Continuous epidural block versus continuous popliteal nerve block for postoperative pain relief after major podiatric surgery in children: a prospective, comparative randomized study

Foot and ankle surgery in children is very painful postoperatively. Adverse effects from opioids and continuous epidural block (CEB) limit their use in children. Continuous popliteal nerve blocks (CPNB) have not been studied for this indication in children. In this prospective, randomized study we evaluated the effectiveness and adverse events of CPNB or CEB in children after podiatric surgery. Fifty-two children scheduled for foot surgery were separated into four groups by age and analgesia technique. After general anesthesia, 0.5 to 1 mL/kg of an equal-volume mixture of 0.25% bupivacaine and 1% lidocaine with 1:200000 epinephrine was injected via epidural or popliteal catheters. In the postoperative period, 0.1 mL x kg(-1) x h(-1) (group CPNB) or 0.2 mL x kg(-1) x h(-1) (group CEB) of 0.2% ropivacaine was administered for 48 h. Niflumic acid was routinely used. Adverse events were noted in each treatment group. Postoperative pain during motion was evaluated at 1, 6, 12, 18, 24, 36, and 48 h. Requirement for rescue analgesia (first-line propacetamol 30 mg/kg 4 times daily or second-line 0.2 mg/kg IV nalbuphine), and motor blockade were recorded. Parental satisfaction was noted at 48 h. Twenty-seven patients were included in the CEB groups and 25 in CPNB groups. There were 32 children 1 to 6 yr of age (CPNB = 15; CEB = 17) and 20 children 7 to 12 yr of age (CPNB = 10; CEB = 10). The demographic data were comparable among groups. Postoperative analgesia was excellent for the two continuous block techniques and in the two age groups. Motor block intensity was equal between techniques. Adverse events (postoperative nausea or vomiting, urinary retention, and premature discontinuation of local anesthetic infusion in the 1- to 6-yr-old group) were significantly more frequent in the CEB group (P < 0.05). Eighty-six percent of the parents in the CEB groups and 100% in the CPNB groups were satisfied. We conclude that although both CEB and CPNB resulted in excellent postoperative analgesia in this study, CPNB was associated with less urinary retention and nausea and vomiting. Therefore, we recommend CPNB as the ideal form of postoperative analgesia after major podiatric surgery in 1- to 12-yr-old children.     

Feasibility of ultrasound-guided peripheral nerve block catheters for pain control on pediatric medical missions in developing countries

Continuous peripheral nerve blocks (CPNB) are effective for postoperative pain management in children in the hospital and at home. CPNB techniques are particularly advantageous when compared with systemic or oral opioids on medical missions to unfamiliar environments with minimal monitoring capacity. In addition, ultrasound-guidance facilitates the placement of perineural catheters in anesthetized children even in the absence of commercially packaged regional anesthesia equipment. We present a series of successful cases employing ultrasound-guided CPNB for postoperative analgesia on medical missions and discuss the impact of this technology on present and future patients in underserved countries.     

连续外周神经阻滞在住院及门诊儿童患者手术后镇痛中的应用

背景本文是对连续外周神经阻滞（CPNB）在本院骨科患儿手术后镇痛中应用的一项核查结果。方法本研究对费城儿童医院2003年2月至2006年7月间，儿童患者应用CPNB行手术后镇痛的局部麻醉登记和医疗记录进行了回顾。在手术后对所有患儿进行随访，直至CPNB作用消退和（或）任何与之相关并发症消失。同期采集的资料还包括感觉及运动阻滞情况、住院患儿的疼痛评分、阿片类药物的使用以及与CPNB相关的并发症。结果217例患儿共放置了226根周围神经阻滞导管（简称导管）。其中108例患儿（112根导管）出院回家后仍进行CPNB。患儿的年龄为4岁至18岁（13．7±3．4）岁。根据患儿的体重和导管放置的位置，以2—12ml/h的初始速度输注局部麻醉药物[0．125％的布比卡因（n=164）]、0．1％的罗哌卡因（n=12）或0．15％的罗哌卡因（n=27））。局部麻醉药平均输注时间为48．4±29．3小时（范围：0～160小时）。手术后最初8、24和48小时不需任何阿片类药物的患儿比例分别为56％、26％、21％。手术后恶心、呕吐的发生率为14％（门诊患儿为13％，住院患儿为15％），记录的并发症发生率为2．8％。3例患儿肢体麻木感时间延长（〉24小时），最终自行恢复；1例患儿发生表皮蜂窝组织炎，经1个疗程的抗生素治疗后消退；1例在家拔除导管困难；还有1例进行CPNB24小时后出现耳鸣，停药并随后拔除导管后症状迅速缓解。结论在专家指导下，对住院及门诊患儿骨科手术后使用CPNB进行手术后镇痛具有可行性。对患者及家属的宣传教育以及定期的随访非常重要，有助于迅速发现和及时处理不良事件。     

Continuous interscalene brachial plexus block for postoperative pain control at home: a randomized,double-blinded,placebo-controlled study

In this study, we investigated the efficacy of patient-controlled regional analgesia for outpatients undergoing moderately painful orthopedic surgery of the shoulder. Preoperatively, patients (n = 20) received an interscalene nerve block and perineural catheter. Postoperatively, patients were discharged home with both oral opioids and a portable infusion pump delivering either 0.2% ropivacaine or 0.9% saline, determined randomly in a double-blinded manner. Daily end points included pain scores, opioid use and side effects, sleep quality, and technique complications. Ropivacaine (n = 10) infusion significantly reduced pain compared with saline (n = 10) infusion. The average pain at rest (scale: 0-10) on postoperative day 1 (median, 25th-75th percentiles) was 4.8 (4.0-5.0) for the saline group, versus 0.0 (0.0-2.0) for the ropivacaine group (P < 0.001). Oral opioid use and related side effects were also significantly decreased in the ropivacaine group. On postoperative day 1, median tablet consumption was 8.0 (6.5-9.5) and 0.5 (0.0-1.0) for the saline and ropivacaine groups, respectively (P < 0.001). Sleep disturbance scores were nearly threefold greater on the first postoperative night for patients receiving saline (P = 0.013). We conclude that after moderately painful orthopedic surgery of the shoulder, ropivacaine infusion using a portable infusion pump and an interscalene perineural catheter at home decreased pain, opioid use and related side effects, and sleep disturbances. IMPLICATIONS: This randomized, double-blinded, placebo-controlled study demonstrated that ropivacaine, infused with a portable infusion pump via an interscalene perineural catheter for 3 days at home, significantly decreased postoperative pain after orthopedic surgery of the shoulder. In addition to providing potent analgesia and increasing patient satisfaction, perineural infusion decreased opioid requirements and their associated side effects.     

The severity and duration of postoperative pain and analgesia requirements in children after tonsillectomy, orchidopexy, or inguinal hernia repair

Objectives: To provide parents of children with accurate information regarding postoperative pain, its management, and functioning following common surgical procedures. Background: The increasing prevalence of pediatric day‐case procedures demands a more thorough understanding of the recovery profiles associated with these operations. Aim: To document postdischarge pain profiles, analgesia requirements, and functional limitation in children following tonsillectomy, orchidopexy, or inguinal hernia repair (IHR). Methods: Following hospital discharge, parents were asked to record their children’s pain levels, analgesia consumption, and degree of functional limitation each day until complete recovery. Pain and functional limitation were measured using the Parents’ Postoperative Pain Measurement (PPPM) scale and Functional Activity Score, respectively. Significant pain was defined as PPPM ≥ 6. Results: One hundred and five patients (50, tonsillectomy; 24, orchidopexy; and 31, IHR) were recruited. Median PPPM was always <6 after IHR, ≥6 only on day 1 after orchidopexy and persisted through to day 8 after tonsillectomy. Mild or severe functional limitation was observed after all surgeries and persisted for 4, 5, and 4 days after median PPPM < 6 after IHR, orchidopexy, and tonsillectomy, respectively. Combination analgesia was commonly administered after orchidopexy and tonsillectomy but less so after IHR. The general practitioner consultation rate following tonsillectomy was 54%. Conclusions: After tonsillectomy, children experience significant pain and severe functional limitation for 7 days after surgery. For many children, pain and functional limitation persists throughout the second postoperative week. In children undergoing orchidopexy, paracetamol and ibuprofen provide adequate analgesia. Pain begins to subside after the first postoperative day, and normal activity resumes after 7 days. After IHR, children experience mild pain that can be treated with paracetamol and return to normal functioning after 4 days.     

Parents' perceptions and use of analgesics at home after children's day surgery

BACKGROUND: Children are found to suffer from unnecessarily severe postoperative pain following day surgery. Reasons for parents' insufficient use of analgesics may be based on misleading perceptions of children's analgesics. The purpose of this study was to describe parents' perceptions and use of analgesics for children after discharge at home. METHODS: In this survey, 840 questionnaires were given to parents, and answers from 201 mothers and 114 fathers whose children, aged 1-6 years, had undergone day surgery in 10 Finnish hospitals are presented. RESULTS: One-third (36%) of the children were assessed as having moderate or severe postoperative pain after discharge. More than three-quarters of the parents had given analgesics to the child. Analgesics were given mostly to children who were assessed to have pain and found to have several types of pain behaviour. Most of the parents had accurate perceptions of children's analgesics, but some of them had misleading perceptions of the nature and adverse effects of children's analgesics, which were related to giving analgesics to the child. Fathers, more often than mothers, seem to have such misleading perceptions. CONCLUSIONS: Parents tended to give analgesics to children who actually needed pain alleviation. Parents' perceptions of children's analgesics were mostly accurate. However, misleading perceptions of children's analgesics also exist among the parents. These misleading perceptions appear to decrease parents' use of children's postoperative pain medication.     

Postoperative symptoms at home following day-case surgery in children: a multicentre survey of 551 children

The incidence and duration of postoperative symptoms in children at home following day-case anaesthesia and surgery was evaluated using a questionnaire completed by parents of 551 children aged 4 months to 13.4 years (mean 3.8 years). They also evaluated the instructions given in hospital for care at home. The incidence of all symptoms was highest at home on the day of the operation. No postoperative symptoms were reported in 79 (14%) children. The incidence of pain was 56% and the only significant predictor was the type of operation, tonsillectomy being the most problematic (mild pain in 38% and severe in 25%; pain lasted 7 days or longer in 33%). Analgesics were given to 78% of all the children reported to have pain on the day of the operation, to 60% the next day and later to 58%; 19 (3%) children were given more than two doses per day. The instructions given in hospital for the treatment of pain were considered inadequate by 12% of parents. Postoperative nausea and vomiting occurred in 13% of children. Predictors by multiple stepwise logistic regression analysis were emetic symptoms in hospital, pain at home, age > 5 years and administration of postoperative opioid (pethidine or fentanyl). Opioid given during anaesthesia (fentanyl or alfentanil) did not increase the incidence. Emetic symptoms were most common after tonsillectomy (31%). The highest incidences of emetic symptoms (37%), sedation (96%) and dizziness (41%) occurred in children who had been given fentanyl for postoperative pain. Undertreatment of nausea in hospital was evident as only two children had received anti-emetics, even though 61 were reported to have emetic symptoms. Administration of effective anti-emetics should be encouraged, as emetic symptoms in hospital were the most significant predictor of nausea and vomiting at home. Treatment of pain at home and instructions for treatment of pain need to be improved.     

Patient outcomes after axillary lymph node dissection for breast cancer: use of postoperative continuous local anesthesia infusion

BACKGROUND: Although considered a safe surgical procedure, axillary lymph node dissection (ALND) is associated with postoperative numbness, paresthesias, pain, and muscle weakness. Despite meticulous surgical technique and the absence of long thoracic or thoracodorsal nerve injury, the risk of these complications are reported as great as 35% to 50%, with a subset of patients developing chronic pain syndromes. METHODS: Female patients (n = 27) undergoing Level I-II ALND for breast cancer were recruited. After ALND, patients were randomized to three groups. Group 1 received standard axillary lymph node dissection. Patients assigned to group 2 or 3 (double-blinded) received 120 h continuous 0.9% saline solution or 0.5% bupivacaine using a catheter placed into the axilla and delivered by an elastomeric pump device. After routine postoperative care, patients were discharged with oral opioid analgesics. Twice-daily assessment of pain, sedation, and nausea were conducted using validated visual-analog scale measures. Daily and total opioid analgesic requirements after surgery were recorded. RESULTS: Patients treated with a continuous infusion of bupivacaine experienced significantly lower pain scores (P < 0.001) during the first 5 postoperative days. Postoperative opioid analgesic requirements also were significantly decreased in the bupivacaine group, and these effects persisted until postoperative day 14 (P < 0.001). Concomitant to the observed decreases in pain and oral opioid requirements, nausea and morning sedation also were significantly reduced. There were no pump-related complications, wound infections, or postoperative axillary fluid collections. CONCLUSIONS: The use of continuous administration of bupivicaine after ALND significantly decreases pain and opioid analgesic requirements, with concomitant decreases in nausea and sedation. This study provides encouraging evidence of the therapeutic benefits of continuous infusion of local anesthesia and may represent a valuable adjunct for surgical patients who require ALND, including those with breast cancer and melanoma.     

Local anesthetic infusion pumps improve postoperative pain after inguinal hernia repair: a randomized trial

Pain after an open inguinal hernia repair may be significant. In fact, some surgeons feel that the pain after open repair justifies a laparoscopic approach. The purpose of this study was to determine if the use of local anesthetic infusion pumps would reduce postoperative pain after open inguinal hernia repair. We performed a prospective, double-blind randomized study of 45 open plug and patch inguinal hernia repairs. Patients were randomized to receive either 0.25 per cent bupivicaine or saline solution via an elastomeric infusion pump (ON-Q) for 48 hours, at 2 cc/h. The catheters were placed in the subcutaneous tissue and removed on postoperative day 3. Both groups were prescribed hydrocodone to use in the postoperative period at the prescribed dosage as needed for pain. Interviews were conducted on postoperative days 3 and 7, and patient's questionnaires, including pain scores, amount of pain medicine used, and any complications, were collected accordingly. During the first 5 postoperative days, postoperative pain was assessed using a visual analog scale. Twenty-three repairs were randomized to the bupivicaine group and 22 repairs randomized to the placebo group. In the bupivicaine group, there was a significant decrease in postoperative pain on postoperative days 2 through 5 with P values <0.05. This significant difference continued through postoperative day 5, 2 days after the infusion pumps were removed. Patients who had bupivicaine instilled in their infusion pump had statistically significant lower subjective pain scores on postoperative days 2 through 5. This significant difference continued even after the infusion pumps were removed. Local anesthetic infusion pumps significantly decreased the amount of early postoperative pain. Pain relief persisted for 2 days after catheter and pump removal.     

超声引导下留置持续外周神经阻滞导管的院外管理：620例患者的经验总结

背景持续外周神经阻滞（continuous peripheral nerve block，CPNB）是骨科手术术后镇痛的最佳选择，但鉴于对置管相关并发症的顾虑，该方法并不常规用于门诊患者，同时在此情况下很难保证患者随时与医生进行联系。本研究对620例按照预设方案接受CPNB的门诊病例进行了分析。方法所有导管均在超声直视下置入。每个患者在手术前都接受充分的口头和书面指导，手术后由麻醉医生提供随时的电话随访服务。所有患者手术后第1天都会在家中接到电话随访。另外，每个患者出院后两周内要接受外科医生复查。结果620例病例中，190例为肌间沟（臂丛神经）置管，206为髂筋膜（股神经）置管，224例为腘窝（坐骨神经）置管。2例患者（0．3％）出现神经阻滞相关的并发症；其症状在手术后6周内得到了缓解；26例患者（4．2％）需要麻醉医生的手术后干预；1例患者返回医院拔除导管。结论此项对大样本门诊患者接受CPNB治疗的研究发现，仅有极少部分患者需要麻醉医生干预。同样，患者可以在家中自行管理和拔除导管而不需要额外随访。这一发现说明给予充分的手术前指导以及与医生进行电话沟通，患者可以舒适地在家中管理并拔除CPNB导管。     

Paediatric day care surgery: a hidden burden for primary care?

The aims of this study were to identify prospectively 'concealed' postoperative problems, to assess the burden of paediatric day care surgery on primary care services and to define a normal recovery period for common children's procedures. At their first postoperative clinic visit, patients and parents were asked directly about postoperative problems, unscheduled contacts with the hospital or other health professionals, and the time taken to resume normal activity and return to school. A total of 651 children, median age 4 years (range 0-16 years) were included. Median time to the first clinic appointment was 42 days (range 4-235 days). There were 100 unscheduled postoperative contacts (15.5% of all episodes) of which 81 were with general practitioners. Most problems recorded were relatively minor, and most requiring major intervention were identified before the child left hospital. There was a very high incidence of wound related problems after circumcision. Most children were 'back to normal' within a few days (median 2 days, range 0-30 days) and back to school within a week (median 6 days, range 1-20 days). There was a high rate of primary care contact despite clear written and verbal advice given in hospital and the offer of open access for any concerns. Recovery from day care surgery was rapid and overall level of patient satisfaction was high.     

下肢截肢术后持续周围神经阻滞的作用：对幻肢综合征症状的影响

背景达90％的截肢者在肢体截肢术后会产生幻肢综合征（phantom limb syndroms，PLS）。尽管现在有很多不同的治疗方法，但没有一种是显著有效的。因此，我们评估了高浓度的局麻药在外周神经的持续输注对预防PLS的效果。方法在术前或术中给71例行下肢截肢术的患者放置一周围神经导管，通过弹力输注泵（非电子）在术中开始以5ml／h的速率持续输注0．5％罗哌卡因，并且持续到术后的第4—83天。在术后的第1天，第1、2、3、4周和第3、6、9、12月评估PLS。为了评估患者在接受罗哌卡因输注时PLS是否存在及其严重程度，在每次评估前中断6—12小时的给药（即直至肢体感觉的恢复）。幻肢痛和残肢痛的程度由5分级的VRS评分系统来评分，其中0分代表无疼痛，4分代表不能忍受的疼痛，而幻肢的感觉被记录为存在或者不存在。如果VRS评分大干1分或者有显著的幻肢感觉出现，罗哌卡因立即以5ml／h的速率重新开始输注。如果患者的VRS评分持续为0或1分并且无幻肢感觉达48小时，则输注完全停止并移除导管。结果局麻药的持续输注时间的中位数是30天（95％的可信区间，25-30天）。在术后第1天，73％的患者主诉有严重的或者不能忍受的疼痛（VRS评分大于2分）。但是，在12个月的评估期的最后患者“严重到不能忍受”的幻肢痛的发生率仅为3％。在第12个月末，患者VRS疼痛评分的百分比：84％的患者为0分，10％的患者为1分，3％的患者为2分，3％的患者为3分，没有患者为4分。但是，在12个月的评估期的最后仍有39％的患者有幻肢感觉。所有患者都能在家中应用这种弹力输注系统。结论术后予以0．5％的罗哌卡因于神经周的持续输注可能是下肢截肢术后治疗幻肢痛和幻肢感觉的有效方法。     

Acute neck cellulitis and mediastinitis complicating a continuous interscalene block

We report a case of acute neck cellulitis and mediastinitis complicating a continuous interscalene brachial plexus block. A 61-yr-old man was scheduled for an elective arthroscopic right shoulder rotator cuff repair. A continuous interscalene block was done preoperatively and 20 mL of 0.5% bupivacaine and 20 mL of 2% mepivacaine were injected through the catheter. Postoperative analgesia was provided by a continuous infusion of bupivacaine, 0.25% at 5 mL/h for 39 h using a 240-mL elastomeric disposable pump. The day after surgery, the patient complained of neck pain. The analgesic block was not fully effective. He was discharged home. Three days later, the patient was readmitted with neck edema and erythema, fever and fatigue. Neck ultrasonography and computed tomographic scan revealed an abscess of the interscalene and sternocleidomastiod muscles and cellulitis, as well as acute mediastinitis. Two blood cultures and surgical samples were positive for Staphylococcus aureus. The infection was treated with surgery, the site was surgically debrided, and a 2-mo course of vancomycin, imipenem, and oxacilline. The technique of drawing local anesthetic from the bottle and filling the elastomeric pump was the most likely cause of infection. This case emphasizes the importance of strict aseptic conditions during puncture, catheter insertion, and management of the local anesthetic infusate.     

Cost-effectiveness analysis of patient-controlled analgesia compared to continuous elastomeric pump infusion of tramadol and metamizole

OBJECTIVES: Little information is available on the cost-effectiveness of postoperative patient-controlled analgesia (PCA). The present study compared PCA to continuous infusion by elastomeric pump. MATERIAL AND METHODS: Fifty ASA 1 or 2 patients undergoing major gynecologic surgery were enrolled for a randomized controlled trial to evaluate the effectiveness and costs derived from intravenous PCA with metamizole and tramadol compared to continuous infusion of the same analgesic solution by elastomeric pump in the 48 hours following surgery. Patient satisfaction and side effects were also recorded. RESULTS: The analgesic effectiveness and side effects of the 2 regimens were similar, although 61% of patients in the elastomeric pump group needed morphine for rescue analgesia compared to 33% in the PCA group (P < .05). In the PCA group, 81% of the patients said they would repeat the analgesic treatment compared to only 56% in the elastomeric pump group (P = .05). The mean number of nursing interventions was 16 for the PCA group and 19 for the elastomeric pump group. The mean cost of the treatment (not including the PCA pump, provided by the manufacturer) was Euros 41.35 for the PCA group and Euros 56.22 for the elastomeric pump group. CONCLUSIONS: The analgesic efficacy of the 2 regimens was similar. However, patient satisfaction was greater with PCA and use of an elastomeric pump was more expensive. In the setting of the present study, postoperative PCA proved to be more advantageous than continuous elastomeric pump infusion.     

Continuous interscalene brachial plexus blockade provides good analgesia at home after major shoulder surgery-report of four cases

PURPOSE: Continuous interscalene brachial plexus blockade (CIBPB) in a hospital setting can provide excellent surgical conditions and postoperative analgesia for major shoulder surgery. This is a case report of four patients on the efficacy and advantages of CIBPB for postoperative analgesia at home. CASE REPORTS: Four patients scheduled for rotator cuff repair under CIBPB were discharged home the day of surgery with an interscalene catheter connected to an automated infusion pump administering 0.2% ropivacaine at 10 mL x hr(-1) for 72 hr. Prior to discharge, patients and their attendant were given verbal and written instructions concerning local anesthetic toxicity and explicit contact information for an anesthesiologist or nurse. Outcomes were measured pre- and postoperatively, including verbal analogue pain scores (pain VAS), verbal analogue nausea scores (nausea VAS), side effects, cognitive function (mini-mental state questionnaire), sleep (hours/night), and patient satisfaction (Likert scale). Postoperative VAS scores over three days were very low. Two patients reported only one episode of nausea. There were no complications associated with local anesthetic toxicity or catheter use. Cognitive function improved over three days. Sleep increased from a mean of five hours before surgery to seven hours over the next three nights. Patient satisfaction with care was high. Significant cost savings were documented. CONCLUSION: The use of CIBPB for 72 hr in patients undergoing major ambulatory shoulder surgery can result in good analgesia with minimal opioid requirement, cost savings and possibly improvement in outcome measures.     

Post-operative symptoms at home in children following day case surgery

BACKGROUND: This prospective questionnaire-based study examined the post-operative symptoms encountered by children who had day case surgery at a dedicated day case surgery unit. The study evaluated the postoperative symptoms at home. The parents also evaluated the instructions given in the hospital for care at home. METHODS: All children aged 1 day - 14 years operated over a one year period were prospectively followed up following elective day case surgery. The incidence and duration of symptoms were evaluated using a structured questionnaire completed by the parents. Also, the instructions given in hospital for care at home were evaluated by the parents using another questionnaire. RESULTS: A total of 100 children were operated during the period. Pain (72%), emetic symptoms (16%) and difficulty with walking (7%) were the commonest symptoms occurring on the way home. There were no unplanned admissions. Two thirds of the parents did not know enough of the treatment of the wound and of the overall recovery of the child. CONCLUSION: Post operative symptoms following elective day case surgery are amenable to treatment and prevention with a wider use of available drugs for peri-operative analgesia.     

Continuous infraclavicular brachial plexus block for postoperative pain control at home: a randomized,double-blinded,placebo-controlled study

BACKGROUND: This randomized, double-blinded, placebo-controlled study investigated the efficacy of patient-controlled regional analgesia using an infraclavicular brachial plexus perineural catheter and a portable infusion pump for outpatients undergoing moderately painful, upper extremity orthopedic surgery. METHODS: Preoperatively, patients (n = 30) received an infraclavicular nerve block and perineural catheter. Postoperatively, patients were discharged home with oral narcotics and a portable infusion pump delivering study solution (0.2% ropivacaine or 0.9% saline) via the catheter for 3 days. Investigators and patients were blinded to random group assignment. Daily end points included pain scores at rest and with limb movement, narcotic use and side effects, sleep quality, patient satisfaction, and symptoms of catheter- or local anesthetic-related complications. RESULTS: Ropivacaine (n = 15) infusion significantly reduced pain compared with saline (n = 15) infusion (P < 0.001). For example, the average pain with movement (scale, 0-10) on postoperative day 1 was 6.1 +/- 2.3 for the saline group versus 2.5 +/- 1.6 for the ropivacaine group (P < 0.001). Oral narcotic use and related side effects were significantly decreased in the ropivacaine group. For example, on postoperative day 1, mean tablet consumption was 5.5 +/- 2.4 and 1.7 +/- 1.6 for the saline and ropivacaine groups, respectively (P < 0.001). Sleep disturbance scores were 10-fold greater for saline administration than for ropivacaine infusion (P < 0.001). Overall satisfaction was significantly greater in the ropivacaine group. No catheter- or local anesthetic-related complications occurred. CONCLUSION: After moderately painful orthopedic surgery of the upper extremity, ropivacaine infusion using a portable, mechanical pump and an infraclavicular brachial plexus perineural catheter at home decreased pain, sleep disturbances, narcotic use and related side effects, and improved overall satisfaction.     

Effect of patient-controlled perineural analgesia on rehabilitation and pain after ambulatory orthopedic surgery: a multicenter randomized trial

BACKGROUND: Efficacy of continuous perineural and patient-controlled ropivacaine infusion at home after orthopedic surgery was compared with patient-controlled intravenous morphine for functional recovery and postoperative analgesia in a multicenter randomized trial. METHODS: Eighty-three patients scheduled to undergo acromioplasty or hallux valgus surgery received an interscalene (n = 40) or popliteal (n = 43) peripheral nerve block with 30 ml ropivacaine, 0.5%. After randomization, patients were discharged home 24 h after surgery with a disposable infusion pump delivering either patient-controlled intravenous morphine (n = 23) or perineural 0.2% ropivacaine infusion, either continuous infusion without bolus (n = 30) or basal infusion plus bolus (n = 30). The patients recorded pain scores on movement and/or walking and were directed to take paracetamol and rescue analgesics if necessary. The time necessary to be able to walk for 10 min; daily activities on days 1, 2, and 3; adverse events; and overall satisfaction scores were noted and graded by the patient. RESULTS: Basal-bolus ropivacaine decreased the time to 10 minutes' walk, optimized daily activities (P < 0.01), and decreased the amount of ropivacaine used. The morphine group had greater pain scores and consumption of morphine and ketoprofen compared with both ropivacaine groups (P < 0.05). The incidence of nausea/vomiting, sleep disturbance, and dizziness increased, and the patient satisfaction score decreased in the morphine group (P < 0.05). CONCLUSIONS: After ambulatory orthopedic surgery, 0.2% ropivacaine delivered as a perineural infusion using a disposable elastomeric pump with patient-controlled anesthesia bolus doses optimizes functional recovery and pain relief while decreasing the consumption of rescue analgesics and ropivacaine, and the number of adverse events.     

Peripheral catheter techniques

With ultrasound, continuous peripheral nerve blocks (CPNBs) are one of the most recent developments in regional anesthesia in children. CPNBs are now used more widely in children because more suitable materials have been marketed, allowing complete, and prolonged postoperative pain control. Their use after orthopedic procedures in children and treatment for complex regional pain syndrome in adolescents has demonstrated the benefits. Perineural catheters have also shown their superiority over other techniques of continuous regional anesthesia in terms of side effects. The efficiency and the safety of these techniques may facilitate early ambulation with improved pain management, treatment at home with disposable pumps, and improved rehabilitation of children. Studies on large cohorts of patients published to date have failed to highlight any severe complications in their use compared with other adult studies. Accidents owing to systemic toxicity are very unlikely if the recommended maximum dose is not exceeded. The safety of continuous regional anesthesia techniques in children relies on the use of low-concentration l-enantiomer solutions (ropivacaine or levobupivacaine) accompanied by low plasma concentrations of local anesthetics, limiting the risk of systemic toxicity of these molecules. CPNB can ensure strong and lasting analgesia in hospital or at home.