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      Comparison of Effectiveness of Ropivacaine Infusion Regimens for Continuous Femoral Nerve Block for Recovery After Total Knee Arthroplasty: A Randomized Double-Blind Trial

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          Abstract

          Purpose

          Continuous femoral nerve block (cFNB) is effective for analgesia after total knee arthroplasty (TKA). However, it is not clear which low-dose regimen of ropivacaine infusion for cFNB provides adequate analgesia and enables rapid recovery. The aim of this study was to compare the effects of different cFNB regimens on rehabilitation of patients after TKA.

          Patients and Methods

          Sixty patients scheduled for TKA were enrolled in this trial. After surgery, patients in the 0.1%, 0.15%, and 0.2% groups received infusion of 10 mL of 0.1%, 6.7 mL of 0.15%, and 5 mL of 0.2% ropivacaine per hour, respectively (n=20), at the dose of 10 mg/h for 48 h. The primary endpoint was time to readiness for discharge. The secondary endpoints were time to first walk, manual muscle testing (MMT) scores, numerical rating scale (NRS) scores at rest and movement, morphine consumption, rescue analgesia, and the incidence of adverse events.

          Results

          The time to readiness for discharge and the time to first walk of the 0.1% group were significantly longer than that of the 0.15% and 0.2% groups. MMT scores of the 0.2% group at 18 h after surgery were significantly lower than those of the 0.1% group. MMT scores of the 0.2% group at 24 and 48 h after surgery were also significantly lower than those of the 0.1% and 0.15% groups. NRS scores at rest and at movement in the 0.1% group were significantly higher than those in the 0.15% and 0.2% groups.

          Conclusion

          Patients administered the regimens of 0.15% and 0.2% ropivacaine infusion for cFNB were ready for discharge earlier than the 0.1% group after TKA, at the dose of 10 mg/h for 48 h. The regimen of 0.15% ropivacaine, which is associated with less quadriceps muscle strength weakness than 0.2%, is recommended for postoperative analgesia after TKA.

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          Most cited references 16

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          Predictors of persistent pain after total knee arthroplasty: a systematic review and meta-analysis.

          Several studies have identified clinical, psychosocial, patient characteristic, and perioperative variables that are associated with persistent postsurgical pain; however, the relative effect of these variables has yet to be quantified. The aim of the study was to provide a systematic review and meta-analysis of predictor variables associated with persistent pain after total knee arthroplasty (TKA).
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            Analgesia and functional outcome after total knee arthroplasty: periarticular infiltration vs continuous femoral nerve block.

            Capacity to ambulate represents an important milestone in the recovery process after total knee arthroplasty (TKA). The purpose of this study was to determine the analgesic effect of two analgesic techniques and their impact on functional walking capacity as a measure of surgical recovery. Forty ASA II-III subjects undergoing TKA were enrolled in a randomized, double-blind, single-centre study receiving 48 h postoperative analgesia with either periarticular infiltration of local anaesthetic (Group I) or continuous femoral nerve block (Group F). Breakthrough pain relief was achieved with patient-controlled analgesia (PCA) morphine. The main outcome was postoperative morphine consumption. Early (postoperative days 1-3) and late (6 weeks) functional walking capacity (2 and 6 min walk tests, 2MWT and 6MWT, respectively), degree of physical activity (CHAMPS), health-related quality of life (SF-12), and clinical indicators of knee function (WOMAC, Knee Society evaluation, and range of motion) were measured. Patients in Group F used the PCA less (P=0.02) to achieve adequate analgesia. Postoperative 2MWT was similar in both groups (P=0.27). Six weeks after surgery, recovery of 6MWT, physical activity, and knee function were significantly improved in Group F (P<0.05). Preoperative walking capacity, physical activity and early total walking time were the independent predictors of early recovery. Distance and time spent walking were the predictors of functional walking exercise capacity at 6 weeks after surgery. Femoral block is associated with lower opioid consumption and a better recovery at 6 weeks than periarticular infiltration. Early postoperative activity measures (2MWT and walking time) were proved to be possible indicators of knee function recovery at 6 weeks after surgery.
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              Ambulatory continuous femoral nerve blocks decrease time to discharge readiness after tricompartment total knee arthroplasty: a randomized, triple-masked, placebo-controlled study.

              The authors tested the hypotheses that, compared with an overnight continuous femoral nerve block (cFNB), a 4-day ambulatory cFNB increases ambulation distance and decreases the time until three specific readiness-for-discharge criteria are met after tricompartment total knee arthroplasty. Preoperatively, all patients received a cFNB (n = 50) and perineural ropivacaine 0.2% from surgery until the following morning, at which time they were randomly assigned to either continue perineural ropivacaine or switch to perineural normal saline. Primary endpoints included (1) time to attain three discharge criteria (adequate analgesia, independence from intravenous analgesics, and ambulation of at least 30 m) and (2) ambulatory distance in 6 min the afternoon after surgery. Patients were discharged with their cFNB and a portable infusion pump, and catheters were removed on postoperative day 4. Patients given 4 days of perineural ropivacaine attained all three discharge criteria in a median (25th-75th percentiles) of 25 (21-47) h, compared with 71 (46-89) h for those of the control group (estimated ratio, 0.47; 95% confidence interval, 0.32-0.67; P <0.001). Patients assigned to receive ropivacaine ambulated a median of 32 (17-47) m the afternoon after surgery, compared with 26 (13-35) m for those receiving normal saline (estimated ratio, 1.21; 95% confidence interval, 0.71-1.85; P = 0.42). Compared with an overnight cFNB, a 4-day ambulatory cFNB decreases the time to reach three important discharge criteria by an estimated 53% after tricompartment total knee arthroplasty. However, the extended infusion did not increase ambulation distance the afternoon after surgery. (ClinicalTrials.gov No. NCT00135889.).
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                Author and article information

                Journal
                J Pain Res
                J Pain Res
                JPR
                jpainres
                Journal of Pain Research
                Dove
                1178-7090
                12 May 2020
                2020
                : 13
                : 997-1005
                Affiliations
                [1 ]Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University , Wenzhou, Zhejiang, People’s Republic of China
                Author notes
                Correspondence: Kejian Shi; Quanguang Wang Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University , Wenzhou, Zhejiang, People’s Republic of ChinaTel +86 13868889697; +86 13736935500Fax +86 57755578999+669697; +86 57755578999+655500 Email wzshikejian@163.com; wangquanguang@163.com
                [*]

                These authors contributed equally to this work

                Article
                247158
                10.2147/JPR.S247158
                7229799
                © 2020 Zhang et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                Page count
                Figures: 4, Tables: 2, References: 20, Pages: 9
                Funding
                This work is supported by the National Natural Science Foundation of China (Grant No. 81900231, Beijing, China), and by Wenzhou Science and Technology Bureau (Y20170645, Wenzhou, China).
                Categories
                Original Research

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