From the Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada.
Department of Anesthesia, Women's College Hospital, Toronto, Canada.
Anesth Analg. 2019 Jan;128(1):58-65. doi: 10.1213/ANE.0000000000002854.
The optimal management of pain after ambulatory anterior cruciate ligament reconstruction (ACLR) is unclear. Femoral nerve block (FNB) is purported to enhance postoperative analgesia, but its effectiveness in the setting of modern multimodal analgesia is unclear. This systematic review examines the effect of adding FNB to multimodal analgesia on analgesic outcomes after ACLR, whether or not the analgesic regimen used included local instillation analgesia (LIA). We retrieved randomized controlled trials evaluating the effects of adding FNB to multimodal analgesia on analgesic outcomes after ACLR, compared to multimodal analgesia alone (control). We designated postoperative opioid consumption at 24 hours as our primary outcome. Secondary outcomes included postoperative opioid consumption at 24-48 hours, rest, and dynamic pain severity between 0 and 48 hours, time to analgesic request, postanesthesia care unit and hospital stay durations, patient satisfaction, postoperative nausea and vomiting, functional outcomes, and long-term (>1 month) quadriceps strength. Eight randomized controlled trials (716 patients) were identified. Five trials compared FNB administration to control, and another 3 compared the combination of FNB and LIA to LIA alone. Compared to control, adding FNB resulted in modest reductions in 24-hour opioid consumption in 2 of 3 trials, and improvements in rest pain at 1 hour in 1 trial and up to 24 hours in another. In contrast, the combination of FNB and LIA, compared to LIA alone, did not reduce opioid consumption in any of the trials, but it did improve pain scores at 20 minutes only in 1 trial. The effect of FNB on long-term quadriceps strength or function after ACLR was not evaluated in the reviewed trials. Contemporary evidence suggests that the benefits of adding FNB to multimodal analgesia for ACLR are modest and conflicting, but there is no incremental analgesic benefit if the multimodal analgesic regimen included LIA. Our findings do not support the routine use of FNB for analgesia in patients having ACLR.
门诊前交叉韧带重建（ACLR）后疼痛的最佳管理方法尚不清楚。股神经阻滞（FNB）据称可以增强术后镇痛效果，但在现代多模式镇痛的背景下，其效果尚不清楚。本系统评价检查了在 ACLR 后多模式镇痛中添加 FNB 对镇痛效果的影响，无论所使用的镇痛方案是否包括局部灌洗镇痛（LIA）。我们检索了评估在 ACLR 后多模式镇痛中添加 FNB 对镇痛效果影响的随机对照试验，与多模式镇痛（对照组）相比。我们将术后 24 小时内的阿片类药物消耗量指定为主要结局。次要结局包括术后 24-48 小时内的阿片类药物消耗量、休息时和 0-48 小时内的动态疼痛严重程度、镇痛请求时间、麻醉后护理病房和住院时间、患者满意度、术后恶心和呕吐、功能结果和长期（>1 个月）股四头肌力量。确定了 8 项随机对照试验（716 名患者）。5 项试验比较了 FNB 给药与对照组，另外 3 项试验比较了 FNB 联合 LIA 与 LIA 单独比较。与对照组相比，3 项试验中的 2 项试验中，添加 FNB 导致 24 小时内阿片类药物消耗量适度减少，1 项试验中 1 小时内休息时疼痛改善，另 1 项试验中 24 小时内疼痛改善。相比之下，与 LIA 单独比较，FNB 联合 LIA 并没有在任何试验中减少阿片类药物的消耗，但在 1 项试验中仅在 20 分钟时改善了疼痛评分。在评价的试验中，没有评估 FNB 对 ACLR 后长期股四头肌力量或功能的影响。目前的证据表明，在多模式镇痛中添加 FNB 对 ACLR 的益处是适度和有冲突的，但如果多模式镇痛方案包括 LIA，则没有额外的镇痛益处。我们的研究结果不支持 ACLR 患者常规使用 FNB 进行镇痛。
