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274: Local infiltration analgesia in total knee arthroplasty: a randomised, double-blind and placebo controlled trial
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274. Local infiltration analgesia in total knee arthroplasty: a randomised, doubleblind and placebo controlled trial L.Ø. Andersen1, B.B. Kristensen1, H. Husted2, K.S. Otte2, H. Kehlet3 1Department of Anaesthesia, Hvidovre University Hospital, Copenhagen, Denmark, 2Department of Orthopaedic Surgery, Hvidovre University Hospital, Copenhagen, Denmark, 3Section for Surgical Pathophysiology 4074, The Juliane Marie Center, Rigshospitalet, Copenhagen, Denmark Background and Aims: A relatively new and promising approach in pain management after total knee arthroplasty (TKA) is Local Infiltration Analgesia (LIA), which includes a systematic intraoperative infiltration of the surgical area with a volume of 150 ml ropivacaine 0.2% and adrenaline (1:1000). Studies report that LIA facilitates recovery and reduces opioid consumption (1). The present study evaluated the LIA technique in a double-blind, placebo-controlled design, in patients receiving bilateral TKA. Methods: 12 patients scheduled for bilateral TKA were randomised to receive LIA in one knee and similar infiltration with saline in the opposite knee. All patients received Patient Controlled Analgesia with intravenous morphine on demand. Pain scores were recorded 4, 8 and 24 hours postoperative, using a Visual Analogue Scale (VAS, 0-100 mm). Results: Throughout the study period, pain scores were significantly lower from the joint infiltrated with Ropivacaine compared to saline. Median VAS scores upon 45° flexion of the knee are shown in Table 1. Conclusion: Local Infiltration Analgesia is a promising technique in pain management after total knee arthroplasty, and has superior analgesic effect compared to similar infiltration with saline. Reference 1. Rostlund T, Kehlet H. High-dose local infiltration analgesia after hip and knee replacement - what is it, why does it work, and what are the future challenges? Acta Orthop; 78: 159-61
Table 1. VASa pain ratings after TKA, from 12 patients upon 45° flexion of the knee. VAS ratings presented as median (range). Ropivacaine ⫹ adrenaline VAS 4 hour post-op., mm. VAS 8 hour post-op., mm. VAS 24 hour post-op., mm.
10 (0–50) 50 (0–80) 55 (0–90)
Placebo
P
70 (40–90) ⬍0.05 80 (50–100) ⬍0.05 75 (30–90) ⬍0.05
Analogue Scale from 0 –100 mm with 10 mm increments, 0 mm ⫽ no pain 100 mm ⫽ worst pain.
aVisual
5
82 Pain management after minimally invasive pectus excavatum repair: retrospective comparison of paravertebral and lumbar epidural patient-controlled analgesia C. Stanz1, A. Gutmann1, M. Vittinghoff1, W. Toller1, J. Schleef2 1Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria, 2Department of Pediatric Surgery, IRCCS Burlo Garofolo, University of Trieste, Trieste, Italy Background and Aims: Although operative correction of pectus excavatum regarding skin incision is minimally invasive and minimal pain is expected, clinical experience revealed that postoperative pain and discomfort required statistically significant increases in days of intravenous analgesics administration compared with the standard open procedure. To avoid the disadvantages of intravenous systemic opiod administration, thoracic epidural catheter technique has been described for appropriate pain management. The use of paravertebral (PA) and lumbar epidural analgesia (LA) for this procedure has not been reported so far. The aim of this investigation was to evaluate retrospectively the efficacy and safety of these two methods. Materials and Methods: We retrospectively analyzed protocols of 36 patients aged 8 to 25 years undergoing minimally invasive repair of pectus excavatum under general anesthesia. 19 patients had bilateral paravertebral catheters placed at the thoracic segment where the bar was planned to be inserted. 17 patients received lumbar epidural catheter placed mainly at L1-L3. Postoperative pain was assessed using the Visual Analogue Scale (1-10). Safety was assessed by incidence of adverse events. Results: Mean VAS was not significantly different in the two groups (PA⫽1.1 vs. LA⫽0.9), and both catheter techniques provided excellent postoperative pain control. While no major adverse event occurred, both analgesic regimes were associated with a low incidence of minor adverse events, including vomiting, urinary retention, Horner’s signs and pruritus, depending on the type of analgesic regime. The number of total minor adverse events in patients receiving LA was higher when compared with patients receiving PA. Conclusions: Paravertebral analgesia turned out to be as reliable as lumbar epidural analgesia. Safety of this method of pain management was superior to LA. The technique however needs experience as paravertebral catheters can be advanced only for a limited distance and need to be fixed carefully.
274. Local infiltration analgesia in total knee arthroplasty: a randomised, doubleblind and placebo controlled trial L.Ø. Andersen1, B.B. Kristensen1, H. Husted2, K.S. Otte2, H. Kehlet3 1Department of Anaesthesia, Hvidovre University Hospital, Copenhagen, Denmark, 2Department of Orthopaedic Surgery, Hvidovre University Hospital, Copenhagen, Denmark, 3Section for Surgical Pathophysiology 4074, The Juliane Marie Center, Rigshospitalet, Copenhagen, Denmark Background and Aims: A relatively new and promising approach in pain management after total knee arthroplasty (TKA) is Local Infiltration Analgesia (LIA), which includes a systematic intraoperative infiltration of the surgical area with a volume of 150 ml ropivacaine 0.2% and adrenaline (1:1000). Studies report that LIA facilitates recovery and reduces opioid consumption (1). The present study evaluated the LIA technique in a double-blind, placebo-controlled design, in patients receiving bilateral TKA. Methods: 12 patients scheduled for bilateral TKA were randomised to receive LIA in one knee and similar infiltration with saline in the opposite knee. All patients received Patient Controlled Analgesia with intravenous morphine on demand. Pain scores were recorded 4, 8 and 24 hours postoperative, using a Visual Analogue Scale (VAS, 0-100 mm). Results: Throughout the study period, pain scores were significantly lower from the joint infiltrated with Ropivacaine compared to saline. Median VAS scores upon 45° flexion of the knee are shown in Table 1. Conclusion: Local Infiltration Analgesia is a promising technique in pain management after total knee arthroplasty, and has superior analgesic effect compared to similar infiltration with saline. Reference 1. Rostlund T, Kehlet H. High-dose local infiltration analgesia after hip and knee replacement - what is it, why does it work, and what are the future challenges? Acta Orthop; 78: 159-61
Table 1. VASa pain ratings after TKA, from 12 patients upon 45° flexion of the knee. VAS ratings presented as median (range). Ropivacaine ⫹ adrenaline VAS 4 hour post-op., mm. VAS 8 hour post-op., mm. VAS 24 hour post-op., mm.
10 (0–50) 50 (0–80) 55 (0–90)
Placebo
P
70 (40–90) ⬍0.05 80 (50–100) ⬍0.05 75 (30–90) ⬍0.05
Analogue Scale from 0 –100 mm with 10 mm increments, 0 mm ⫽ no pain 100 mm ⫽ worst pain.
aVisual
5
82 Pain management after minimally invasive pectus excavatum repair: retrospective comparison of paravertebral and lumbar epidural patient-controlled analgesia C. Stanz1, A. Gutmann1, M. Vittinghoff1, W. Toller1, J. Schleef2 1Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria, 2Department of Pediatric Surgery, IRCCS Burlo Garofolo, University of Trieste, Trieste, Italy Background and Aims: Although operative correction of pectus excavatum regarding skin incision is minimally invasive and minimal pain is expected, clinical experience revealed that postoperative pain and discomfort required statistically significant increases in days of intravenous analgesics administration compared with the standard open procedure. To avoid the disadvantages of intravenous systemic opiod administration, thoracic epidural catheter technique has been described for appropriate pain management. The use of paravertebral (PA) and lumbar epidural analgesia (LA) for this procedure has not been reported so far. The aim of this investigation was to evaluate retrospectively the efficacy and safety of these two methods. Materials and Methods: We retrospectively analyzed protocols of 36 patients aged 8 to 25 years undergoing minimally invasive repair of pectus excavatum under general anesthesia. 19 patients had bilateral paravertebral catheters placed at the thoracic segment where the bar was planned to be inserted. 17 patients received lumbar epidural catheter placed mainly at L1-L3. Postoperative pain was assessed using the Visual Analogue Scale (1-10). Safety was assessed by incidence of adverse events. Results: Mean VAS was not significantly different in the two groups (PA⫽1.1 vs. LA⫽0.9), and both catheter techniques provided excellent postoperative pain control. While no major adverse event occurred, both analgesic regimes were associated with a low incidence of minor adverse events, including vomiting, urinary retention, Horner’s signs and pruritus, depending on the type of analgesic regime. The number of total minor adverse events in patients receiving LA was higher when compared with patients receiving PA. Conclusions: Paravertebral analgesia turned out to be as reliable as lumbar epidural analgesia. Safety of this method of pain management was superior to LA. The technique however needs experience as paravertebral catheters can be advanced only for a limited distance and need to be fixed carefully.