Single-injection or Continuous Femoral Nerve Block for Total Knee Arthroplasty?
Single-injection or Continuous Femoral Nerve Block for Total Knee Arthroplasty?
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DOI：
10.1007/s11999-013-3192-3
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发表时间：
2014-05-01
影响因子：
4.2
通讯作者：
Brull, Richard
中科院分区：
文献类型：
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作者：
Albrecht, Eric;Morfey, Dorothea;Brull, Richard
全膝关节置换术后股神经阻滞的理想局麻方案是在镇痛和活动度之间取得平衡，目前还没有明确的方案，我们比较了两种固定剂量的罗哌卡因用于全膝关节置换术后股神经阻滞和单次注射罗哌卡因股神经阻滞的剂量和浓度，以确定（1）出院准备时间，（2）早期疼痛评分和镇痛药消耗量，（3）术后镇痛时间。以及（3）功能结果，包括恢复时的活动范围和WOMAC评分。99名患者被分配到三个连续股神经阻滞组中的一个，用于该随机、安慰剂对照、双盲试验：高浓度组2%输注）、低浓度组（0.1%输注）或安慰剂输注组（0.9%输注盐水）。在术后第2天（POD）停止输注。主要结局是出院准备时间。次要结局包括阿片类药物消耗、疼痛和功能结局。93名患者完成了研究方案;由于主办机构对疼痛方案的意外改变，研究提前停止，此时仅招募了所需患者数量的61%。（高浓度组，62小时[95%置信区间[CI]，51-72小时];低浓度组，73小时[95% CI，63-83小时];安慰剂输注组，65小时[95% CI，56-75小时]; p = 0.27）。低浓度组患者在输注期间的吗啡消耗量明显减少（POD 1，高浓度组，56 mg [95% CI，42-70 mg];低浓度组，35 mg [95% CI，27-43 mg];安慰剂输注组，48 mg [95% CI，38-59 mg]，p = 0.02; POD 2，高浓度组，50 mg [95% CI，41-60 mg];低浓度组，33 mg [95% CI，24-42 mg];安慰剂输注组，39 mg [95% CI，30-48 mg]，p = 0.04）;然而，在疼痛评分或阿片类药物相关副作用方面，现有数据没有重大差异。同样，两组之间的功能结局也没有重要差异，基于这项研究，在达到所需样本量之前提前终止，我们无法证明，与TKA后传统的单次注射股神经阻滞相比，连续股神经阻滞中固定剂量罗哌卡因输注的浓度和体积的变化会影响出院准备时间。低浓度罗哌卡因输注可以减少术后阿片类药物的消耗，但在疼痛评分、副作用或功能结局方面没有任何重要差异。这些初步数据可用于为未来的随机试验提供统计学把握度信息。II级，治疗性研究。有关证据等级的完整描述，请参见作者指南。
The ideal local anesthetic regime for femoral nerve block that balances analgesia with mobility after total knee arthroplasty (TKA) remains undefined.We compared two volumes and concentrations of a fixed dose of ropivacaine for continuous femoral nerve block after TKA to a single injection femoral nerve block with ropivacaine to determine (1) time to discharge readiness; (2) early pain scores and analgesic consumption; and (3) functional outcomes, including range of motion and WOMAC scores at the time of recovery.Ninety-nine patients were allocated to one of three continuous femoral nerve block groups for this randomized, placebo-controlled, double-blind trial: a high concentration group (ropivacaine 0.2% infusion), a low concentration group (ropivacaine 0.1% infusion), or a placebo infusion group (saline 0.9% infusion). Infusions were discontinued on postoperative Day (POD) 2. The primary outcome was time to discharge readiness. Secondary outcomes included opioid consumption, pain, and functional outcomes. Ninety-three patients completed the study protocol; the study was halted early because of unanticipated changes to pain protocols at the host institution, by which time only 61% of the required number of patients had been enrolled.With the numbers available, the mean time to discharge readiness was not different between groups (high concentration group, 62 hours [95% confidence interval [CI], 51-72 hours]; low concentration group, 73 hours [95% CI, 63-83 hours]; placebo infusion group 65 hours [95% CI, 56-75 hours]; p = 0.27). Patients in the low concentration group consumed significantly less morphine during the period of infusion (POD 1, high concentration group, 56 mg [95% CI, 42-70 mg]; low concentration group, 35 mg [95% CI, 27-43 mg]; placebo infusion group, 48 mg [95% CI, 38-59 mg], p = 0.02; POD 2, high concentration group, 50 mg [95% CI, 41-60 mg]; low concentration group, 33 mg [95% CI, 24-42 mg]; placebo infusion group, 39 mg [95% CI, 30-48 mg], p = 0.04); however, there were no important differences in pain scores or opioid-related side effects with the numbers available. Likewise, there were no important differences in functional outcomes between groups.Based on this study, which was terminated prematurely before the desired sample size could be achieved, we were unable to demonstrate that varying the concentration and volume of a fixed-dose ropivacaine infusion for continuous femoral nerve block influences time to discharge readiness when compared with a conventional single-injection femoral nerve block after TKA. A low concentration of ropivacaine infusion can reduce postoperative opioid consumption but without any important differences in pain scores, side effects, or functional outcomes. These pilot data may be used to inform the statistical power of future randomized trials.Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.