasty (TKA). Its impact on functional recovery is less well known. OBJECTIVES: To evaluate the functional benefits of RA after TKA. DESIGN: Systematic review with a random-effects meta-analysis of randomised controlled trials comparing LRA with systemic analgesia on function in adults undergoing TKA for osteoarthritis. DATABASE SOURCES: MEDLINE, EMBASE, LILAC, Cochrane, CTRD databases. OUTCOMES: Length of stay (LOS) in hospital and early knee flexion range of motion (ROM), early and long-term knee function, serious adverse effects. RESULTS: Twenty-three studies (1246 patients) were included. LOS was significantly shorter for RA than for systemic analgesia (0.90 days, 95% confidence interval 0.3 to 1.4). Subgroup analyses found that only infiltration analgesia decreased the LOS. ROM during the first week was significantly higher for all techniques of RA than for systemic analgesia (9.23°, 95% confidence interval 4.6 to 13.9). No impact of regional analgesia techniques on global function in the longer term was demonstrated. No difference in serious adverse effects was found between RA and systemic analgesia. CONCLUSION: RA techniques compared with systemic analgesia have a beneficial impact on the LOS and the ROM achieved in the early postoperative period. Global function in the longer term after surgery seems unaffected by peri-operative RA. TRIAL REGISTRATION: CRD42014013995.

Effect of early ultrasound-guided femoral nerve block on preoperative opioid consumption in emergency patients with hip fracture: a randomized trial.

BACKGROUND AND IMPORTANCE: Ultrasound-guided femoral nerve block (FNB) could be used as part of a multimodal preoperative pain management for patients with hip fracture. Evidence of the effects of its early implementation in the emergency room as an immediate alternative to intravenous morphine titration is sparse. OBJECTIVE: To investigate the effect of an early ultrasound-guided FNB performed by emergency physicians on preoperative opioid consumption, compared to standard pain management. DESIGN, SETTING, AND PARTICIPANTS: This open randomized controlled trial was conducted in the Emergency Department of a French hospital with patients with neck or trochanteric femoral fracture who had a pain score ≥7 out of 10 points at triage. INTERVENTION: Patients were randomized to receive an initial analgesia with an early ultrasound-guided FNB or with standard pain management. The continuation of pain treatment followed standardized pain control guidelines until hospital discharge in both groups. OUTCOME MEASURE AND ANALYSIS: The primary outcome was preoperative opioid consumption truncated 48h after triage time, and converted in morphine milligram intravenous equivalents (MME). Secondary outcomes were time to pain relief, time for regaining walk, opioid consumption and occurrence of opioid and FNB adverse effects during the hospital stay. Exploratory outcomes included ease and duration of the procedure. MAIN RESULTS: We randomized 35 patients: 17 to standard pain management and 18 to ultrasound-guided FNB, among whom 30 patients completed the protocol. The median of preoperative opioid consumption was reduced by 60% in the ultrasound-guided FNB group compared to standard group [6 MME (3-9) vs. 15 MME (11-18)], with a consumption difference of 9 MME (95% CI: 3-14, P  < 0.001). Throughout hospital stay, opioid consumption was reduced by 56% in the ultrasound-guided FNB group compared to standard group, with a consumption difference of 11.5 MME (95% CI: 0.5-22).Times to pain relief and for regaining walk did not differ between groups. Opioid adverse events occurrence were reduced by 40% (95% CI: 5.1-74.9) in the ultrasound-guided FNB group compared to standard group. No adverse effects of FNB have been detected. CONCLUSION: Early ultrasound-guided FNB resulted in reducing preoperative opioid consumption, without delaying time to pain relief.

Prevalence of hypothermia on admission to recovery room remains high despite a large use of forced-air warming devices: Findings of a non-randomized observational multicenter and pragmatic study on perioperative hypothermia prevalence in France.

BACKGROUND: Despite the availability of effective warming systems, the prevalence of hypothermia remains high in patients undergoing surgery. Occurrence of perioperative hypothermia may influence the rate of postoperative complications. Recommendations for the prevention of inadvertent perioperative hypothermia have been developed and are effective to reduce the frequency of perioperative hypothermia when professionals comply with. French Society of Anesthesiology (SFAR) decided to promote guidelines for the prevention of inadvertent hypothermia, and to conduct beforehand a pragmatic assessment of the prevalence of hypothermia in France. The hypothesis was that the rate of hypothermic patients (Tc<36°C) admitted to the RR remains high (around 50%), and that was the consequence of a warming device underutilization and/or was related to the type of health facilities. METHODS: An observational, prospective and multi-centric study was conducted in France between October 2014 and May 2016 among patients over 45 years undergoing non-cardiac, non-outpatient surgery with anesthesia lasting >30 minutes in 52 centers. Patients undergoing pulmonary or proctologic surgery and those having non-invasive procedures performed under general anesthesia (for example, digestive endoscopy) were excluded from our study. Patients being operated under plexus anesthesia alone, surgeries involving hemorrhaging or infection, and patients presenting at least one organ failure were also excluded. The primary endpoint was the percentage of patients with a core temperature (Tc) <36°C on admission to the recovery room (RR). RESULTS: Among 893 subjects (median age 66.9 years), prevalence of hypothermia on admission to the RR was 53.5%. At least one warming system was used for 90.4% of the patients. Identified risk factors for Tc<36°C included age≥70 years (OR = 1.41 [CI95%: 1.02-1.94]), duration of anesthesia from 1 to 2 hours (OR = 1.94 [CI95%: 1.04-3.64]) and a decrease in Tc of >0.5°C between anesthesia induction and surgical incision (OR = 1.82 [CI95%: 1.15-2.89]). Only a combination of pre-warming and intraoperative warming prevented a Tc<36°C (OR = 0.48 [CI95%: 0.24-0.96]). CONCLUSIONS: The prevalence of hypothermia among patients admitted to the RR remains high. Our results suggest that only the combination of pre-warming and intraoperative warming significantly decreases it.