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Anesth Analg 2003;96:414-417
© 2003 International Anesthesia Research Society

AMBULATORY ANESTHESIA

Patient-Controlled Perineural Analgesia After Ambulatory Orthopedic Surgery: A Comparison of Electronic Versus Elastomeric Pumps

Xavier Capdevila, MD, PhD*, Philippe Macaire, MD{dagger}, Philippe Aknin, MD{dagger}, Christophe Dadure, MD*, Nathalie Bernard, MD*, and Sandrine Lopez, MD*

*Department of Anesthesia and Critical Care Medicine, Lapeyronie University Hospital, Montpellier; and {dagger}Department of Anesthesia, Clinique du Parc, Lyon, France.

Address correspondence and reprint requests to Xavier Capdevila, MD, PhD, Département d’Anesthésie Réanimation A, Hôpital Lapeyronie, 371 Avenue du Doyen G Giraud, 34295 Montpellier, France. Address e-mail to x-capdevila{at}chu-montpellier.fr


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 References
 

IMPLICATIONS: Patient-controlled perineural analgesia techniques using Infusor LV5® disposable elastomeric or two types of electronic pumps provide efficient pain relief at home after ambulatory orthopedic procedures. Elastomeric pumps resulted in fewer technical problems and led to better patient satisfaction scores than Microjet® electronic pumps.


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 References
 
Postoperative pain is a major challenge in the practice of anesthesia for ambulatory orthopedic surgery (1–3). Despite the use of long-acting local anesthesia in peripheral nerve blocks (PNB), 11% of patients report wound pain during the first 24 or 48 postoperative hours, and 17% to 22% of patients require opioid analgesics 7 days after surgery (1,4).

Pain is a common reason for delayed discharge (5) and unanticipated hospital readmission. Orthopedic patients are the largest group who undergo PNB (6). PNB provide excellent anesthesia but also optimize postoperative analgesia, decrease hospital stay, and reduce the rate of unanticipated hospital readmission and probably health care costs as well (7,8). Recently, bolus injection (9), continuous infusion (10,11), and patient-controlled perineural administration (PCPA) (12–15) of local anesthetics at home after ambulatory orthopedic surgery have been described. Prospective studies will be required to compare efficacy and evaluate adverse events related to PCPA devices. This prospective, randomized study compared the efficacy of three pumps that are different in their deployment, adjustments, and ergonomics, available for postoperative analgesia.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 References
 
Seventy-six ASA physical status I, II, and III patients scheduled for orthopedic surgery were included in this prospective study once institutional approval and written informed consent were obtained. After oral premedication, all continuous PNB were performed in the preoperative holding area using a nerve stimulator (Stimuplex®, Braun, Melsungen, Germany) and a standard insertion procedure (16). An initial bolus of 0.5% ropivacaine was injected (15-mL dose for femoral nerve block, 15 mL for interscalene block, and 3 mL for tibial nerve block). The catheter was then advanced 3 cm (tibial nerve at the ankle), 5 cm (interscalene), and 12 cm (femoral nerve) past the distal end of the needle. The same amount of 0.5% ropivacaine was injected through the catheter and it was secured.

Surgical anesthesia for anterior cruciate ligament repair procedures combined femoral and sciatic nerve blocks. Hallux valgus surgery was performed after a tibial nerve block combined with deep peroneal and saphenous nerve infiltrations. Thirty minutes after PNB, the patients were transferred to the operating room.

During surgery, patients received a continuous propofol infusion (1 mg · kg-1 · h-1). At the conclusion of surgery, patients were transferred to the postanesthetic care unit. For PCPA, patients were randomly assigned to one of three groups. Patients in Group 1 received a disposable elastomeric infusion pump (Infusor LV5®, Baxter, Maurepas, France; Fig. 1A). In Group 2, patients received a Graseby patient-controlled analgesia (PCA) pump (Graseby 9300 Ambulatory Infusion Pump®, Graseby Medical, Watford Hertfordshire, UK; Fig. 1B), and those in Group 3 received a Microject® PCA pump (Microject Infusion Pump, Sorenson Medical, West Jordan, UT; Fig. 1C). The patients then received a 5 mL/h continuous basal infusion and 5-mL boluses of 0.2% ropivacaine with a lockout time of 20–30 min. In Group 1, the patient or the nurse injected the bolus by means of a syringe connected to the catheter by a three-way tap. Patients were transferred to the surgical ward for the first postoperative night. They were directed to take 100 mg of ketoprofen orally twice a day for 3 days. A nurse or the anesthesiologist made a follow-up visit on the third postoperative day.



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  		Figure 1. Pumps and delivery systems used for the patient-controlled perineural analgesia (PCPA). (A) Disposable elastomeric pump (Infusor LV5®); (B) Electronic patient-controlled analgesia (PCA) pump (Graseby 9300®); (C) Electronic PCA micropump (Microject® Infusion pump).

 
The patient was given a form to record visual analog scale (VAS) pain scores (ranging from 0 mm for no pain to 100 mm for the worst imaginable pain) recorded four times a day (the clock time of each bolus administration). The use of rescue analgesic tablets was standardized. If after bolus administration the VAS score remained more than 30 mm, two tablets of oral acetaminophen plus codeine were taken, and then a new VAS value was recorded. Overall satisfaction scores concerning analgesia and ease of pump use (from 0 for unsatisfied to 10 for fully satisfied) were recorded by the patients at the end of the 48-h period. Technical problems concerning the PCPA and adverse events were also noted. A nurse of a home care service managed the patient twice a day. The PCPA catheter was removed by the nurse. Total ropivacaine consumption was recorded at the end of the studied period.

The nurses were instructed to record all adverse effects. PCPA technical problems, self-administration related problems, and infectious adverse events were noted as well.

A power analysis was used centered on the expected difference between the groups regarding two factors, VAS and scores of patient satisfaction. For a risk {alpha} of 0.05 and a power of 80%, 20 patients were required in each group for a 20% difference in values. This difference was found in the patient satisfaction scores. Statistical analysis was performed using version 6.11 SAS software (SAS Institute, Cary, NC). The quantitative data were expressed as median (extremes) or mean ± SD. VAS values were expressed as the median (10th–25th–75th–90th percentiles). Comparisons between groups were performed using the Mann-Whitney test with Bonferroni correction for nonparametric data and the {chi}2 test for categorical data. A significance threshold of P < 0.05 was retained.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 References
 
Seventy-six patients were included. Eight patients were excluded (PNB failure, catheter insertion problems, or requiring hospitalization). Demographic data and types of surgery were comparable among the three groups (Table 1). Postanesthesia care unit pain scores and minimal and maximal pain scores within the 48-h study period are reported in Figure 2. The median values of these VAS scores were low (i.e., from 6 mm to 13 mm and from 21 mm to 25 mm, respectively, for minimal and maximal VAS values) without any difference among groups. Over the 48-h period, 4 (range, 3–5) effective boluses were administered by Group 1 patients, 6 (range, 1–15) in Group 2, and 10 (range, 1–10) in Group 3 (P < 0.05 versus Group 1). Eight patients in Group 1, 9 in Group 2, and 11 in Group 3 used rescue analgesia (acetaminophen + codeine) twice during the studied period (not significant). Total ropivacaine consumption values and technical problems with PCPA devices noted by patients and nurses are shown in Table 1. Median satisfaction scores were 9 (range, 5–10), 8 (range, 5–10), and 6 (range, 2–10) (P < 0.05 versus Group 1) in Groups 1, 2, and 3, respectively.


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  		Table 1. Demographic Data, Type of Surgery, Surgery Times, and Device Problems in the Three Groups
 


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  		Figure 2. Comparison of the postanesthetic care unit (PACU) and 48-h minimal and maximal visual analog scale (VAS) values of pain in the three groups (Group 1, elastomeric disposable pumps; Group 2, Graseby 9300 pumps; Group 3, Microjet pumps). The box represents the 25th–75th percentiles. The dark line is the median. The extended bars represent the 10th–90th percentiles, and the dark circles represent the values outside this range. PACU: pain score on discharge of PACU.

 
There was no unanticipated hospital readmission or infectious complications after discharge in our study population. There was no unsuccessful continuous PNB at home and no episode of acute or chronic local anesthetic toxicity. One patient reported postoperative nausea and vomiting at home. Spontaneously regressive laryngeal nerve block was observed in one Group 1 patient. One patient in Group 1 had dysesthesias in the femoral nerve distribution persisting for 10 h. Three catheters were prematurely and inadvertently pulled out in each group.


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
References
 
In this study, we demonstrated that LV5® disposable, nonmechanical pumps are as effective as the studied electronic PCA pumps for postoperative pain relief, are associated with fewer technical problems, and consequently lead to better satisfaction scores in patients than Microjet® electronic pumps.

In one study, 50% of patients undergoing ambulatory orthopedic surgery reported postoperative wound pain at 24 hours (1). Another study reported such pain in 11% of patients at home during the first 48 postoperative hours (2). Recently, White (8) highlighted the usefulness of PNB in the ambulatory setting. The author reported that PNB techniques are simple, safe, and effective approaches to providing perioperative analgesia and that continuous PNB with disposable pumps may improve pain control. Our study demonstrated that continuous peripheral blocks using three PCA devices at home are effective in resolving pain after ambulatory orthopedic surgery for the 48-hour study period. These results confirm those reported by Grant et al. (6) who achieved low VAS scores during 24 hours for most of the patients treated by continuous PNBs. There was no unexpected readmission to the hospital in our patients. This was probably because the previously trained nurses of the home health care network managed postoperative analgesia and because the pain relief provided by the PCA PNBs was optimal and played a greater role than the device.

The satisfaction of our patients concerning the quality of their postoperative analgesia and ease of pump use was very good in Groups 1 and 2. Our results show that continuous infusion of ropivacaine by means of LV5® disposable elastomeric pumps associated with bolus injections of the same drug by a nurse is a simple technique for patients in their home. Some patients of Group 1 may have been reassured by the presence of a nurse at reinjection, despite the fact that in the other groups, a nurse visited at home twice a day. The small degree of satisfaction in the patients of Group 3 was related to the number of technical problems involving the PCA device that was used. Technical difficulties linked to this PCA device have been reported in the literature (17) and have led to the early discontinuation of this analgesic technique.

However, the essential question is whether ambulatory management with PNB provides a level of care equivalent to that of inpatient management. The nurses of the home care network had to be trained in ambulatory implementation of these techniques of continuous PNB. In our study, none of the patients had any major adverse effect related to the material having led to re-hospitalization.

The use of electronic PCA pumps is reassuring because it allows the physician to use variable rates of infusion and to adapt to any additional patient needs. Their use in PNBs is safe and effective in both hospitalized (18) and ambulatory patients (12,13). Unfortunately, their use is not always straightforward for the patient (17).

Disposable elastomeric pumps with a fixed continuous infusion rate at home (10,11) seem to have no major adverse effects, but they do not permit an adaptation of the infusion rate of local anesthetic to varying patient needs. Moreover, there are variations of the theoretical infusion rate during the first 60 hours of their use (15,19). Patient control may be achieved by providing a clamp (14,15). Ganapathy et al. (15) used disposable elastomeric pumps (50 mL/h infusion rate) to infuse 0.3% ropivacaine into a popliteal catheter for analgesia after foot surgery. Bolus injections of 10–12 mL were allowed every 2 hours by opening a clamp for 10–15 minutes. Those authors reported that two of the 11 hospitalized patients received the entire content of the pump in a single infusion because no one closed the clamp. In our study, there were no adverse events related to self-injection in Group 1 patients. Because the additional bolus injections are handled by a home care nurse substantially improves the security of this analgesic technique.

With the technique used by the patients in this study, PCPA with the three devices seemed to be safe and effective for pain relief at home. LV5® disposable elastomeric pumps were associated with fewer technical problems and greater patient satisfaction than Microjet® electronic pumps. Improvements in disposable elastomeric pumps that will soon be available should further contribute to safe and effective use of this type of analgesia at home (20).


   Acknowledgments
 
Financial support was obtained from the Association pour le Développement et la Recherche en Anesthésie Réanimation, CHU Lapeyronie, Montpellier, France.


   Footnotes
 
Presented, in part, at the annual meeting of the American Society of Regional Anesthesia, May 10-13, 2001, Vancouver, Canada.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 

  1. Chung F, Un V, Su J. Postoperative symptoms 24 hours after ambulatory anaesthesia. Can J Anaesth 1996; 43: 1121–7.[Web of Science][Medline]
  2. Chung F, Ritchie E, Su J. Postoperative pain in ambulatory surgery. Anesth Analg 1997; 85: 808–16.[Abstract]
  3. Beauregard L, Pomp A, Choinière M. Severity and impact of pain after day-surgery. Can J Anaesth 1998; 45: 304–11.[Web of Science][Medline]
  4. Klein SM, Nielsen KC, Greengrass RA, et al. Ambulatory discharge after long-acting peripheral nerve blockade: 2382 blocks with bupivacaine. Anesth Analg 2002; 94: 65–70.[Abstract/Free Full Text]
  5. Chung F, Mezei G. Factors contributing to a prolonged stay after ambulatory surgery. Anesth Analg 1999; 89: 1352–9.[Abstract/Free Full Text]
  6. Grant SA, Nielsen KC, Greengrass RA, et al. Continuous peripheral nerve block for ambulatory surgery. Reg Anesth Pain Med 2001; 26: 209–14.[Web of Science][Medline]
  7. Williams BA, DeRiso BM, Figallo CM, et al. Benchmarking the perioperative process. III. Effects of regional anesthesia clinical pathway techniques on process efficiency and recovery profiles in ambulatory orthopedic surgery. J Clin Anesth 1998; 10: 570–8.[Web of Science][Medline]
  8. White PF. The role of non-opioid analgesic techniques in the management of pain after ambulatory surgery. Anesth Analg 2002; 94: 577–85.[Free Full Text]
  9. Klein SM, Greengrass RA, Grant SA, et al. Ambulatory surgery for multi-ligament knee reconstruction with continuous dual catheter peripheral nerve blockade. Can J Anaesth 2001; 48: 375–8.[Web of Science][Medline]
  10. Klein SM, Greengrass RA, Gleason DH, et al. Major ambulatory surgery with continuous regional anesthesia and a disposable infusion pump. Anesthesiology 1999; 91: 563–5.[Web of Science][Medline]
  11. Klein SM, Grant SA, Greengrass RA, et al. Interscalene brachial plexus block with a continuous catheter insertion system and a disposable infusion pump. Anesth Analg 2000; 91: 1473–8.[Abstract/Free Full Text]
  12. Corda DM, Enneking FK. A unique approach to postoperative analgesia for ambulatory surgery. J Clin Anesth 2000; 12: 595–9.[Web of Science][Medline]
  13. Mak PHK, Tsui SL, Ip WI, Irwin MG. Brachial plexus infusion of ropivacaine with patient controlled supplementation. Can J Anaesth 2000; 47: 903–6.[Web of Science][Medline]
  14. Rawal N, Axelsson K, Hylander J, et al. Postoperative patient-controlled local anesthetic administration at home. Anesth Analg 1998; 86: 86–9.[Web of Science][Medline]
  15. Ganapathy S, Amendola A, Lichfield R, et al. Elastomeric pumps for ambulatory patient controlled regional analgesia. Can J Anaesth 2000; 47: 897–902.[Web of Science][Medline]
  16. Capdevila X, Biboulet P, Morau D, et al. Continuous three-in-one block for postoperative pain after lower limb orthopedic surgery: where do the catheters go? Anesth Analg 2002; 94: 1001–6.[Abstract/Free Full Text]
  17. Macintyre PE. Safety and efficacy of patient-controlled analgesia. Br J Anaesth 2001; 87: 36–46.[Abstract/Free Full Text]
  18. Borgeat A, Schäppi B, Biasca N, Gerber C. Patient-controlled analgesia after major shoulder surgery: patient-controlled interscalene analgesia versus patient-controlled analgesia. Anesthesiology 1997; 87: 1343–7.[Web of Science][Medline]
  19. Valente M, Aldrete A. Comparison of accuracy and cost of disposable, nonmechanical pumps used for epidural infusions. Reg Anesth 1997; 22: 260–6.[Web of Science][Medline]
  20. Chelly JE, Greger J, Gebhard R. Ambulatory continuous perineural infusion: are we ready? Anesthesiology 2000; 93: 581.[Web of Science][Medline]



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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press