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Point estimates and summarized TSA results for primary outcomes. Pain-relieving and morphine-sparing effects are reported with 95% CI. LIA, Local Infiltration Analgesia; NSAIDs, Nonsteroidal Anti-Inflammatory Drugs; TSA, trial sequential analysis. Green: a priori estimated information size (APIS) reached and effective. Yellow: APIS not reached, significant so far. Orange: APIS not reached, insignificant so far. Red: APIS reached and futile.
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Citations
... Multimodal pain management approach is now considered the standard method to achieve optimal pain control, while minimizing the need for opioids and their adverse events [5]. It includes the use of oral pharmacological agents and different regional analgesic interventions [11]. The mainstay of oral analgesics is paracetamol and non-steroidal anti-inflammatory drugs, other studies suggest the use of gabapentin and anticonvulsants [5]. ...
Background
Fascia iliaca compartment block (FICB) is one of the regional nerve blocks used to reduce pain after total hip arthroplasty (THA). We aim to assess the efficacy of FICB in reducing post-operative pain and opioid consumption.
Methods
We searched PubMed, Web of Science, Cochrane Library, Embase, and Scopus on February 19, 2023, and we updated our search in august 2023 using relevant search strategy. Studies were extensively screened for eligibility by title and abstract screening, followed by full-text screening. We extracted the data from the included studies, and then pooled the data as mean difference (MD) or odds ratio (OR) with a 95% confidence interval (CI), using Review Manager Software (ver. 3.5).
Results
FIBC significantly reduced analgesic consumption at 24 h (MD = -8.75, 95% CI [-9.62, -7.88] P < 0.00001), and at 48 h post-operatively. (MD = -15.51, 95% CI [-26.45, -4.57], P = 0.005), with a significant sensory block of the femoral nerve (P = 0.0004), obturator nerve (P = 0.0009), and lateral femoral cutaneous nerve (P = 0.002). However, FICB was not associated with a significant pain relief at 6, 24, and 48 h postoperatively, except at 12 h where it significantly reduced pain intensity (MD = -0.49, 95% CI [-0.85, -0.12], P = 0.008). FICB was also not effective in reducing post-operative nausea and vomiting (MD = 0.55, 95% CI [0.21, 1.45], P = 0.23), and was associated with high rates of quadriceps muscle weakness (OR = 9.09, % CI [3.70, 22.30], P = < 0.00001).
Conclusions
FICB significantly reduces the total analgesic consumption up to 48 h; however, it is not effective in reducing post-operative pain, nausea and vomiting and it induced postoperative muscle weakness.
... Therefore, to provide a more comprehensive coverage on the wide range of lumbar plexus, multiple-level block techniques, e.g., LPB at L2 and L3, at L3 and L4, or even combined with T12-L1 paravertebral block (PVB), were applied in some studies [8][9][10][11]. However, it is conceivable that these expert techniques may require more operator expertise, consume more performance time, increase the discomfort of the patients, and have a greater risk of complications [2,[12][13][14]. Thus, a both effective and convenient method should be investigated. ...
Introduction
The lumbar plexus originates from multiple segments of the spinal cord. Both single-level lumbar plexus block (LPB) and transmuscular quadratus lumborum block (TQLB) are commonly used to provide analgesia for the patients undergoing total hip arthroplasty (THA). However, neither of them can completely cover the lumbar plexus. Multiple-level LPB is also not recommended since this expert technique involves more potential risks. To achieve a better anesthetic effect and avoid risks, we propose to combine ultrasound-guided LPB with TQLB with Shamrock approach. We aim to assess the anesthetic efficacy of this combination technique and expect it will be an ideal alternative for conventional LPBs in THA.
Methods and analysis
In this prospective randomized controlled trial, 84 patients schedule for THA will be enrolled. The patients will be randomly assigned at a 1:1:1 ratio to receive LPB at L3 level (P group), T12 paravertebral block combined with LPB at L3 and L4 levels (TP group), or LPB combined with TQLB at L3 level (PQ group). Each method will be evaluated in terms of the successful rate of sensory blockade, postoperative pain, performance time of block, requirement for intraoperative sufentanil, cumulative doses of intraoperative vasoactive medications, and adverse events.
Ethics and dissemination
The study protocol has been approved by the institutional review board (IRB) at Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, China (No.2020–031). The results will be disseminated in a peer-reviewed journal and the ClinicalTrials.gov registry.
Trial registration
ClinicalTrials.gov, NCT04266236 . Registered on 10 February 2020. ClinicalTrials.gov PRS: Record Summary NCT04266236 .
... Described as 'the surgery of the century', total hip arthroplasty (THA) is characterised by moderate-tosevere early postoperative pain. 1,2 This is one of the main factors limiting postoperative functional recovery, with the peak pain intensity being typically at around 6 h after surgery with spinal anaesthesia. 3 THA by the posterolateral approach (PLTHA) remains one of the most popular surgical techniques, due in part to fewer postoperative complications. ...
Background:
Pain after a posterolateral approach for total hip arthroplasty (THA) may affect early functional recovery. Supra-inguinal fascia iliaca (SFIB) and pericapsular nerve group (PENG) blocks have been proposed as promising analgesia techniques.
Objectives:
This trial was conducted to compare a PENG with a SFIB for controlling postoperative pain and for providing functional recovery.
Design:
Noninferiority monocentric randomised controlled study.
Setting:
One hundred and two patients scheduled for a total hip arthroplasty via the posterolateral approach under spinal anaesthesia were prospectively allocated to two groups. Data acquisition occurred between October 2021 and July 2022 at the University Hospital of Liege.
Patients:
One hundred and two patients completed the trial.
Interventions:
Group SFIB received supra-inguinal fascia iliaca block (SFIB) (40 ml ropivacaine 0.375%), whereas group PENG received a PENG block (20 ml ropivacaine 0.75%).
Main outcome measures:
Rest and mobilisation pain on a 0 to 10 numeric rating scale at fixed time points: 1 and 6 h after surgery, on day-1 and day-2 at 8 a.m.,1 p.m. and 6 p.m. On day-1 and day-2, evolution of quality-of-recovery-15 score was assessed, and timed-up-and-go, 2 and 6 min-walking tests. The noninferiority margin was set as 1 numeric rating scale point 6 h after surgery.
Results:
Six hours after surgery, pain scores in group PENG were noninferior to those of group SFIB, with a difference between medians at 0 (95% CI -0.93 to 0.93). There were no significant differences between the groups regarding rest and dynamic pain trajectories during the first 48 postoperative hours, with no significant effects of group (rest P = 0.800; dynamic P = 0.708) or interaction between group and time (rest P = 0.803; dynamic P = 0.187). Similarly, no significant differences were observed regarding motor and functional recovery as assessed by timed-up-and-go (P = 0.197), 2 min (P = 0.364), and 6 min walking (P = 0.347) tests and quality-of-recovery-15 (P = 0.417) score.
Conclusion:
Following a total hip arthroplasty via the posterolateral approach, a PENG block is noninferior to SFIB regarding postoperative pain control 6 h after surgery, and functional recovery.
Trial registration:
European Clinical Trial Register under EudraCT-number 2020-005126-28 (https://www.clinicaltrialsregister.eu/ctr-search/trial/2020-005126-28/BE).
... Postoperative analgesic management in THA is indeed challenging with a variety of options like spinal and epidural analgesia. The nerve block options include femoral block, sciatic block, posterior lumbar plexus block, fascia iliaca block, and periarticular local anesthesia infiltration [12][13]. Quadratus lumborum block (QLB) is a newly introduced technique for analgesia for THA [7,11,[16][17]. ...
Background: Primary objective:
• Duration of block
• Post-operative pain score
• Post-operative rescue analgesic consumption
Secondary objective:
• To observe patient satisfaction score
• Occurrence of post-operative complications if any.
Methods: A total of 60 patients, aged between 18-60yrs, belonging to ASA I & II with hip osteoarthritis requiring total hip arthroplasty (THA) were divided into two groups of 30 each. Patients were randomized into two groups and were given ipsilateral USG guided anterior QLB in the fascial plane between QL and psoas major muscles after surgery. Group C received 30ml NS and group T received 30ml of inj. Ropivacaine 0.2%. Post operatively patient received inj. PCM 1G TDS. Duration of block, requirement of rescue analgesia, VAS score and side effects were the parameters those were monitored and compared.
Results: Mode pain score by VAS was significantly lower in T group(p
... [1] The psoas compartment block (PCB) or the lumbar plexus block, especially a continuous infusion, is an effective technique for providing analgesia following posterior total hip arthroplasty (THA). [2] However, PCB has been associated with serious complications, namely retroperitoneal haematoma, total spinal anaesthesia, and cardiac arrest. [3] The transmuscular quadratus lumborum block (TQLB) involves depositing local anaesthetic (LA) anterior to the quadratus lumborum muscle (QL) in the plane between the QL and psoas major muscles (PMM) at the 4 th lumbar vertebra (L4) level. ...
Background and aims:
Analgesia for hip surgery involves cutaneous anaesthesia at the site of the skin incision and the anterior hip capsule. This study aimed to compare continuous ultrasound (US)-guided transmuscular quadratus lumborum block (TQLB) with psoas compartment block (PCB) for analgesia in patients undergoing total hip arthroplasty (THA) under general anaesthesia (GA).
Methods:
This randomised, observer-blinded trial included 18-70-year-old American Society of Anesthesiologists physical status I-III patients undergoing THA under GA with either US-guided continuous TQLB or PCB. Primary objectives included a visual analogue scale (VAS; 0-100 mm) at rest and mobilisation at 6 h postoperatively (analysed by intention to treat and per protocol) using a non-inferiority margin of 20 mm. Secondary objectives included VAS at other time points, 24-h fentanyl consumption (analysed using the Wilcoxon rank-sum test), sensory dermatomes anaesthetised, motor weakness 30 min after block, and haemodynamic response to skin incision (analysed using the Chi-squared or Fisher's exact test). A P value less than 0.05 was considered statistically significant.
Results:
VAS (0-100 mm) score at 6 h on rest was 25.34 ± 14.25 and 27.3 ± 9.6, mean difference (MD) was 1.9 [-3.3, 7.1] and at movement was 35.1 ± 23.0 and 38.6 ± 17.0, MD was 3.5 [-5.2, 12.2], in the PCB (n = 29) and QLB (n = 30) groups, respectively (i.e. less than the non-inferiority margin). However, VAS (rest) at 1, 12, and 24 h postoperatively and median (IQR) 24-h fentanyl consumption was significantly higher in the QLB group (1212.5 [300-2345] μg] when compared to the PCB group (635 [100-1645] μg; P = 0.0004).
Conclusion:
Though statistically, continuous QLB was non-inferior to continuous PCB for pain at rest and mobilisation at 6-hours postoperatively, a higher 24-hour perioperative fentanyl consumption and VAS show that QLB was clinically inferior to PCB.
... Total hip arthroplasty (THA) is an effective procedure for treating advanced osteoarthritis and other hip diseases, improving patient hip function and quality of life 1,2 . However, the procedure often causes moderate-to-severe postoperative pain, limiting early recovery 3,4 . Despite multimodal analgesia minimizing opioid use in recent years, the opioid epidemic remains a problem, generating challenges for optimal pain control during the perioperative period of THA. ...
Objective:
This study aimed to evaluate the efficacy of different dexamethasone doses in the perioperative period of total hip arthroplasty (THA).
Patients and methods:
We randomly divided 180 patients into three groups: three perioperative saline injections (Group A, placebo); two perioperative doses of 15 mg dexamethasone plus a postoperative saline injection at 48 h (Group B); and three perioperative doses of dexamethasone (10 mg) (Group C). Primary outcomes were postoperative pain at rest and while walking. We also recorded consumption of analgesics and antiemetics, incidence of postoperative nausea and vomiting (PONV), C-reactive protein (CRP) and interleukin-6 (IL-6) levels, postoperative length of stay (p-LOS), range of motion (ROM), nausea, Identity-Consequence-Fatigue-Scale (ICFS), and severe complications (e.g., incidence of surgical site infection, SSI and gastrointestinal bleeding, GIB).
Results:
Group B and C had significantly lower pain scores at rest than Group A on postoperative day 1. Group B and C also had significantly lower dynamic pain score, CRP, and IL-6 than Group A on postoperative day 1, 2, and 3. Patients in Group B and C had lower PONV incidence, reduced use of analgesics and antiemetics, improved ROM, shorter p-LOS, lower VAS nausea score, and lower ICFS than Group A patients. On postoperative day 3, patients in Group C had significantly lower dynamic pain and ICFS scores, IL-6, and CRP than Group B patients, as well as higher ROM. None of the groups exhibited SSI or GIB.
Conclusions:
Dexamethasone provides short-term advantages in reducing pain, PONV, inflammation, and ICFS, and increasing ROM in the early postoperative period after THA. Dexamethasone efficacy in reducing post-THA pain, inflammation, and PONV at 10 mg and 15 mg is similar during the first 48 h. Dexamethasone (30 mg) divided into three 10 mg doses was superior to two doses (15 mg) in reducing pain, inflammation, and ICFS, as well as in increasing ROM on postoperative day 3.
... Consequently, several of the most used interventions within the field are still based on poor evidence relying on tradition, expert opinions, studies of basic physiology, nonrandomised studies, or underpowered trials with poor methodological quality. [17][18][19][20][21] About half of all recommendations in clinical guidelines in anaesthesiology are based on a low level of evidence. 22 This poses a treatment dilemma, since several of these interventions could have no beneficial effects, and some may even be harmful. ...
Evidence in perioperative care is insufficient. There is an urgent need for large perioperative research programmes, including pragmatic randomised trials, testing daily clinical treatments and unanswered question, thereby providing solid evidence for effects of interventions given to a large and growing number of patients undergoing surgery and anaesthesia. This may be achieved through large collaborations. Collaboration for Evidence-based Practice and Research in Anaesthesia (CEPRA) is a novel collaborative research network founded to pursue evidence-based answers to major clinical questions in perioperative medicine. The aims of CEPRA are to 1) improve clinical treatment and outcomes and optimise the use of resources for patients undergoing anaesthesia and perioperative care, and 2) disseminate results and inform caretakers, patients and relatives, and policymakers of evidence-based treatments in anaesthesia and perioperative medicine. CEPRA is inclusive in its concept. We aim to extend our collaboration with all relevant clinical collaborators and patient associations and representatives. Although initiated in Denmark, CEPRA seeks to develop an international network infrastructure, e.g., with other Nordic countries. The work of CEPRA will follow the highest methodological standards. The organisation aims to structure and optimise any element of the research collaboration to reduce economic costs and harness benefits from well-functioning research infrastructure. This includes successive continuation of trials, harmonisation of outcomes, and alignment of data management systems. This paper presents the initiation and visions of the CEPRA network. CEPRA aims to be inclusive, patient-focused, methodologically sound, and to optimise all aspects of research logistics. This will translate into faster research conduct, reliable results, and accelerated clinical implementation of results, thereby benefiting millions of patients whilst being cost and labour-saving.
... [4][5][6][7] Therefore, multimodal analgesia with systemic analgesics, local infiltration analgesia (LIA) and nerve blocks is recommended in Enhanced Recovery After Surgery (ERAS) protocols and other guidelines for post-operative pain treatment after total hip arthroplasty (THA) and total knee arthroplasty (TKA). [8][9][10][11][12][13][14] These guidelines are based on some of the more than 500 randomised controlled trials (RCTs), that have been conducted in this field, often with opioid consumption as the primary efficacy outcome. 11,15 However, it is unclear to what degree these trials used non-opioid multimodal analgesia as co-interventions (analgesics administered equally in all groups as adjunct to the intervention/control). ...
... While we demonstrate that trialists increasingly used nonopioid analgesics in pain management research, still a large part of the published literature did not use multimodal analgesic regimens that reflect current clinical practice. 13,14 For example, only half of trials published between 2010 and 2020 used a combination of paracetamol, NSAIDs or steroids, which would reflect recently updated ERAS recommendations and procedure-specific post-operative pain management (PROSPECT) guidelines. [16][17][18]20,24 Despite the low use of non-opioid multimodal analgesia, trials included in this review reported similar opioid requirements to that of two recent observational studies on opioid use in the clinical setting. ...
Background:
The leading principle in peri-operative pain management is multimodal analgesia, which reduces opioid requirements and associated adverse effects. Pragmatic pain trials should optimally test interventions in addition to multimodal non-opioid analgesics and interventions to ensure clinical relevance and baseline levels of opioid consumption that reflect clinical settings. We aimed to investigate opioid consumption and use of non-opioid analgesics administered adjunct to interventions in post-operative pain trials after total hip and knee arthroplasty.
Methods:
A systematic literature search was conducted 7 January 2020 in The Cochrane Library's CENTRAL, PubMed, and EMBASE. Trials investigating analgesic interventions for post-operative pain in adults undergoing total hip or knee arthroplasty were included. The primary outcome was the aggregated median 0-24 h post-operative opioid consumption. Further, we assessed the use of paracetamol, non-steroidal anti-inflammatory drugs, gabapentinoids, high-dose glucocorticoids, local infiltration analgesia and nerve blocks administered as co-interventions equally to all participants. We assessed trends over time for all outcomes.
Results:
Of 14,200 records, 570 trials were included. Median 0-24 h opioid consumption was 21 and 22 mg iv morphine equivalents in hip and knee arthroplasty trials, respectively. Meta-regression showed no overall linear correlation between opioid consumption and publication year. The use of multimodal non-opioid analgesia increased over time, though only 48% of trials published from 2010 to 2020 administered two or more non-opioid analgesics. Applying more non-opioid analgesics was associated with lower opioid consumption in intervention groups.
Conclusion:
Post-operative 0-24 h morphine consumption was median 21-22 mg. The demonstrated differences in non-opioid multimodal analgesic regimens between research and clinical settings, can potentially diminish the demonstrated opioid-sparing effects of trial interventions when such are implemented in a clinical context.
... Perioperative pain management is crucial with regards to patient satisfaction, early ambulation, improved patient outcome and cost-effectiveness. [1] The WHO, International Association for Study of Pain (IASP) and its European Federation declared that, 'Pain Management is a fundamental human right and the aim must be to turn it into a global reality. [2] An important concept in pain management is of pre-emptive analgesia. ...
... This is not least due to the fact that different and even contradictory demands are made on an optimal postoperative pain therapy: high analgesic efficacy without motor impairment and limitation of patient mobilization, good tolerability without dizziness, constipation or nausea, and an application controlled by the patient and adapted to his or her needs. In their review, Højer Karlsen et al. concluded that "[…] the available randomized placebo-controlled trials [do] not allow a designation of a 'best proven intervention'" [5]. ...
Background:
Insufficient pain control after lower limb arthroplasty results in delayed recovery and increased risk for pain chronicization. The ideal kind of analgesia is still discussed controversially. We conducted a retrospective analysis of single-center routine data from a German university hospital, including patients receiving either total hip (THA) or knee arthroplasty (TKA).
Methods:
All patients received general anesthesia. Patients undergoing THA received either continuous epidural ropivacaine infusion (0.133%, Epi) or patient-controlled analgesia (PCA) with the Wurzburg Pain Drip (tramadol, metamizole and droperidol, WPD) or with piritramide (Pir). After TKA, patients received either continuous femoral nerve block (ropivacaine 0.2%, PNB) or Pir.
Results:
The analyzed cohort comprised 769 cases. Use of WPD after THA (n = 333) resulted in significantly reduced Numeric Rating Scale (NRS) values at rest, compared to Epi (n = 48) and Pir (n = 72) (.75 [IQR 1.14] vs. 1.17 [1.5], p = .02 vs. 1.47 [1.33], p < .0001) as well as maximum NRS scores (2.4 [1.7] vs. 3.29 [1.94], p < .001 vs. 3.32 [1.76], p < .0001). Positive feedback during follow-up visits was significantly increased in patients with a WPD PCA (p < .0001), while negative feedback (senso-motoric weakness/technical problems/nausea/dizziness/constipation) was particularly increased in Epi patients and lowest in those with WPD (p < .0001). After TKA, Pir (n = 131) resulted in significantly reduced NRS values at rest, compared to PNB (n = 185) (1.4 [1.4] vs. 1.6 [1.68], p = .02). Positive feedback was increased in patients with a Pir PCA in comparison with PNB (p = .04), while negative feedback was increased in PNB patients (p = .04). Overall, WPD presented with the lowest rate of any complications (8.7%), followed by Pir (20.2%), PNB (27.6%) and Epi (31.3%) (p < .001).
Conclusions:
In the assessed population, the use of a WPD PCA after THA offered better pain control and patient comfort in comparison with continuous epidural or piritramide-based analgesia. After TKA, the use of a Pir PCA provided superior analgesia and a lower complication rate compared to continuous PNB.
