Continuous epicapsular ropivacaine 0.3% infusion after minimally invasive hip arthroplasty: a prospective, randomized, double-blinded, placebo-controlled study comparing continuous wound infusion with morphine patient-controlled analgesia.

BACKGROUND: In this study, we investigated the impact of a continuous wound infusion with ropivacaine 0.3% on pain and morphine consumption after minimally invasive hip arthroplasty. METHODS: Seventy-six consecutive patients scheduled for elective minimally invasive hip replacement using spinal anesthesia were prospectively included in this double-blind study. Epicapsular placement of a 15-cm fenestrated catheter was performed by the surgeon. Patients were randomized to receive either 20 mL ropivacaine 0.3% (R-group) or 20 mL NaCl 0.9% (P-group) applied into the wound as a bolus before wound closure. A continuous infusion of either ropivacaine 0.3% or placebo was then infused at 8 mL/h for 48 hours after surgery with an elastomeric pump. Morphine IV-patient-controlled analgesia was offered to all patients. Morphine consumption, pain at rest and with motion, and total and unbound ropivacaine plasma concentration were recorded during the 48-hour study period. Postoperative follow-up was performed at 3 months. RESULTS: Demographic and surgical data were similar in both groups. Mean morphine consumption was significantly lower in the R-group than in the P-group during the first 48 postoperative hours: 45.4 ± 9.5 vs 69.7 ± 9.6 (P < 0.0001). There was a mean reduction of 14.4 mg for the first 24 postoperative hours (95% confidence interval [CI] 12.6 to 16.1) and 20.8 mg for the next 24 hours (95% CI 19.1 to 22.4). Pain scores at rest and with motion were lower in the R-group (P < 0.0001). Mean patient satisfaction increased 22.7% from baseline (CI 95% 15.9 to 29.6) in the R-group. Total and unbound ropivacaine plasma concentrations were below toxic levels in the R-group. The free ropivacaine concentration was 0.14 and 0.11 µgmol/L at T(24) and T(48), respectively, in the R-group. At 3 months postoperatively, hip pain and analgesic consumption were similar, but a significant reduction in wound discomfort to touch (31.2; 95% CI 27.7 to 34.7) and pressure (24; 95% CI 20.1 to 27.9) was observed in the R-group (P < 0.0001). CONCLUSIONS: Continuous epicapsular wound infusion with ropivacaine 0.3% after minimally invasive hip replacement is an efficient technique for reducing morphine consumption and improving the quality of postoperative analgesia. The beneficial effects of this technique are still present 3 months after surgery.

Interscalene brachial plexus anesthesia with ropivacaine 5 mg/mL and bupivacaine 5 mg/mL: effects on electrocardiogram.

BACKGROUND: Cardiotoxicity is the most severe complication of long-acting local anesthetics. The aim of this trial is to compare early signs of depression of cardiac conduction linked with the administration of either ropivacaine or bupivacaine for interscalene block. METHODS: Thirty-two patients (American Society of Anesthesiologists I/II) scheduled for elective shoulder arthroscopy were prospectively enrolled to receive, in a randomized and double-blind fashion, either 40 mL of ropivacaine 5 mg/mL or 40 mL of bupivacaine 5 mg/mL for interscalene block. Holter monitoring was started the night before surgery and continued until the end of the study. Peripheral blood sampling was performed before administration of local anesthetics (= baseline) and 15, 20, 25, 30, 35, 40, 45, 60, and 360 minutes after completion of the interscalene block for measurement of total and unbound concentration of the 2 local anesthetics. Alpha-1-acid-glycoprotein was measured at baseline, t(30), and t(360). RESULTS: All anesthetic blocks in both groups were successful and comparable. Electrocardiographic recordings for QRS, QT, and QTC intervals did not change and were similar in both groups. In the bupivacaine group, significant prolongation of the PQ interval was noted 15 minutes after drug application and remained significantly prolonged until t(60). Total and unbound plasma local-anesthetic concentrations were comparable between both groups at all times. In both groups, local-anesthetic plasma mean levels reached a peak between 30 and 45 minutes after the bolus application. The highest mean plasma levels were 0.103 (+/-0.05) mg/L for unbound ropivacaine and 0.084 (+/-0.03) mg/L for unbound bupivacaine, which occurred in both groups at t(30). CONCLUSIONS: Electrocardiographic recordings were similar in both groups, except for a significant prolongation of the PQ interval in the bupivacaine group at plasma levels below threshold for cardiotoxicity.

Orthopaedic surgery in the elderly.

The orthopaedic surgeon brings to the operating room some of the greatest challenges for the anaesthesiologist. Various factors, such as age, health status, disease process, type and extent of operative procedure, provide differing circumstances, which an anaesthesiologist is obliged to cope with. This contrasts to other surgical specialities in which patient factors and operative procedures are much more predictable. The number of older patients in orthopaedics is steadily growing, and the anaesthesiologist has to take all measures to permit an early and efficient rehabilitation, a concept which is now widely recognized for improving the success of orthopaedic surgical procedures. Factors which may hinder this concept are post-operative pain, central nervous system dysfunction, fatigue, deep sedation, delayed enteral feeding and absorption. There is no evidence that regional anaesthesia without the use of the continuous regional analgesic technique decreases morbidity and mortality as compared to general anaesthesia, in this context. However, the advantages of continuous analgesia through a perineural spinal or epidural catheter are promising and deserve further investigation. The concept of the optimal post-operative multimodal regimen needs to be defined. The application of NSAID and paracetamol is an integral part of this concept, and the dose of opioids should be titrated to the lowest efficient dose needed. Thus, this chapter discusses the different controversies and future trends of anaesthesia with regard to the elderly in orthopaedic surgery.

Brachial plexus block.

PURPOSE OF REVIEW: In recent years there has been a renewed interest in regional anesthesia, particularly peripheral nerve blockade, in order not only to improve the patient's well being, but also to meet the requirements of modern orthopedic surgery. These requirements include appropriate conditions to perform early and efficient rehabilitation. RECENT FINDINGS: The upper extremity is well designed for the practice of the perineural catheter technique, since we have three main approaches, interscalene, infraclavicular and axillary, which allow all territories involved in specific surgical procedures to be blocked with only one shot or catheter. Recent developments have focused on modification of traditional technical approaches, improving the safety of the procedure, finding a more efficient way to administer the local anesthetic through the perineural catheter, and examining new indications and modes of performing regional anesthesia. SUMMARY: Early rehabilitation is currently a key point for the success of orthopedic surgery. The rapid development of peripheral nerve blockade gives the anesthesiologist the means to face this new challenge.

Anaesthesia for shoulder surgery.

Early and efficient rehabilitation is necessary for improving outcome after shoulder surgery. Pain, which is severe to very severe in this condition, is the major factor which compromises early physical therapy. Interscalene block is a well recognized and efficient technique for controlling pain after major open shoulder surgery. Among the different approaches which have been described, the modified lateral technique is the safest to perform and the most suitable for insertion of an interscalene catheter. A number of different techniques have been tried to control pain after shoulder surgery. However, the application of a continuous infusion of local anaesthetics through an interscalene catheter is actually the best technique available to achieve pain relief at rest and on movement after this type of surgery. This chapter emphasizes the advantages of the modified lateral approach, the use of patient-controlled interscalene analgesia and the traps and tricks of the interscalene block. Thus, this chapter demonstrates why interscalene anaesthesia and analgesia are the most appropriate techniques for shoulder surgery.

Projected complex sensations after interscalene brachial plexus block.

IMPLICATIONS: The development of projected complex sensations mimicking phantom pain after interscalene block is reported. The recognition of this entity is important because it may be confused with some other cardiac, esophageal, or visceral pathologies.

Interscalene and infraclavicular block for bilateral distal radius fracture.

UNLABELLED: Brachial plexus blockade is a suitable technique for surgery of the forearm, because it provides good intraoperative anesthesia as well as prolonged postoperative analgesia when long-acting local anesthetics are used. However, simultaneous blockade of both upper extremities has rarely been performed (1), because local anesthetic toxicity caused by the amount of drug needed to achieve an efficient block on both sides may be a problem. We report a case of successful bilateral brachial plexus block with ropivacaine in a patient with bilateral distal radius fracture, with each fracture requiring an open osteosynthesis. IMPLICATIONS: This case report presents the performance of a simultaneous blockade of both upper extremities in a patient who sustained a bilateral distal radius fracture. The patient was known to be difficult to intubate and to have a severe hypersensitivity to opioids.

Evaluation of the lateral modified approach for continuous interscalene block after shoulder surgery.

BACKGROUND: Continuous interscalene block is the technique of choice for postoperative pain relief treatment after shoulder surgery. The authors prospectively evaluated the modified lateral approach for the performance of the interscalene catheter block and monitored 700 patients for clinical efficacy and complications during the first 6 months after placement of the catheter. METHODS: A total of 700 adults scheduled to undergo elective shoulder surgery performed with an interscalene brachial plexus block through an interscalene catheter were included in this study. The interscalene brachial plexus block procedure was standardized for all patients. Difficulties in placement of the catheter, clinical efficacy of anesthesia and analgesia, patient satisfaction, and acute and chronic complications were recorded. Patients were observed daily for 5 days for any complications and were evaluated at 1, 3, and 6 months after surgery. Persistence of neurologic complication was investigated by electroneuromyography. RESULTS: A total of 700 adults completed the study. Easy placement of the catheter (one attempt) was achieved in 86% of the patients. Resistance to thread the catheter was encountered in 6%; no major complications were observed during injection of the initial bolus. The success rate for anesthesia was 97%. Postoperative analgesia was efficient in 99%. The concentration and the rate of infusion of ropivacaine had to be increased in 31 patients (6%). In five patients (0.7%), signs of local infection around the puncture point were noted; in one patient (0.1%), a collection of pus was surgically drained. Patient satisfaction was 9.6 on a scale of 0-10. Minor neurologic complications (paresthesias, dysesthesias, pain not related to surgery) were observed in 2.4%, 0.3%, and 0% at 1, 3, and 6 months, respectively. At 1 month, three sulcus ulnaris syndromes, one carpal tunnel syndrome, and one complex regional pain syndrome were diagnosed. Two patients (0.2%) had sensory-motor deficit, which necessitated 19 and 28 weeks to recover. Electromyography was suggestive of partial axonotmesis. CONCLUSION: The lateral modified approach provides good conditions for placement of the interscalene catheter. Anesthesia and analgesia performed through the catheter are efficient. The rates of infection and neurologic complications are low, and patient satisfaction is high.

Use of a double epidural catheter provides effective postoperative analgesia after spine deformity surgery.

PURPOSE: Spine deformity surgery is a painful procedure in which pain control is difficult to obtain. The aim of this study was to evaluate the efficacy of double epidural catheters in this setting. METHODS: Twenty-three patients scheduled for an elective spine deformity surgery were included prospectively. At the end of surgery, the surgeon inserted two epidural catheters, one cranial, one caudal to the surgical field. In the recovery room the catheters were both injected with a bolus of bupivacaine 0.0625%. In the absence of any neurological abnormality a continuous infusion of bupivacaine 0.0625%, fentanyl 2 microg.mL(-1) and clonidine 3 microg.mL(-1) was administered at a rate of 10 mL.hr(-1) through each catheter for 48 hr. Pain score, sedation level, motor block and side-effects were checked regularly. RESULTS: Complete analgesia (VAS=0) was obtained at rest in all patients. During mobilization and physiotherapy four patients (17%) had a VAS 30. No motor block was observed. Four patients (17%) had nausea and vomiting. No excessive sedation, pruritus or respiratory depression were observed. Early mobilization was possible in all patients. CONCLUSION: Postoperative epidural analgesia by means of a double catheter is an effective technique to control pain after spine deformity surgery and is associated with a low incidence of side-effects.