Continuous Low-Dose 3-in-1 Nerve Blockade for Postoperative Pain Relief After Total Knee Replacement

Abstract

We have investigated the value of a 3-in-1 nerve block, followed by a continuous low-dose infusion of bupivacaine into the femoral nerve sheath for postoperative analgesia after total knee replacement. Thirty-seven patients were randomly allocated to either a control group or a study group. The study group had a catheter placed in the ipsilateral femoral nerve sheath. A 3-in-1 nerve block was then performed in the study group with injection of 30 mL of 0.25% bupivacaine through the catheter. This was followed by a continuous infusion of 0.125% bupivacaine at 6 mL/h. The study group had significantly lower pain scores 4 and 24 h postoperatively (P less than 0.01) and required less postoperative opioid analgesic medication (P less than 0.01) than the control group. The authors conclude that a continuous low-dose infusion into the femoral nerve sheath results in better pain relief than conventional intramuscularly administered narcotics after total knee arthroplasty.

The posterior lumbar plexus (psoas compartment) block and the three-in-one femoral nerve block provide similar postoperative analgesia after total knee replacement

“…[1][2][3][4][5][6][7] It may allow faster rehabilitation as measured by the maximal degree of knee flexion and walking distance obtained in the early postoperative days, length of hospitalization, and total length of rehabilitation. [1][2][3][4][5] Postoperative epidural analgesia is relatively contraindicated since these patients are usually anticoagulated for the prevention of deep venous thrombosis and pulmonary embolism.…”

“…8 Thus, many clinicians now rely on a continuous three-in-one femoral nerve (FEM) block to provide postoperative analgesia after TKR. [2][3][4]6 The femoral, or anterior, approach to the lumbar plexus is simple and has virtually no risk of major complications; however, postoperative pain scores from patients receiving continuous FEM blocks are higher than those measured in patients receiving continuous epidural analgesia, at least up to four hours after the surgery. 2 Inability of the femoral approach to block the sciatic nerve may explain its decreased efficacy compared to epidural analgesia; however, Allen et al found no benefit from the addition of a single injection sciatic nerve block to a FEM block in patients undergoing TKR.…”

Postoperative Pain Control for Total Knee Arthroplasty: Continuous Femoral Nerve Block Versus Intravenous Patient Controlled Analgesia

“…A systematic review of 112 studies between 1996 and 2005 by the PROSPECT working group supports the use of femoral nerve blocks for postoperative analgesia for primary TKA, based on the reduction in pain scores and supplemental analgesia (10). Of the 112 studies, 5 investigated the use of continuous infusion femoral nerve block versus placebo (8,(18)(19)(20)(21), all of which noted reduced pain scores at rest and with motion at 24 and 48 hours with CFNB.…”

Physiologic Advantages of Peripheral Nerve Blockade Translate to Decreased Length of Stay and Improved Patient Satisfaction

“…The opioid sparing in the CPNB group lead to decreased incidence of nausea and other opioid-related side-effects. 3 Similarly, Edwards et al 12 showed that CPNBs could decrease opioid consumption on postoperative days 0, 1, and 2 compared to single shot PNBs in patients who underwent Total Knee Arthroplasty (TKA). Indeed, PNBs protect against opioidinduced cardiovascular, respiratory, and gastrointestinal side effects.…”

“…Indeed, PNBs protect against opioidinduced cardiovascular, respiratory, and gastrointestinal side effects. 8,12,13 Although continuous PNBs have been shown to be more efficacious in treating postoperative pain 9,12-28 and decreasing opioid use, single injection PNBs have been demonstrated to provide superior pain control and decreased side-effects compared to opioid monotherapy. 8,13 Altering the concentration of the local anesthetic used in the block can also modify narcotic consumption.…”