Department of Anesthesiology, University of California San Diego, San Diego, CA, USA Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, USA VA Healthcare System, San Diego, CA, USA Department of Anesthesiology, University of California San Francisco, San Francisco, CA, USA Department of Anesthesiology, Alta Bates Summit Medical Center, Oakland, CA, USA Department of Orthopaedics, Alta Bates Summit Medical Center, Oakland, CA, USA Department of Anesthesiology, University of Florida, Gainesville, FL, USA Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA Department of Epidemiology and Health Policy Research, University of Florida, Gainesville, FL, USA General Clinical Research Center, University of Florida, Gainesville, FL, USA.
Pain. 2010 Sep;150(3):477-484. doi: 10.1016/j.pain.2010.05.028. Epub 2010 Jun 22.
A continuous femoral nerve block (cFNB) involves the percutaneous insertion of a catheter adjacent to the femoral nerve, followed by a local anesthetic infusion, improving analgesia following total knee arthroplasty (TKA). Portable infusion pumps allow infusion continuation following hospital discharge, raising the possibility of decreasing hospitalization duration. We therefore used a multicenter, randomized, triple-masked, placebo-controlled study design to test the primary hypothesis that a 4-day ambulatory cFNB decreases the time until each of three predefined readiness-for-discharge criteria (adequate analgesia, independence from intravenous opioids, and ambulation 30m) are met following TKA compared with an overnight inpatient-only cFNB. Preoperatively, all patients received a cFNB with perineural ropivacaine 0.2% from surgery until the following morning, at which time they were randomized to either continue perineural ropivacaine (n=39) or switch to normal saline (n=38). Patients were discharged with their cFNB and portable infusion pump as early as postoperative day 3. Patients who were given 4 days of perineural ropivacaine attained all three criteria in a median (25th-75th percentiles) of 47 (29-69)h, compared with 62 (45-79)h for those of the control group (Estimated ratio=0.80, 95% confidence interval: 0.66-1.00; p=0.028). Compared with controls, patients randomized to ropivacaine met the discharge criterion for analgesia in 20 (0-38) versus 38 (15-64)h (p=0.009), and intravenous opioid independence in 21 (0-37) versus 33 (11-50)h (p=0.061). We conclude that a 4-day ambulatory cFNB decreases the time to reach three important discharge criteria by an estimated 20% following TKA compared with an overnight cFNB, primarily by improving analgesia.
连续股神经阻滞（cFNB）涉及经皮将导管插入股神经附近，然后进行局部麻醉剂输注，可改善全膝关节置换术（TKA）后的镇痛效果。便携式输注泵可在出院后继续输注，从而有可能缩短住院时间。因此，我们采用多中心、随机、三盲、安慰剂对照研究设计来检验主要假设，即与仅在住院过夜的股神经阻滞相比，为期 4 天的门诊 cFNB 可减少 TKA 后达到三个预定出院标准（充分镇痛、无需静脉内阿片类药物以及能够行走 30 米）的时间。术前，所有患者在手术时均接受股神经周围罗哌卡因 0.2%的 cFNB，直至次日早晨，此时他们被随机分配继续接受股神经周围罗哌卡因（n=39）或改用生理盐水（n=38）。患者可以在术后第 3 天尽早带着股神经阻滞和便携式输注泵出院。接受 4 天股神经周围罗哌卡因的患者中位数（25 至 75 百分位数）在 47（29-69）小时内达到了所有三个标准，而对照组的中位数为 62（45-79）小时（估计比值=0.80，95%置信区间：0.66-1.00；p=0.028）。与对照组相比，随机接受罗哌卡因的患者在 20（0-38）小时而非 38（15-64）小时内达到了镇痛的出院标准（p=0.009），在 21（0-37）小时而非 33（11-50）小时内达到了静脉内阿片类药物独立的出院标准（p=0.061）。我们的结论是，与仅在住院过夜的股神经阻滞相比，TKA 后接受为期 4 天的门诊 cFNB 可使达到三个重要出院标准的时间估计缩短 20%，主要是通过改善镇痛效果。
