A Comparison of Epidural Analgesia With Combined Continuous Femoral-Sciatic Nerve Blocks After Total Knee Replacement

Abstract

Epidural analgesia remains the "gold standard" of pain relief after total knee replacement. However, peripheral nerve block is gaining popularity because the incidence of side effects may be reduced. Our study tests this postulate. Sixty patients were prospectively randomized to receive either epidural infusion or combined continuous femoral and sciatic nerve blocks. Ropivacaine 2 mg/mL plus sufentanil 1 mug/mL was given either epidurally or through the femoral nerve catheter, and ropivacaine 0.5 mg/mL was given through the sciatic nerve catheter using elastomeric infusers (delivering 5 mL/h for 55 h). The primary outcome measure was the total incidence of side effects (urinary retention and moderate to severe degrees of dizziness, pruritus, sedation, and nausea/vomiting on the first postoperative day). Intensity of motor blockade, pain at rest and on mobilization, and rehabilitation indices were also registered for 72 h. One or more side effects were present in 87% of patients in the epidural group whereas only 35% of patients in the femoral and sciatic block groups were affected on the first postoperative day (P = 0.0002). Motor blockade was more intense in the operated limb on the day of surgery and the first postoperative day in the peripheral nerve block group (P = 0.001), whereas the non-operated limb was more blocked in the epidural group on the day of surgery (P = 0.0003). Pain on mobilization was well controlled in both groups and there were no differences in the length of hospital stay. Rehabilitation indices were similar. The results demonstrate a reduced incidence of side effects in the femoral/sciatic nerve block group than in the epidural group on the first postoperative day.

Lateralizing Epidural Catheter Placement as Evidenced by Electrical Stimulation

“…Typically, epidural catheters are placed using the midline approach, wherein there is no control over catheter placement [2]. Catheters are likely to lie in the contralateral epidural space contributing to ineffective analgesia and side effects, including contralateral leg numbness and weakness [10,13]. This study suggests that epidural analgesia could be improved by using the paramedian approach to selectively administer postoperative epidural analgesia, thereby reducing the likelihood of side effects and optimizing local anesthetic/pain control delivery.…”

“…At one time, epidural analgesia had been considered the gold standard for postoperative analgesia, but its use has dwindled for a number of reasons, including a high rate of unreliability [8] and side effects [7,10,13]. Typically, epidural catheters are placed using the midline approach, wherein there is no control over catheter placement [2].…”

Use of a Single Injection Femoral Nerve Block in the Patients of Total Knee Replacement with Concomitant Epidural Analgesia

“…Several analgesic regimens express post operative pain relief concerns for the patients ho undergo TKR surgeries [7]. The epidural analgesia is shared with other parenteral methods which are customarily used.…”

Ūmaus Skausmo Malšinimas Po Totalinės Kelio Sąnario Artroplastikos: Epidurinė Analgezija Ar Nervų Blokada?

“…Kadangi ankstesnė studija [12] jau yra įrodžiusi, kad paciento kontroliuojama analgezija (PKA) yra mažiau efektyvi nei epidū-rinė analgezija ir juosmeninio rezginio blokada, todėl pasirinkome palyginti dvi pastarąsias. Mūsų studija nepaneigė kitų studijų [12,13], kad epidūrinė analgezija ir juosmeninio rezginio blokada suteikia efektyvią skausmo kontrolę pirmomis pooperacinėmis ir ankstyvomis reabilitacijos dienomis. Epidūrinė analgezija iki šių dienų yra auksinis standartas pacientams po totalinės kelio sąnario artroplastikos.…”