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Abstract |
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We prospectively studied the continuous "modified" femoral three-in-one block for postoperative pain after total knee arthroplasty. Sixty-two patients undergoing elective knee arthroplasty under spinal anesthesia with bupivacaine (B) and fentanyl were randomized to receive 0.2% B, 0.1% B, or placebo at 10 mL/h for 48 h after an initial bolus of 30 mL of the same solution via the femoral block catheter. The catheters were inserted under the fascia iliaca using a "double pop" technique and a peripheral nerve stimulator and were advanced 15–20 cm cranially. Venous plasma levels of B, desbutylbupivacaine, and 4-hydroxy B were measured daily for 3 days. All patients received patient-controlled analgesia with morphine and indomethacin suppositories for 48 h. Using computed tomography, we evaluated the catheter location for 20 patients. The catheter tips, located superior to the upper third of the sacroiliac joint in the psoas sheath, were labeled as ideally located. The group receiving 0.2% B had a larger block success rate, smaller morphine consumption in the immediate postoperative period (15 vs 22 mg) and during the first postoperative day (9 vs 18 mg), and achieved a greater range of motion in the immediate postoperative period (91° ± 10° vs 80° ± 13°). Visual analog scores for pain during both rest and activity were low but similar between the groups. Forty percent of the catheters evaluated were ideally located. Ideal location and use of 0.2% B resulted in 100% success of blockade of all three nerves. The S1 root was blocked in up to 76% of patients. The plasma levels of B, 4-hydroxy B, and des-butylbupivacaine were below the toxic range during the infusion. We conclude that continuous fascia iliaca block with 0.2% B results in opioid-sparing and improved range of motion during the immediate postoperative period. Larger doses of bupivacaine may safely be used in the immediate postoperative period if needed.
Implications: Continuous fascia iliaca block with 0.2% bupivacaine reduces opioid requirements and improves range of motion in the immediate postoperative period compared with a placebo and 0.1% bupivacaine. Plasma levels are below the toxic range with this dose. Only 40% of the catheters are positioned in the ideal location. With the smaller dose of bupivacaine, the success rate with this block is small.
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Introduction |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Total knee joint arthroplasty is associated with significant postoperative pain. This subset of patients has an increased risk of deep venous thrombosis and, therefore, receives perioperative prophylactic anticoagulants such as coumadin. Response to coumadin can be variable in a group of elderly patients, resulting in unacceptably prolonged prothrombin time, which may increase the risk of catheter removal with epidural analgesia (1). The knee joint is supplied by the femoral, obturator, and sciatic nerves. Some cutaneous areas of surgical incision after knee arthroplasty are in the lateral femoral cutaneous nerve distribution. The osteotomal segments of femur and tibia in the knee joint supplied by the sciatic nerve are from the S1 root (2). Femoral three-in-one block, described originally by Winnie et al. (3), produces blockade of femoral, obturator, and lateral femoral cutaneous nerves and has been investigated in the treatment of postoperative pain after knee arthroplasty with variable results (4–10). Some investigators have found that the obturator nerve is often not blocked by this technique (11). Dalens et al. (12) state that "a multi-effective block can only develop when the local anesthetic is introduced behind the fascia iliaca." We initially tried the continuous fascia iliaca block with the catheter inserted at least 20 cm cranially and observed sensory block in the S1 distribution in a few patients using 0.25% bupivacaine. Some of these patients did not use any opiates in the immediate postoperative period. We report the efficacy of this modified block for postoperative pain after knee arthroplasty.
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Methods |
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After we recieved institutional review board approval, 62 consenting adults of either sex between the ages of 18 and 80 yr, ASA physical status I–III, scheduled for elective unilateral knee arthroplasty, were included in the study. Patients who had significant medical or psychiatric problems, were unable to cooperate with the study protocol, had contraindications to spinal anesthesia, or had allergy to bupivacaine, indomethacin, morphine, or codeine were excluded. Patients were randomized to one of three groups to receive 0.2% bupivacaine (0.2%B), 0.1% bupivacaine (0.1%B), or saline as placebo (S) via the femoral catheter. All patients received a spinal anesthetic with hyperbaric bupivacaine 13–15 mg, fentanyl 13–15 µg, and epinephrine 100 µg at the L2-4 interspace. Intraoperative sedation consisted of titrated doses of midazolam and propofol infusion. The range of knee flexion achieved at the end of surgery was documented.
At the end of surgery, the fascia iliaca block was initiated using a bullet-tipped needle and catheter using a "double pop" technique to enter the fascia iliaca 1.5 cm lateral to the femoral artery. The needle tip location was further adjusted using a peripheral nerve stimulator to achieve good quadriceps contractions with <0.8 mA of current. The sheath was distended with 20 mL of the study solution, and the cannula was advanced further 1 cm. Through this cannula, a 20-gauge styletted epidural catheter was advanced at least 20 cm cranially. An additional 10 mL of the solution was injected via this catheter. The catheter was secured, and an infusion of study drug was started on arrival in the recovery room at a rate of 10 mL/h and continued for 48 h. The ease of insertion of the catheter and the length at skin were recorded.
All patients had venous blood drawn for the measurement of bupivacaine and its metabolites on arrival in the recovery room and daily for the next 3 days at 8:00 AM. The serum was separated from the blood within 1 h, stored at -70°C, and analyzed using a Hewlett-Packard (Palo Alto, CA) modular HP 1100 system with the variable wavelength detector set at 205 NM and a 15 cm reversed phase DB-18 column (Supelco Park, Bellafonte, PA). Gradient elution was done with a mixture of acetonitrile and phosphate buffer at a pH of 2.6. Liquid-liquid extraction was done using a mixture of cyclohexane and dichloromethane, using mepivacaine as internal standard. The lower limit of detection was 0.1 µg for bupivacaine and des-butylbupivacaine and 0.04 µg for 4-hydroxy bupivacaine.
All patients received 100 mg of indomethacin rectally every 12 h for 48 h. Patients also had access to morphine via patient-controlled analgesia (PCA), started at a dose of 1.5 mg with a lockout time of 6 min. The dose of morphine was increased to 2 mg if the attending nurse deemed the pain control poor and the Visual Analog Scale (VAS) pain score was greater than 50 on a 100-mm scale (0 = no pain, and 100 = worst pain possible). Morphine consumption every 12 h was obtained from the PCA printouts.
An independent observer, blinded to the randomization, evaluated VAS scores for pain during rest and movement twice daily starting on the evening of surgery. Sensory testing was done in the femoral, lateral femoral cutaneous, obturator distribution, and along the lateral side of foot (S1 distribution) twice daily using ice. Motor block was not evaluated objectively. Patients were asked about subjective weakness in their thigh muscles during physiotherapy. The incidence of nausea and vomiting were noted. Patients were asked specific questions during these visits to elicit any signs of local anesthetic toxicity.
At the end of 48 h of infusion, computed tomography (CT) was performed in 20 patients. Contiguous 10-mm scans were acquired from the level of the lesser trochanter to the mid lumbar spine after the injection of 1–3 mL of dilute (10%) lopamidol-300 (Isovue, Squibb Diagnostics-Canada, Montreal, Quebec, Canada) through the indwelling catheter. The course of the catheter was documented, as well as the level and location of the catheter tip. The interpretations were done by one radiologist. Catheters were labeled "ideal" if the course of the catheter was along the iliopsoas with the tip located between the sacral promontory or within 2 cm from the upper end of sacroiliac joint and the lateral borders of L4-5 spine (Fig. 1). Catheters that were coiled in the region of the femoral head or positioned at or below the lower end of the sacroiliac joint were labeled "unsatisfactory."
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A blinded physiotherapist recorded the range of flexion achieved daily for the first 3 days. The range of flexion maintained during the patients postoperative visit at 6 wk was documented by the blinded surgeon.
Parametric data were compared using analysis of variance with Bonferroni’s correction for repeated measures. Nonparametric data were compared using 
2 test. A P of < 0.05 was considered statistically significant. This study has adequate power to detect 30% difference among the groups for analgesic efficacy and bupivacaine levels.
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Results |
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The demographics and surgical times were similar among the three groups (Table 1). The block was considered successful only if there was documented loss of sensation to ice in the femoral, obturator, and lateral femoral cutaneous distribution. The block success rates of the individual nerves/dermatomes during the postoperative period in the groups that received bupivacaine are depicted in Figure 2. The success rate of block of femoral, lateral femoral cutaneous, obturator nerves, and S1 root were higher in the 0.2%B group compared with the 0.1%B group. None of the patients in the placebo group had a sensory block. All patients, including those in the placebo group, had subjective weakness of thigh muscles in the postoperative period.
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The VAS pain scores during rest and activity are depicted in Figure 3. There is a trend for lower VAS pain scores during activity but, overall, the VAS pain scores during rest and activity were similar among the groups in the immediate postoperative period. From the first postoperative day on, all patients achieved a VAS score of <30 during rest.
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Morphine consumption (Fig. 4) during the first 4 h after the patient made the first demand for a morphine dose (0–4 h) was significantly lower in the 0.2%B group. This was also seen during the first postoperative day between 8:00 AM and 8:00 PM, but, during the night of surgery, the morphine use was similar among the groups. Patients with a successful block used less morphine compared with the patients with the failed block (16 ± 10 mg vs 22 ± 12 mg, P = 0.04). There was no difference in the morphine consumption in the rest of the time periods. The total morphine consumption (S = 73 ± 33 mg, 0.1%B = 84.6 ± 64 mg vs 0.2%B = 49 ± 19 mg; P = 0.06) and hourly morphine use were similar among the groups, with a trend toward smaller doses in the 0.2%B group.
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The incidence of nausea and vomiting were similar among the groups. No patient had clinical evidence of local anesthetic toxicity. One patient in the 0.2%B group had weakness of hip flexors lasting just under 6 wk from which he spontaneously recovered completely.
The range of motion achieved at the end of surgery was similar among the three groups. The increased range of motion achieved by the patients in the 0.2%B group reached statistical significance only on the first postoperative day.
CT evaluation revealed that 8 of the 20 catheters were in the ideal position (40%). Seven of these catheters were in at least 20 cm cranially. Among the catheters that were evaluated with CT, only 19 had ease of insertion documented. Fourteen catheters were labeled "easy to insert," and 5 were labeled "difficult."
Among the patients who had CT evaluation, six received placebo (two in ideal location), five received 0.2%B (four ideal) and nine received 0.1%B (two ideal). All patients who received 0.2%B, irrespective of the catheter location, had a successful block (100%). The success rate with 0.1% bupivacaine infusion with the ideally located catheter was 50%. Morphine consumption during postoperative Day 1 was smaller in the group with catheters in the ideal location (2.7 ± 2.6 mg vs 21.9 ± 17.4 mg). The morphine consumption during the rest of the observation period, as well as the VAS pain scores from this small subset of patients, was not different.
The results of the plasma levels of bupivacaine and its metabolites are given in Table 2. The bupivacaine levels on the second postoperative day are slightly higher compared with the first postoperative day in the 0.2%B and 0.1%B groups. The levels on the third day (more than 12 h after termination of infusion) are similar to the first postoperative day. The maximal bupivacaine level recorded was 3.03 µg/mL in one patient in the 0.2%B group on the second postoperative day. This patient had no signs or symptoms of local anesthetic toxicity.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Continuous lumbar plexus block via the inguinal route has been reported to produce good analgesia and to be narcotic-sparing by some investigators (4–6,9,10,13), whereas others have been unable to document benefits with prolonged infusion (7,8). Adequate analgesia after knee surgery may require block of S1 as well as the femoral, lateral femoral cutaneous, and obturator nerves. To achieve this, two factors seem to be important; the tip of the catheter should lie at the level of the transverse processes of L4 or L5 vertebra, and an adequate volume and concentration of local anesthetic should be delivered to ensure blocking at least two nerve roots above and below the level of the catheter tip. The single injection technique of Winnie et al. (3) achieves this using a large volume of local anesthetic with distal pressure in the femoral perineural sheath, after identifying the nerve with paresthesia. Our technique aims at inserting the needle under the fascia iliaca, where the nerve runs in the groove between iliacus and psoas muscles, and it is possible to position a catheter in an optimal location using this modification. Unfortunately, ideal location is achieved only in 40% of patients as documented by CT. A larger volume delivered more proximally may be more likely to anesthetize the S1 root, although total sciatic block does not occur. Future studies are needed to look at the efficacy of either additional boluses and/or an increase in infusion rate on the block success rate.
All of our patients had excellent pain relief. We may have had some preemptive analgesic effect with spinal anesthesia, which included intrathecal fentanyl and rectal indomethcin, resulting in difficulty measuring an improvement with this intervention. Many patients in our institution use PCA morphine at night for sedation, because they are not allowed any other sedative when they are on PCA. This may explain the lack of difference with morphine consumption among the groups during the night of surgery.
Allen et al. (10) note that a single femoral block gives as good a pain relief as a combined femoral and sciatic block after knee arthroplasty, lasting eight hours, and suggest that the sciatic supply to the knee joint is minor. They note some opiate-sparing on the first postoperative day similar to ours. Singelyn et al. (9), in a prospective study, documented excellent postoperative analgesia using a femoral catheter after open knee surgery, with fewer side effects compared with epidural analgesia. They used a mixture of 0.125% bupivacaine with sufentanyl and clonidine for infusion in both groups, and the role of absorbed narcotic and clonidine in analgesia are difficult to separate. We did not use any opioids, as the presence of opiate receptors in the peripheral nerve axons is questionable, although the presence of opiate receptors is well known in the dorsal horn neuron as well as in the sensory nerve terminals in tissues. Clonidine does block conduction in C fibers and thus may improve analgesia.
Anker-Moller et al. (13) note that bupivacaine 0.125% at 0.14 mL · kg-1 · h-1 gave the same pain relief as 0.25% bupivacaine given at the same rate, but their sample size is small (10 patients per group). Hirst et al. (8), using doses similar to our 0.1%B group, could not find any beneficial effects of a femoral nerve block beyond the recovery period.
Singelyn et al. (14) reported development of epidural anesthesia with the femoral three-in-one block when the catheter was inserted 24 cm cranially into the psoas sheath. Their contrast study indicates that it should be easy to block the S1 root with the local anesthetic, provided the location of the tip of the catheter is optimal. Our study confirms similar findings with CT.
All our patients, including the placebo group, had subjective weakness in their thigh muscles postoperatively, possibly a result of a disruption of the quadriceps tendon during surgery. Unfortunately, we did not quantitatively measure motor block. It is interesting to note that a significant number of patients who received 0.2% bupivacaine developed sensory block in the S1 dermatome.
Some of the catheters that were labeled "easy to insert" had coiled up in the femoral head area, even though the length inserted had been 20 cm. Thus, the length of insertion or ease of insertion is a poor indicator of location of the catheter. Initiation of the block under spinal anesthesia theoretically could mask intraneuronal injection, resulting in nerve trauma. We feel that the use of bullet-tipped needle, inserted using the fascial click, and then adjusted to produce good quadriceps contractions with a higher current strength than what is traditionally recommended offers a margin of safety. We have not had any neurological damage using this technique in the last five years.
Many radiological studies with contrast injection have been reported (7,9) with the femoral three-in-one block, but this is the first report of evaluation of these catheters with contrast enhanced CT, which gives us a better view of the location of the catheter in relation to fascia and muscle as well as the location of its tip. Six of the catheters studied were in the placebo group, reducing the number of patients in whom block success could be correlated with catheter localization.
No patient had clinical signs or symptoms of systemic local anesthetic toxicity. The catheter either lies in the psoas or in close proximity to it, delivering the local anesthetic in this area, which could result in increased absorption of delivered bupivacaine by the muscle. This could lead to systemic local anesthetic toxicity or local myotoxicity caused by sequestration of bupivacaine into the muscle. One patient in the 0.2%B group developed prolonged weakness of the hip flexor lasting 6 weeks, associated with no sensory deficits.
Dahl et al. (4) measured total bupivacaine levels during continuous lumbar plexus block over 16 hours and documented levels below 2.1 µg/mL. Esteve et al. (15) also note that the levels at 24, 36, and 48 hours of infusion were higher than the levels on the day of surgery. In our study, the bupivacaine levels were well below the toxic range, even in the 0.2%B group during the first 24 hours, when postoperative pain was most severe. We recommend that during the first postoperative day, one can safely use either a higher concentration and/or larger volume of bupivacaine. Venous plasma levels of drugs such as bupivacaine, which are highly protein bound with a large volume of distribution (120 L), may not reflect what is bound to the excitable tissues in the heart and the brain. Unfortunately, we did not measure the free arterial bupivacaine levels, which might have better correlation with the amount of drug delivered to various organs with toxicity.
Beyond 24 hours, the levels of des-butylbupivacaine continue to rise and may add to cumulative toxicity. Its toxic potential is reported to be one-eighth that of bupivacaine (16). The bupivacaine levels fell by only 25% on the third postoperative day, more than 12 hours after termination of infusion. One has to keep this in mind should these patients require reinsertion of the catheter and/or another regional anesthetic block during this period. The clearance reported by Esteve et al. (15) of 2.59 ± 0.91 mL · min-1 · kg-1 seems higher than is implied by our plasma levels, but a majority of the patients in our study were 66–70 years old.
Continuous fascia iliaca block with 0.2%B reduces opioid requirements and improves range of motion only in the immediate postoperative period. This block may be useful when continuous passive motion is initiated in the early postoperative period, because it improves analgesia during activity. Plasma levels are below the toxic range with the dose used, and therefore higher infusion rates or boluses may be safely used in the early postoperative period if necessary. Only 40% of the catheters are positioned in the ideal location, and neither ease of insertion nor length of catheter inserted predicts this. With the smaller dose of bupivacaine, the success rate with this block is unacceptably low.
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References |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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- Enneking KF, Benzon H. Oral anticoagulants and regional anesthesia: a perspective. Reg Anesth 1998;23:140–5.
- Brown DL. Atlas of regional anesthesia. Philadelphia:WB Saunders, 1992:71.
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Winnie AP, Ramamurthy S, Durrani Z. The inguinal paravascular technique of lumbar plexus anesthesia: the 3 in 1 block. Anesth Analg 1973;52:989–96.
[Free Full Text] - Dahl JB, Christiansen CL, Daugaard JJ, et al. Continuous blockade of the lumbar plexus after knee surgery–postoperative analgesia and bupivacaine plasma concentrations: a controlled clinical trial. Anaesthesia 1988;43:1015–8.[Medline]
- Serpell MG, Millar FA, Thomson MF. Comparison of lumbar plexus block versus conventional opioid analgesia after total knee replacement. Anaesthesia 1991;46:275–7.[Web of Science][Medline]
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Edwards ND, Wright EM. Continuous low dose 3 in 1 blockade for postoperative pain relief after total knee replacement. Anesth Analg 1992;75:265–7.
[Abstract/Free Full Text] - Lang SA, Yip RW, Chang PC, Gerard MA. The femoral 3 in 1 block revisited. J Clin Anesth 1993;5:292–6.[Web of Science][Medline]
- Hirst GC, Lang SA, Dust WN, et al. Femoral Nerve Block: single injection versus continuous infusion for total knee arthroplasty. Reg Anesth 1996;21:292–7.[Web of Science][Medline]
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Singelyn FJ, Deyaert M, Joris D, et al. Effects of intravenous patient controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty. Analg 1998;87:88–92.
[Abstract/Free Full Text] -
Allen HW, Liu SS, Were PD, et al. Peripheral nerve blocks improve analgesia after total knee replacement surgery. Analg 1998;87:93–7.
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Parkinson SK, Mueller JB, Little WL, et al. Extent of blockade with various approaches to the lumbar plexus. Anesth Analg 1989;68:243–8.
[Abstract/Free Full Text] -
Dalens B, Vanneuville G, Tanguy A. Comparison of fascia iliaca compartment block with the 3 in 1 block in children. Anesth Analg 1989;69:705–13.
[Abstract/Free Full Text] - Anker-Moller E, Spangsberg N, Dahl JB, et al. Continuous blockade of the lumbar plexus after knee surgery: a comparison of plasma concentrations and analgesic effect of bupivacaine 0.25% and 0.125%. Acta Anaesthesiol Scand 1990;34:468–72.[Web of Science][Medline]
- Singelyn FJ, Contreras V, Gouverneur JM. Epidural anesthesia complicating continuous 3 in 1 lumbar plexus blockade. Anesthesiology 1995;83:217–20.[Web of Science][Medline]
- Esteve M, Veillette Y, Ecoffey C, et al. Continuous block of the femoral nerve after surgery of the knee: pharmacokinetics of bupivacaine. Ann Fr Anesth Reanim 1990;9:322–5.[Web of Science][Medline]
- de Jong RH. Local anesthetics. St Louis:Mosby Publications, 1993.
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