Brazilian Journal of Anesthesiology
https://app.periodikos.com.br/journal/rba/article/doi/10.1590/S0034-70942003000200006
Brazilian Journal of Anesthesiology
Artigo Científico

Analgesia pós-operatória em cirurgia ortopédica: estudo comparativo entre o bloqueio do plexo lombar por via perivascular inguinal (3 em 1) com ropivacaína e a analgesia subaracnóidea com morfina

Postoperative analgesia following orthopedic surgery: a study comparing perivascular lumbar plexus inguinal block with ropivacaine (3 in 1) and spinal anesthesia with morphine

Neuber Martins Fonseca; Roberto Araújo Ruzi; Fernando Xavier Ferreira; Fabrício Martins Arruda

http://dx.doi.org/10.1590/S0034-70942003000200006 Braz J Anesthesiol, vol.53, n2, p.188-197, 2003
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Resumo

JUSTIFICATIVA E OBJETIVOS: O bloqueio do plexo lombar pelo acesso perivascular inguinal, chamado de bloqueio 3 em 1, tem sido utilizado para analgesia pós-operatória. O objetivo deste estudo foi comparar a analgesia pós-operatória do bloqueio 3 em 1 a da morfina subaracnóidea em pacientes submetidos a cirurgias ortopédicas em membro inferior (MI). MÉTODO: Foram estudados 40 pacientes escalados para cirurgia ortopédica de MI, de ambos os sexos, estado físico ASA I e II, com idades entre 15 e 75 anos, distribuídos em 2 grupos (M e BPL). Foi realizada anestesia subaracnóidea em todos os pacientes, em L3-L4 ou L4-L5, com 20 mg de bupivacaína isobárica a 0,5%. No grupo M (n = 20) foi associado 50 µg de morfina ao anestésico local. No grupo BPL (n = 20) foi realizado o bloqueio 3 em 1 ao término da cirurgia, utilizando 200 mg de ropivacaína a 0,5%. Avaliou-se a analgesia e a intensidade da dor às 4, 8, 12, 14, 16, 20 e 24 horas após o término da cirurgia, o nível do bloqueio subaracnóideo, o tempo cirúrgico e as complicações. RESULTADOS: A duração da analgesia no grupo BPL foi de 13,1 ± 2,47, enquanto no grupo M todos os pacientes referiam dor e ausência de bloqueio motor no primeiro instante avaliado (4 horas). Houve falha do bloqueio de um dos 3 nervos em 3 pacientes. A incidência de náusea e prurido foi significativamente maior no grupo M. Quanto à retenção urinária, não houve diferença significante entre os grupos. Não houve depressão respiratória, hipotensão arterial ou bradicardia. A analgesia pós-operatória foi mais efetiva no grupo BPL, comparada ao grupo M às 4, 8, 12,14 e 16 horas. Às 20 e 24 horas não houve diferença significante entre os grupos. CONCLUSÕES: A analgesia pós-operatória proporcionada pelo bloqueio 3 em 1 apresentou efeitos colaterais inferiores à morfina subaracnóidea com tempo de analgesia semelhante.

Palavras-chave

ANALGESIA, ANALGÉSICOS, ANALGÉSICOS, ANESTÉSICOS, ANESTÉSICOS, TÉCNICAS ANESTÉSICAS, TÉCNICAS ANESTÉSICAS, TÉCNICAS ANESTÉSICAS

Abstract

BACKGROUND AND OBJECTIVES: Perivascular Lumbar plexus inguinal block, (3-in-1 block) has been used for postoperative analgesia. This study aimed at comparing postoperative analgesia of 3-in-1 block and spinal morphine in patients submitted to lower limb orthopedic surgeries (LL). METHODS: Forty ASA I - II patients of both genders, aged 15 to 75 years, scheduled for LL orthopedic surgeries, were distributed in two groups: (M and LPB). Spinal anesthesia was performed in all patients at L3-L4 or L4-L5 with 20 mg of 0.5% isobaric bupivacaine. In group M (n = 20), 50 µg morphine were associated to local anesthetics. In group LPB (n = 20) 3-in-1 blockade was performed after surgery with 200 mg of 0.5% ropivacaine. Analgesia and pain intensity were evaluated at 4, 8, 12, 14, 16, 20 and 24 hours after surgery completion, in addition to spinal blockade level, surgery duration and complications. RESULTS: Analgesia duration in group LPB was 13.1 ± 2.47 while all group M patients referred pain and lack of motor block in the first moment evaluated (4 hours). There has been blockade failure in one of the three nerves in three patients. The incidence of nausea and pruritus was significantly higher in group M. There was no significant difference between groups in urinary retention. There were no respiratory depression, arterial hypotension or bradycardia. Postoperative analgesia was more effective in group LPB as compared to group M at 4, 8, 12, 14 and 16 hours. There were no significant differences between groups at 20 and 24 hours. CONCLUSIONS: Postoperative analgesia induced by 3-in-1 blockade showed less side-effects as compared to spinal morphine with similar analgesia duration.

Keywords

ANALGESIA, ANALGESICS, ANALGESICS, ANESTHETICS, ANESTHETICS, ANESTHETIC TECHNIQUES, ANESTHETIC TECHNIQUES, ANESTHETIC TECHNIQUES

Referências

Imbelloni LE. Bloqueio 3 em 1 para analgesia pós-operatória. Rev Bras Anestesiol. 1999;49:412.

Tarkkila P, Tuominen M, Huhtala J. Comparison of intrathecal morphine and continuous femoral 3-in-1 block for pain after major knee surgery under spinal anaesthesia. Eur J Anaesth. 1998;15:6-9.

Kalso E. Effects of intrathecal morphine, injected with bupivacaine, on pain after orthopaedic surgery. Br J Anaesth. 1983;55:415-422.

Bengtsson M, Löfström JB, Merits H. Postoperative pain relief with intrathecal morphine after major hip surgery. Reg Anesth. 1983;8:138-143.

Tarkkila P, Törn K, Tuominen M. Premedication with promethazine and transdermal scopolamine reduces the incidence of nausea and vomiting after intrathecal morphine. Acta Anaesthesiol Scand. 1995;39:983-986.

Singelyn FJ, Deyaert M, Jorist D. 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. Anesth Analg. 1998;87:88-92.

Capdevila X, Barthelet Y, Biboulet P. Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery. Anesthesiology. 1999;91:8-15.

Enneking FK, Wedel DJ. The art and science of peripheral nerve blocks. Anesth Analg. 2000;90:1-2.

Winnie AP, Ramamurthy S, Durrani Z. The inguinal paravascular technique of lumbar plexus anesthesia: the 3 em 1 block. Anesth Analg. 1973;52:989-996.

David LB. Atlas of Regional Anesthesia. 1999:103-110.

Dalens B. Bloqueios do Plexo Lombar e de seus Ramos Proximais. Anestesia Locoregional do Recém-nascido ao Adulto. 1999:325-351.

Lonsdale M. 3-in-1 block: confirmation of Winnie’s anatomical hypothesis. Anesth Analg. 1988;67:601-602.

Oliva Filho AL. Bloqueios de Nervos Periféricos. Anestesiologia Principios e Técnicas. 1997:379-380.

Misra U, Pridie AK, McClymont C. Plasma concentrations of bupivacaine following combined sciatic and femoral 3 in 1 nerve blocks in open knee surgery. Br J Anaesth. 1991;66:310-313.

Patel NJ, Flashburg MH, Pashin S. A regional anesthetic technique compared to general anesthesia for outpatient knee arthroscopy. Anesth Analg. 1986;65:186-187.

Tierney E, Lewis G, Hurtig JB. Femoral nerve block with bupivacaine 0.25% for post-operative analgesia after open knee surgery. Can J Anaesth. 1987;34:455-458.

Serpel MG, Millar FA, Thomson MF. Comparison of lumbar plexus block versus conventional opioid analgesia after total knee replacement. Anaesthesia. 1991;46:275-277.

Schultz P, Anker-Moller E, Dahi JB. Postoperative pain treatment after open knee surgery: continuos lumbar plexus block with bupivacaine versus epidural morphine. Reg Anesth. 1991;16:34-37.

Tondare AS, Nadkarni AV. Femoral nerve block for fractured shaft of femur. Can Anaesth Soc J. 1982;29:270-271.

Hood G, Edbrooke DL, Gerrish SP. Postoperative analgesia after triple nerve block for fractured neck of femur. Anaesthesia. 1991;46:138-140.

Imbelloni LE, Gouveia MA. Analgesia pós-operatória com bloqueio do plexo lombar: comparação entre as técnicas com cateter e com estimulação do nervo femoral. Rev Bras Anestesiol. 2001;51:28-36.

Imbelloni LE, Beato L, Gouveia MA. Bloqueio 3 em 1 para analgesia pós-operatória em cirurgias ortopédicas de grande porte. Rev Bras Anestesiol. 2000;50(^s25).

Imbelloni LE. Bloqueio 3 em 1 com bupivacaína a 0,25% para analgesia pós-operatória em cirurgias ortopédicas. Rev Bras Anestesiol. 2000;50:221-224.

Fournier R, Van Gessel E, Gaggero G. Postoperative analgesia with 3 in 1 femoral nerve block after prosthetic hip surgery. Can J Anaesth. 1998;45:34-38.

Madej TH, Ellis FR, Halsali PJ. Evaluation of 3 in 1 lumbar plexus block in patients having muscle biopsy. Br J Anaesth. 1989;62:515-517.

Ritter JW. Femoral nerve "sheath" for inguinal paravascular lumbar plexus blocks is not found in human cadavers. J Clin Anesth. 1995;7:470-473.

Dalens B, Vanneuville G, Tanguy A. Comparison of the fascia iliac compartment block with the 3-in-1 block in children. Anesth Analg. 1989;69:705-713.

Lang SA, Yip RW, Chang PC. The femoral 3-in-1 block revised. J Clin Anesth. 1993;5:292-296.

Edwards ND, Wright EM. Continuous low-dose 3-in-1 nerve blockade for postoperative pain relief after total knee replacement. Anesth Analg. 1992;75:265-267.

Parkinson SK, Mueller JB, Little WL. Extent of blockade with various approaches to the lumbar plexus. Anesth Analg. 1989;68:243-248.

Atanassoff PG, Weiss BM, Brull SJ. Electromyography comparison of obturator nerve block to three-in-one block. Anesth Analg. 1995;81:529-533.

Capdevila X, Biboulet P, Morau D. Continuous three-in-one block for postoperative pain after lower limb orthopedic surgery: where do the catheters go?. Anesth Analg. 2002;94:1001-1006.

Huskisson EC. Measurement of pain. Lancet. 1974;2:1127-1131.

Kremer E, Atkinson JH. Measurement of pain: patient preference does not confound pain measurement. Pain. 1981;10:241-248.

Boogaerts JG, Vanacker E, Seidel L. Assessment of postoperative nausea using a visual analogue scale. Acta Anaesthesiol Scand. 2000;44:470-474.

Cousins MJ, Mather LE. Intrathecal and epidural administration of opioids. Anesthesiology. 1984;61:276-310.

Dahl JB, Anker-Moller E, Spansberg N. Continuous lumbar plexus block after arthroplasty. Anaesthesia. 1988;43:989-996.

Hirst GC, Lang SA, Dust WN. Femoral nerve block: single injection versus continuous infusion for total knee arthroplasty. Reg Anesth. 1996;21:292-297.

Etches RC, Warriner CB, Badner . Continuous intravenous administration of ketorolac reduces pain and morphine consumption after total hip or knee arthroplasty. Anesth Analg. 1995;81:1175-1180.

Tierney E, Lewis G, Hurtig JB. Femoral nerve block with bupivacaine 0.25% for postoperative analgesia after open knee surgery. Can J Anaesth. 1987;34:455-458.

Mulroy MF, Larkin KL, Batra MS. Femoral nerve block with 0.25% or 0.5% bupivacaine improves postoperative analgesia following outpatient artroscopic anterior ligament repair. Reg Anesth Pain Med. 2001;26:24-29.

Hugh A, Spencer L, Paul W. Peripheral nerve blocks improve analgesia after total knee replacement surgery. Anesth Analg. 1998;87:93-97.

Misra U, Pridie AK, McClymont C. Plasma concentrations of bupivacaine following combined sciatic and femoral 3 in 1 nerve blocks in open knee surgery. Br J Anaesth. 1991;66:310-313.

Fanelli G, Casati A, Beccaria P. A double-blind comparison of ropivacaine, bupivacaine and mepivacaine during sciatic and femoral nerve blockade. Anesth Analg. 1998;87:597-600.

Greengrass RA, Klein SM, Ercole FJ. Lumbar plexus and sciatic nerve block for knee arthroplasty: comparison of ropivacaine and bupivacaine. Can J Anaesth. 1998;45:1094-1096.

Marhofer P. Three in one block with ropivacaine: evaluation of sensory onset time and quality of sensory block. Anesth Analg. 2000;90:125-128.

Casati A, Cappeleni G. Regional anaesthesia for outpatient knee arthroscopy: a randomized clinical comparison of two different anesthetic techniques. Acta Anaesthesiol Scand. 2000;44:543-547.

Reiz S, Haggmark S, Johansson G. Cardiotoxicity of ropivacaine: a new amide local anaesthetic agent. Acta Anaesthesiol Scand. 1989;33:93-98.

Seeberger MD, Urwyler A. Paravascular lumbar plexus block: block extension after femoral nerve stimulation and injection of 20 vs 40 ml mepivacaine 10 mg/ml. Acta Anaesthesiol Scand. 1995;39:769-773.

Allen JG. Postoperative analgesia following total knee arthroplasty: A study comparing spinal anesthesia and combined sciatic-femoral 3 in 1 block. Reg Anesth Pain Med. 1998;23:142-146.

Yassuda H, Sakata RK. Bloqueio de Nervos Periféricos. Anestesiologia. 2001:613-642.

Uhrbrand AB, Jensen TT. Iatrogen n. femoralis neuropathy after blockade of plexus lumbalis (3-i-1 block). Ugeskr Laeger. 1988;150:428-429.

Joehr M. Spaete komplikation der kontinuierlichen blocade des n. femoralis. Teg Anaesth. 1987;10:37-38.

Lynch J, Trojan S, Arhelger S. Intermittent femoral nerve blockade for anterior cruciate ligament repair: Use of a catheter technique in 208 patients. Acta Anaesthesiol Belg. 1991;42:207-212.

Lalourcey L, Nouvelon E, Cuvillon P. Incidence des complications des blocs 3 en 1 pour analgésie continue chez 125 patients. Ann FR Anesth Réanim. 1998;17:822.

Singelyn FJ, Contreras V, Gouverneur JM. Epidural anesthesia complicating continuous 3-in-1 lumbar plexus blockade. Anesthesiology. 1995;83:217-220.

Edkin BS. Femoral nerve block as an alternative to parenteral narcotics for pain control after anterior cruciate ligament reconstruction. Artroscopy. 1995;11:404-409.

Kehlet H, Dahl JB. The value of ‘multimodal’ or ‘balanced analgesia’ in postoperative pain treatment. Anesth Analg. 1993;77:1048-1056.

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