A Comparison of US and Evoked Motor Response-guided Placement of Continuous Femoral Nerve Block Following TKA
Study Details
Study Description
Brief Summary
The purpose of this study is to determine which technique for catheter placement in continuous femoral nerve block (FNB) is most successful - guidance with (1) ultrasound or (2) nerve stimulation and ultrasound. Sensory and motor assessment scores will be obtained post-FNB. Patient controlled analgesia and opiate consumption is also recorded along with pain scores for the first 48 hour post-FNB.
| Condition or Disease | Intervention/Treatment | Phase |
|---|---|---|
|
N/A |
Detailed Description
Continuous femoral nerve block (cFNB) is a widely used regional anesthetic technique for many lower limb operations, such as total knee arthroplasty (TKA), anterior cruciate ligament repair, tibial osteotomy and patellar surgery. It provides superior pain relief, faster ambulation, shorter hospital stays and less risk of side effects in comparison to patient controlled analgesia (PCA), local anesthetic wound infiltration, or single shot femoral nerve block (FNB).
Stimulating catheters were introduced in 1999 to provide an objective end point to guide continuous nerve block catheter position by maintaining the desired evoked muscle response with nerve stimulation (NS). The main advantages of stimulating catheters are faster onset of sensory and motor block and reduction of local anesthetic drugs consumption. In recent years the precise insertion of continuous catheters has improved especially with the introduction of ultrasound (US)-guided imaging to regional anesthesia practice and advances in scanning techniques. That led to a call to reduce cost by switching to non-stimulating catheters. However, most studies comparing both catheters lacked anesthetic technique standardization and adequate sample size.
In this prospective randomized controlled trial, we compared postoperative analgesic efficacy and opioids consumption in patients having cFNB insertion using US alone and that of US combined with NS.
Study Design
Arms and Interventions
| Arm | Intervention/Treatment |
|---|---|
| Experimental: Ultrasound Femoral catheters inserted using ultrasound only |
Device: Ultrasound
Femoral catheter inserted using ultrasound only
|
| Active Comparator: Ultrasound + Nerve Stimulation Femoral catheters inserted using ultrasound with nerve stimulation |
Device: Ultrasound + Nerve Stimulation
Femoral catheter inserted using ultrasound and nerve stimulation
|
Outcome Measures
Primary Outcome Measures
- Mean numeric pain score (NRS) [24 hours post-block insertion]
Pain score assessed 24 hours post-block insertion using numeric pain scale from 0-10
Secondary Outcome Measures
- Time to perform the block [At the time of block procedure]
Time required to perform the block procedure
- Sensation over the skin of the thigh to determine sensory block using 3 point grading scale [30 min post-block insertion]
Sensory block evaluation examined the sensation over the skin of the thigh
- Quadriceps muscle strength to determine motor block using 3 point grading scale [30 min post-block insertion]
Motor block evaluation examined quadriceps muscle strength by grading the ability or inability to extend the leg of the limb to be operated on against gravity after the hip is passively flexed at 45°
- Total hydromorphone used (oral and intravenous PCA) [24 hours post-block]
Total amount of hydromorphone consumed within 24 hours post-block
- Total hydromorphone used (oral and intravenous PCA) [48 hours post-block]
Total amount of hydromorphone consumed within 48 hours post-block
Eligibility Criteria
Criteria
Inclusion Criteria:
-
American Society of Anesthesiologists physical status I to III patients
-
Aged 18-75 scheduled for unilateral TKA
Exclusion Criteria:
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History of significant psychiatric problems
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BMI > 40 kg/m^2
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Prior surgery in the inguinal region
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Neurological disease with sensory or motor deficit
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Diabetic neuropathy
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Contraindication to any study medications
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Daily opioid consumption >10 mg PO morphine (or equivalent) for 2 weeks prior to surgery
Contacts and Locations
Locations
| Site | City | State | Country | Postal Code | |
|---|---|---|---|---|---|
| 1 | Sunnybrook Health Sciences Centre | Toronto | Ontario | Canada | M4Y 1H1 |
Sponsors and Collaborators
- Sunnybrook Health Sciences Centre
Investigators
- Principal Investigator: Imad Awad, MBChB, Sunnybrook Health Sciences Centre
Study Documents (Full-Text)
None provided.More Information
Publications
- Boezaart AP, de Beer JF, du Toit C, van Rooyen K. A new technique of continuous interscalene nerve block. Can J Anaesth. 1999 Mar;46(3):275-81.
- Cappelleri G, Ghisi D, Ceravola E, Guzzetti L, Ambrosoli AL, Gemma M, Cornaggia G. A randomised controlled comparison between stimulating and standard catheters for lumbar plexus block. Anaesthesia. 2015 Aug;70(8):948-55. doi: 10.1111/anae.13077. Epub 2015 Mar 21.
- Carli F, Clemente A, Asenjo JF, Kim DJ, Mistraletti G, Gomarasca M, Morabito A, Tanzer M. Analgesia and functional outcome after total knee arthroplasty: periarticular infiltration vs continuous femoral nerve block. Br J Anaesth. 2010 Aug;105(2):185-95. doi: 10.1093/bja/aeq112. Epub 2010 Jun 14.
- Casati A, Fanelli G, Koscielniak-Nielsen Z, Cappelleri G, Aldegheri G, Danelli G, Fuzier R, Singelyn F. Using stimulating catheters for continuous sciatic nerve block shortens onset time of surgical block and minimizes postoperative consumption of pain medication after halux valgus repair as compared with conventional nonstimulating catheters. Anesth Analg. 2005 Oct;101(4):1192-1197. doi: 10.1213/01.ane.0000167232.10305.cd.
- Dauri M, Fabbi E, Mariani P, Faria S, Carpenedo R, Sidiropoulou T, Coniglione F, Silvi MB, Sabato AF. Continuous femoral nerve block provides superior analgesia compared with continuous intra-articular and wound infusion after anterior cruciate ligament reconstruction. Reg Anesth Pain Med. 2009 Mar-Apr;34(2):95-9. doi: 10.1097/AAP.0b013e31819baf98.
- Martínez Navas A, Vázquez Gutierrez T, Echevarría Moreno M. Continuous lateral popliteal block with stimulating catheters. Acta Anaesthesiol Scand. 2005 Feb;49(2):261-3.
- Paul JE, Arya A, Hurlburt L, Cheng J, Thabane L, Tidy A, Murthy Y. Femoral nerve block improves analgesia outcomes after total knee arthroplasty: a meta-analysis of randomized controlled trials. Anesthesiology. 2010 Nov;113(5):1144-62. doi: 10.1097/ALN.0b013e3181f4b18. Review.
- Pham Dang C, Lelong A, Guilley J, Nguyen JM, Volteau C, Venet G, Perrier C, Lejus C, Blanloeil Y. Effect on neurostimulation of injectates used for perineural space expansion before placement of a stimulating catheter: normal saline versus dextrose 5% in water. Reg Anesth Pain Med. 2009 Sep-Oct;34(5):398-403. doi: 10.1097/AAP.0b013e3181b48648.
- Salinas FV, Liu SS, Mulroy MF. The effect of single-injection femoral nerve block versus continuous femoral nerve block after total knee arthroplasty on hospital length of stay and long-term functional recovery within an established clinical pathway. Anesth Analg. 2006 Apr;102(4):1234-9.
- Shum CF, Lo NN, Yeo SJ, Yang KY, Chong HC, Yeo SN. Continuous femoral nerve block in total knee arthroplasty: immediate and two-year outcomes. J Arthroplasty. 2009 Feb;24(2):204-9. doi: 10.1016/j.arth.2007.09.014. Epub 2008 Mar 4. Erratum in: J Arthroplasty. 2016 May;44(3):431. Anaesth Intensive Care. 2016 May;44(3):428-9. J Arthroplasty. 2018 Mar;33(3):e1.
- 373-2011