Brazilian Journal of Anesthesiology
https://app.periodikos.com.br/journal/rba/article/doi/10.1590/S0034-70942007000500006
Brazilian Journal of Anesthesiology
Scientific Article

Controle da dor pós-operatória da artroplastia total do joelho: é necessário associar o bloqueio do nervo isquiático ao bloqueio do nervo femoral?

Control of postoperative pain following total knee arthroplasty: is it necessary to associate sciatic nerve block to femoral nerve block?

Affonso H. Zugliani; Nubia Verçosa; José Luiz Gomes do Amaral; Louis Barrucand; Cátia Salgado; Márcia Borges Hage Karam

Downloads: 0
Views: 1074

Resumo

JUSTIFICATIVA E OBJETIVOS: A artroplastia total do joelho (ATJ) promove grande trauma tecidual, produzindo intensa dor no pós-operatório. A analgesia pós-operatória de boa qualidade é fundamental, devendo-se considerar que a mobilização articular precoce é um importante aspecto para obtenção de bons resultados. Há controvérsias na literatura sobre a eficácia do bloqueio isolado do nervo femoral. O objetivo deste estudo foi avaliar a analgesia pós-operatória com a associação do bloqueio dos nervos isquiático e femoral. MÉTODO: Foram estudados 17 pacientes submetidos à ATJ sob raquianestesia, divididos em dois grupos: A e B. No Grupo A (n = 9) foi realizado bloqueio do nervo femoral e no Grupo B (n = 8), bloqueio dos nervos femoral e isquiático. Os bloqueios foram realizados no pós-operatório imediato utilizando-se 20 mL de ropivacaína a 0,5% em cada um. A dor foi aferida nas primeiras 24 horas pela Escala Analógica Visual e escala verbal. Foi observado o tempo decorrido entre os bloqueios e a primeira queixa de dor (M1). RESULTADOS: A mediana do tempo de analgesia (M1) no Grupo A foi de 110 min. e no Grupo B de 1.285 min. (p = 0,0001). Não foram observadas complicações atribuíveis às técnicas utilizadas. CONCLUSÃO: O bloqueio do nervo isquiático, quando associado ao bloqueio do nervo femoral, nas condições deste estudo, melhorou de maneira significativa a qualidade da analgesia pós-operatória da ATJ.

Palavras-chave

ANALGESIA, CIRURGIA, Ortopédica, TÉCNICAS ANESTÉSICAS, Regional

Abstract

BACKGROUND AND OBJECTIVES: Total knee arthroplasty (TKA) causes severe tissue trauma, leading to severe postoperative pain. Good postoperative analgesia is fundamental and one should consider that early mobilization of the joint is an important aspect to obtain good results. There is a controversy in the literature on the efficacy of isolated femoral nerve block. The objective of this study was to evaluate postoperative analgesia with the association of sciatic and femoral nerve block. METHODS: Seventeen patients undergoing TKA under spinal anesthesia were divided in two groups: A and B. In Group A (n = 9), femoral nerve block was performed, while in Group B (n = 8), femoral and sciatic nerve block were done. The blockades were done in the immediate postoperative period with 20 mL of 0.5% of ropivacaine. Pain was evaluated in the first 24 hours using the Visual Analog Scale and the verbal scale. The length of time between the nerve block and the first complaint of pain (M1) was also evaluated. RESULTS: The median of the duration of analgesia (M1) in Group A was 110 min, while in Group B it was 1285 min (p = 0.0001). There were no complications related to the technique used. CONCLUSIONS: Sciatic nerve block, when associated with femoral nerve block, under the conditions of the present study, improved significantly the quality of postoperative analgesia in TKA.

Keywords

ANALGESIA, ANESTHETIC TECHNIQUES, Regional, SURGERY, Orthopedic

References

Allen JG, Denny NM, Oakman N. Postoperative analgesia following total knee arthroplasty. Reg Anesth Pain Med. 1998;23:142-146.

Singelyn FG, Deyoert M, Joris D. Efects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia and continuous three-in-one block postoperative pain and knee rehabilitation after unilateral total knee arthroplasty. Anesth Analg. 1998;87:88-92.

Chelly JE, Greger J, Gebhard R. Continuous femoral blocks improve recovery and outcome of patients undergoing total knee arthroplasty. J Arthropl. 2001;16:436-445.

Morin AM, Kratz CD, Eberhart LHJ. Postoperative analgesia and functional recovery after total-knee replacement: comparison of a continuous posterior lumbar plexus (Psoas Compartment) block, a continuous femoral nerve block, and the combination of a continuous femoral and sciatic nerve block. Reg Anesth Pain Med. 2005;30:434-445.

Raj P, Knar D, Denson D. Comparison of continuous epidural infusion of a local anesthetic and administration of systemic narcotics in the management of pain after total knee replacement surgery. Anesth Analg. 1987;66:401-406.

Schultz P, Christensen EF, Dahl JB. Postoperative pain treatment after open knee surgery: continuous lumbar plexus block with bupivacaine versus epidural morphine. Reg Anesth. 1991;16:34-37.

Wang H, Boctor B, Verner J. The effect of single-injection femoral nerve block on rehabilitation an length of hospital stay after total knee replacement. Reg Anesth Pain Med. 2002;27:139-144.

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

Ganapathy S, Wasserman RA, Watson JT. Modified continuous femoral three-in-one block for postoperative pain after total knee artroplasty. Anesth Analg. 1999;89:1197-1202.

Ping H, Cheong KF, Lim A. Intraoperative single-shot "3-in-1" femoral nerve block with ropivacaine 0.25%, ropivacaine 0.5% or bupivacaine 0.25% provides comparable 48 hr analgesia after unilateral total knee replacement. Can J Anesth. 2001;48:1102-1108.

Allen HW, Liu SS, Ware PD. Peripheral nerve blocks improve analgesia after total knee replacement surgery. Anesth Analg. 1998;87:93-97.

Phan-Dang C, Gautheron E, Guilley J. The value of adding sciatic block to continuous femoral block for analgesia after total knee replacement. Reg Anesth Pain Med. 2005;30:128-133.

Guay J. Peripheral nerve blocks for postoperative pain relief after total knee replacement: more questions than answers. Anesthesiology. 2005;100:154.

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

Beck GP. Anterior approach to sciatic nerve block. Anesthesiology. 1963;24:222-224.

Singelyn FJ, Gouverneur JMA. Extended "three-in-one" block after total knee arthroplasty: continuous versus patient-controlled techniques. Anesth Analg. 2000;91:176-180.

Weber A, Fournier R, VanGessel E. Sciatic nerve block and the improvement of femoral nerve block analgesia after total knee replacement. Eur J Anaesthesiol. 2002;19:834-836.

Cook P, Stevens J, Gaudron C. Comparing the effects of femoral nerve block versus femoral and sciatic nerve block on pain and opiate consumption after total knee arthroplasty. J Arthroplasty. 2003;18:583-586.

Ben-David B, Schmalenberger K, Chelly JE. Analgesia after total knee arthroplasty: is continuous sciatic blockade needed in addition to continuous femoral blockade?. Anesth Analg. 2004;98:747-749.

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.

Eledjan JJ, Cuvillon F, Capdevila X. Postoperative analgesia by femoral nerve block with ropivacaine 0,2% after major knee surgery: continuos versus patient-controlled techniques. Reg Anesth Pain Med. 2002;27:604-611.

Simon MAM, Vree TB, Gielen MJM. Plasma concentrations after high doses of mepivacaine with epinephrine in the combined psoas compartment/sciatic nerve block. Reg Anesth. 1990;15:256-260.

Elmas C, Atanassof PG. Combined inguinal paravascular (3-in-1) and sciatic nerve block for lower limb surgery. Reg Anesth. 1993;18:88-92.

Moore CS, Sheppard D, Wildsmith JAW. Thigh rotation and the anterior approach to the sciatic nerve: a magnetic resonance imaging study. Reg Anesth Pain Med. 2004;29:32-35.

Mansour NY, Bennetts FE. An observational study of combined continuous lumbar plexus and single-shot sciatic nerve blocks for post-knee surgery analgesia. Reg Anesth. 1996;21:287-291.

Mcnamee DA, Parks L, Milligan KR. Post-operative analgesia following total knee replacement: an evaluation of the addition of an obturator nerve block to combined femoral and sciatic nerve block. Acta Anaesthesiol Scand. 2002;46:95-99.

Kaloul I, Guay J, Cote C. The posterior lumbar plexus (psoas compartment) block and the three-in-one femoral nerve block provide similar postoperative analgesia after total knee replacement. Can J Anesth. 2004;51:45-51.

5dd820af0e8825990313f286 rba Articles
Links & Downloads

Braz J Anesthesiol

Share this page
Page Sections