Local Infiltration Analgesia for Total Knee Arthroplasty

Transcription

1 Local Infiltration Analgesia for Total Knee Arthroplasty Colin J.L. McCartney MBChB FCARCSI FRCA FRCPC Director of Regional Anesthesia Research Department of Anesthesia Sunnybrook Health Sciences Centre Associate Professor University of Toronto Ontario, Canada

2 Total Knee Arthroplasty n Common surgical procedure with >30,000 procedures per annum in Canada n Painful with significant acute pain if not carefully managed n Pain relief important to facilitate rehabilitation n But is it really that painful??

3 Is Total Knee Replacement Painful?

4 How painful is it?

5 But is severe acute pain a problem after TKA?

6 But is severe acute pain a problem after TKA?

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8 Is Total Knee Replacement Painful?

9 What is the optimal method of pain relief after TKA?

10 Singelyn paper

11 Singelyn et al 1998

12 What is the optimal method of pain relief after TKA? n Epidural analgesia or FNB superior to opioids alone after TKA (Capdevila, Singelyn) n Epidural analgesia associated with greater adverse effects: hypotension, urinary retention

13 Peripheral Nerve Block Techniques n Technically demanding n Difficult to teach n Requires extra anesthetic time n May cause motor block and potentially precipitate falls (Ilfeld 2010) n? Incidence of use in Ontario

14 Continuous femoral block n Successfully used in a number of centres n Infusion of ropivacaine % at rates of 5ml/h+/- bolus 5ml n Careful liaison with surgeons and physiotherapists required n Very good pain relief can result with collaboration

15 Data from Brian s study n RCDB 50 patients undergoing TKA n cfnb or placebo n Multimodal analgesia n Time to achieve three distinct discharge criteria

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17 Ilfeld et al 2008

18 Continuous femoral block n Successfully used in a number of centres n Infusion of ropivacaine % at rates of 5ml/h+/- bolus 5ml n Careful liaison with surgeons and physiotherapists required n Problems: technically more challenging, takes time to perform

19 The Problem with PNBs

20 Local Infiltration Analgesia n Common procedure for several surgical procedures (Scott 2010) with evidence of efficacy n LIA also used for TKA n First randomized study Bianconi et al demonstrating benefit over placebo n Subsequent series by Kerr and Kohan n RCTs by Toftdahl, Carli and Affas

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22 Summary of Research to Date

23 n R, SB 40 patients n LIA or cfnb n Both groups had ketorolac n Outcome measurement limited to <24h

24 Toftdahl

25 R, DB 40 patients LIA or cfnb Immediate postoperative outcomes Functional outcomes 6 weeks after surgery BJA 2010

26 Carli F et al BJA 2010

27 Carli F et al BJA 2010

28 Critique of studies to date: n Prior to Toftdahl: case series and RCTs comparing LIA with placebo n Toftdahl: unblinded n Carli: underpowered for primary outcome n Affas: unblinded, no functional outcomes n Need for a high quality, adequately powered comparison between LIA and FNB including pain and functional outcomes

29 Kehlet review

30 n LIA possibly useful for TKA n Not useful for THA n? Use of fast-track protocol n? Benefit of continuous catheter n? Place of individual components n? Management of acute pain after discharge

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32 In summary n TKA is painful with a high incidence of chronic pain n For analgesia epidural=cfnb n Epidural limited by AEs and failure rate n cfnb superior to ssfnb n cfnb superior to LIA n However both areas require further study

33 What questions need answered? n Is LIA equivalent to cfnb for TKA n Is FNB=IT opioids for TKA n Do we need to use a catheter for LIA? n What components of LIA are useful? n Is compression or ice useful? n What about long duration (liposomal) local anesthetics? n What factors affect development of chronic pain after TKA

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35 Summary n LIA is a relatively new technique for pain control after TKA n At the present time the evidence is unclear as to whether it provides equivalent or superior analgesia to PNBs after TKA n A high quality RCT is needed to answer this question