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LETTERS TO THE EDITOR

Extended Femoral Nerve Sheath Block After Total Hip Arthroplasty

Department of Anesthesiology and Intensive Care Medicine, University of Cologne, Cologne, Germany

To the editor:

I read with interest the report by Singelyn et al. (1) on the comparison of continuous versus patient-controlled femoral nerve sheath block after total hip arthroplasty. Although patient-controlled analgesia boluses (5 mL per 30 min) of 0.125% bupivacaine with clonidine 1 µg/mL and sufentanil 0.1 µg/mL were associated with the smallest local anesthetic consumption and the most patient satisfaction, I do not agree it is the regional technique of choice after total hip arthroplasty. We showed recently that the continuous epidural infusion (with a rate in mL/h calculated by [height in cm - 100] x 0.1) of ropivacaine 0.1% + 1 µg/mL sufentanil provided superior pain relief after total hip replacement with only minimal side effects over a postoperative period of 48 h (2). Because of the low concentration of local anesthetic used and the individually adapted infusion rate, we did not see any potential risk of toxicity caused by accumulation of ropivacaine after a prolonged period of infusion. Moreover, motor block is negligible during epidural infusion and patients can be mobilized soon. In addition, information on the degree of motor block with bupivacaine 0.125% + clonidine + sufentanil would have been interesting.

Finally I would like to emphasize that patients in the present study received an additional 90 mg per day IV ketorolac, the maximum daily recommended dose of this potent nonsteroidal antiinflammatory drug (3). Is the patient-controlled analgesia femoral nerve sheath block indeed the technique of choice for postoperative analgesia after hip arthroplasty disregarding the favorable epidural combination of small-dose ropivacaine and sufentanil?

References

1. Singelyn FJ, Vanderelst PE, Gouverneur J-M A. Extended femoral nerve sheath block after total hip arthroplasty: continuous versus patient-controlled techniques. Anesth Analg 2001; 92: 455–9.[Abstract/Free Full Text]
2. Kampe S, Weigang C, Kaufmann J et al. Postoperative analgesia with no motor block by continuous epidural infusion of ropivacaine 0.1% and sufentanil after total hip replacement. Anesth Analg 1999; 89: 395–8.[Abstract/Free Full Text]
3. Park G, Fulton B, Senthuran S, eds. Inflammation and non-steroidal anti-inflammatory drugs. In: The management of acute pain, 2nd ed. Oxford: Oxford University Press, 2000:104.

Response

Department of Anesthesiology, St. Luc Hospital, Brussels, Belgium

In Response:

We agree with Kampe et al. (1) that continuous epidural analgesia is an efficient analgesic technique after total hip replacement (THR). In our experience with more than 1300 patients, it provides comparable pain relief but is associated with a significantly higher incidence of side effects (such as urinary retention and arterial hypotension) and technical problems (such as prematurely dislodged catheter) than extended femoral nerve sheath block (2). In a recent randomized, prospective study, we demonstrated that the analgesic technique has no influence on the postoperative rehabilitation after THR (3). Its primary goal is thus to provide only postoperative patient comfort, i.e., efficient pain relief with the lowest incidence of side effects and/or technical problems. That is why we consider extended femoral nerve sheath block as the analgesic technique of choice after THR. The present study (4) assessed only the most appropriate technique to maintain such block.

References

1. Kampe S, Weigand C, Kaufmann J, et al. Postoperative analgesia with no motor block by continuous epidural infusion of ropivacaine 0.1% and sufentanil after total hip replacement. Anesth Analg 1999; 89: 395–8.
2. Singelyn FJ, Gouverneur JM. Postoperative analgesia after total hip arthroplasty: IV PCA with morphine, patient-controlled epidural analgesia, or continuous "3-in-1" block? A prospective evaluation by our acute pain service in more than 1300 patients. J Clin Anesth 1999; 11: 550–4.[Web of Science][Medline]
3. Singelyn FJ, Ebongo F, Symens B, Joris D. Influence of the analgesic technique on postoperative rehabilitation after total hip replacement [abstract]. Reg Anesth Pain Med 2001; 26: 39.
4. Singelyn FJ, Vanderelst P, Gouverneur JM. Extended femoral nerve sheath block after total hip arthroplasty: continuous versus patient-controlled techniques. Anesth Analg 2001; 92: 455–9.

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