The assessment of pain.

BACKGROUND By targeting the distal branches of the femoral nerve in the mid-thigh, the adductor canal block (ACB) can preserve quadriceps muscle strength while providing analgesia similar to a conventional femoral nerve block (FNB) for inpatients undergoing major knee surgery. In this randomized, double-blind, noninferiority trial, the authors hypothesized that ACB provides postoperative analgesia that is at least as good as FNB while preserving quadriceps strength after outpatient anterior cruciate ligament reconstruction. METHODS A total of 100 patients were randomized to receive ACB or FNB with 20 ml ropivacaine 0.5% (with epinephrine). The authors sequentially tested the joint hypothesis that ACB is noninferior to FNB for cumulative oral morphine equivalent consumption and area under the curve for pain scores during the first 24 h postoperatively and also superior to FNB for postblock quadriceps maximal voluntary isometric contraction. RESULTS The authors analyzed 52 and 48 patients who received ACB and FNB, respectively. Compared with preset noninferiority margins, the ACB-FNB difference (95% CI) in morphine consumption and area under the curve for pain scores were -4.8 mg (-12.3 to 2.7) (P = 0.03) and -71 mm h (-148 to 6) (P < 0.00001), respectively, indicating noninferiority of ACB for both outcomes. The maximal voluntary isometric contraction for ACB and FNB at 45 min were 26.6 pound-force (24.7-28.6) and 10.6 pound-force (8.3-13.0) (P < 0.00001), respectively, indicating superiority of ACB. CONCLUSION Compared with FNB, the study findings suggest that ACB preserves quadriceps strength and provides noninferior postoperative analgesia for outpatients undergoing anterior cruciate ligament reconstruction.

Adductor Canal Block Provides Noninferior Analgesia and Superior Quadriceps Strength Compared with Femoral Nerve Block in Anterior Cruciate Ligament Reconstruction.

Background Our aim was to review the recent evidence for the efficacy of peripheral regional anaesthesia. Methods Following a systematic literature search and selection of publications based on prospectively agreed upon criteria, we produced a narrative review of the most commonly performed peripheral regional anaesthetic blocks for surgery on the upper limb, the lower limb, and the trunk. We considered short-term and longer-term benefits and complications among the outcomes of interest. Results Where good quality evidence exists, the great majority of the blocks reviewed were associated with one or any combination of reduced postoperative pain, reduced opioid consumption, or increased patient satisfaction. For selected surgical procedures, the use of blocks avoided general anaesthesia and was associated with increased efficiency of the surgical pathway. The exceptions were supraclavicular block, where there was insufficient evidence, and transversus abdominis plane block, where the evidence for efficacy was conflicting. The evidence for the impact of the blocks on longer-term outcomes was, in general, inadequate to inform clinical decision making. Permanent complications are rare. Conclusions The majority of peripheral regional anaesthetic techniques have been shown to produce benefits for patients and hospital efficiency. Further interventional trials are required to clarify such benefits for supraclavicular block and transversus abdominis plane block and to ascertain any longer-term benefits for almost all of the blocks reviewed. Permanent complications of peripheral regional anaesthetic blocks are rare but accurate estimates of their incidence are yet to be determined.

Peripheral regional anaesthesia and outcome: lessons learned from the last 10 years

https://escholarship.org/content/qt6wt5s2ff/qt6wt5s2ff.pdf?t=oz1wx3

Anesthesia and Analgesia Practice Pathway Options for Total Knee Arthroplasty: An Evidence-Based Review by the American and European Societies of Regional Anesthesia and Pain Medicine.

Background
Major knee surgery is a common operative procedure to help people with end-stage knee disease or trauma to regain mobility and have improved quality of life. Poorly controlled pain immediately after surgery is still a key issue for this procedure. Peripheral nerve blocks are localized and site-specific analgesic options for major knee surgery. The increasing use of peripheral nerve blocks following major knee surgery requires the synthesis of evidence to evaluate its effectiveness and safety, when compared with systemic, local infiltration, epidural and spinal analgesia.

Objectives
To examine the efficacy and safety of peripheral nerve blocks for postoperative pain control following major knee surgery using methods that permit comparison with systemic, local infiltration, epidural and spinal analgesia.

Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 1, 2014), MEDLINE and EMBASE, from their inception to February 2014. We identified ongoing studies by searching trial registries, including the metaRegister of controlled trials (mRCT), clinicaltrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP).

Selection criteria
We included participant-blind, randomized controlled trials of adult participants (15 years or older) undergoing major knee surgery, in which peripheral nerve blocks were compared to systemic, local infiltration, epidural and spinal analgesia for postoperative pain relief.

Data collection and analysis
Two review authors independently assessed study eligibility and extracted data. We recorded information on participants, methods, interventions, outcomes (pain intensity, additional analgesic consumption, adverse events, knee range of motion, length of hospital stay, hospital costs, and participant satisfaction). We used the 5-point Oxford quality and validity scale to assess methodological quality, as well as criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We conducted meta-analysis of two or more studies with sufficient data to investigate the same outcome. We used the I² statistic to explore the heterogeneity. If there was no significant heterogeneity (I² value 0% to 40%), we used a fixed-effect model for meta-analysis, but otherwise we used a random-effects model. For dichotomous data, we present results as a summary risk ratio (RR) and a 95% confidence interval (95% CI). Where possible, we calculated the number needed to treat for an additional beneficial outcome (NNTB) or for an additional harmful outcome (NNTH), together with 95% CIs. For continuous data, we used the mean difference (MD) and 95% CI for similar outcome measures. We describe the findings of individual studies where pooling of data was not possible.

Main results
According to the eligibility criteria, we include 23 studies with 1571 participants, with high methodological quality overall. The studies compared peripheral nerve blocks adjunctive to systemic analgesia with systemic analgesia alone (19 studies), peripheral nerve blocks with local infiltration (three studies), and peripheral nerve blocks with epidural analgesia (one study). No study compared peripheral nerve blocks with spinal analgesia.Compared with systemic analgesia alone, peripheral nerve blocks adjunctive to systemic analgesia resulted in a significantly lower pain intensity score at rest, using a 100 mm visual analogue scale, at all time periods within 72 hours postoperatively, including the zero to 23 hours interval (MD -11.85, 95% CI -20.45 to -3.25, seven studies, 390 participants), the 24 to 47 hours interval (MD -12.92, 95% CI -19.82 to -6.02, six studies, 320 participants) and the 48 to 72 hours interval (MD -9.72, 95% CI -16.75 to -2.70, four studies, 210 participants). Subgroup analyses suggested that the high levels of statistical variation in our analyses could be explained by larger effects in people undergoing total knee arthroplasty compared with other types of surgery. Pain intensity was also significantly reduced on movement in the 48 to 72 hours interval postoperatively (MD -6.19, 95% CI -11.76 to -0.62, two studies, 112 participants). There was no significant difference on movement between these two groups in the time period of zero to 23 hours (MD -6.95, 95% CI -15.92 to 2.01, five studies, 304 participants) and 24 to 47 hours (MD -8.87, 95% CI -27.77 to 10.03, three studies, 182 participants). The included studies reported diverse types of adverse events, and we did not conduct a meta-analysis on specific types of adverse event. The numbers of studies and participants were also too few to draw conclusions on the other prespecified outcomes of: additional analgesic consumption; median time to remedication; knee range of motion; median time to ambulation; length of hospital stay; hospital costs; and participant satisfaction. There were insufficient data to compare peripheral nerve blocks and local infiltration or between peripheral nerve blocks and epidural analgesia.

Authors' conclusions
All of the included studies reported the main outcome of pain intensity but did not cover all the secondary outcomes of interest. The current review provides evidence that the use of peripheral nerve blocks as adjunctive techniques to systemic analgesia reduced pain intensity when compared with systemic analgesia alone after major knee surgery. There were too few data to draw conclusions on other outcomes of interest. More trials are needed to demonstrate a significant difference when compared with local infiltration, epidural analgesia and spinal analgesia.

Peripheral nerve blocks for postoperative pain after major knee surgery

CONTEXTAnterior cruciate ligament (ACL) reconstruction surgery is associated with moderate to severe postoperative pain, which may be ameliorated by peripheral nerve blocks. The adductor canal block (ACB) is an almost exclusively sensory nerve block that has been demonstrated to reduce pain and opio

Analgesic efficacy of ultrasound-guided adductor canal blockade after arthroscopic anterior cruciate ligament reconstruction: a randomised controlled trial

Jørgen Haraszuk

Papers

Analgesic efficacy of ultrasound-guided adductor canal blockade after arthroscopic anterior cruciate ligament reconstruction: a randomised controlled trial