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See also Chapter 7, LIA technique for TKA • Bupivacaine 0.25% or ropivacaine 0.25% delivered Review of evidence
intra-articularly as wel as subcutaneously at the • Four clinical trials have shown a beneficial effect of donor site, via indwel ing catheter, at at least 4 mL/h continuous delivery of ropivacaine (Andersen KV et al. for 48 h, improves pain relief and reduces opioid 2010; Bianconi et al. 2003; Gomez-Cardero & Rodriguez- Merchan 2010) or bupivacaine (Ong et al. 2010) through • Further large studies are needed to establish the an indwel ing catheter fol owing TKA.
role of different catheter locations (intra-articular vssubcutaneous donor sites, or at both sites), as wel as • These studies used multiholed catheters, placed optimal drug concentration, combination regimens subcutaneously or intra-articularly. One study used two catheters, placed subcutaneously and intra-articularly • CFNB is superior to surgical site catheter analgesia. • Continuous surgical site infusion seems to be a good • One study compared continuous ropivacaine infusion alternative in patients when CFNB is not possible.
using an intra-articular multiholed catheter and an extra-articular catheter (Dobrydnjov et al. 2011).
• Three studies investigated the efficacy of bolus bolus administration of ropivacaine (Andersen LØ et al. administration of ropivacaine via intracapsular (Andersen LØ et al. 2010a; Andersen LØ et al. 2010b) • A comparison of high volume vs high concentration of or subcutaneous (Andersen LØ et al. 2010c) catheters.
ropivacaine also showed no difference in efficacy fol owing • Four continuous infusion studies reported positive bolus administration (Andersen LØ et al. 2010b).
outcome measures, including reduced pain at rest and • Bolus administration of subcutaneous ropivacaine did not during movement and reduced opioid consumption, show any improvement in pain scores compared with compared with placebo (Bianconi et al. 2003, Gomez- placebo (Andersen LØ et al. 2010c). There was no Cardero & Rodriguez-Merchan 2010), epidural infusion additional benefit of a bolus intra-articular infiltration of + intravenous anaesthesia (Andersen KV et al. 2010) or ketorolac, morphine and bupivacaine, compared with intravenous morphine (Ong et al. 2010).
continuous infusion of levobupivacaine (Ong et al. 2010).
• There was no evidence of local or systemic toxicity.
• A comparison of intra-articular vs extra-articular catheter placement showed no difference in pain scoresor opioid consumption fol owing continuous infusion ofropivacaine (Dobrydnjov et al. 2011).
• A comparison of intracapsular vs intra-articular catheter placement showed no difference in efficacy fol owing Practical details for TKA
intracapsular with intra-articular catheter placement (Andersen LØ et al. 2010a). One study of continuous • Multiholed catheters were used in al studies.
infusion compared intra- with extra-articular catheter • There are no comparative studies between catheter types.
placement (Dobrydnjov et al. 2011). One study used two catheters, placed subcutaneously and intraarticularly A fenestrated catheter is advisable, in order to cover more extensively the surgical incision and improve the local A fenestrated catheter is advisable, in order to cover more extensively the surgical incision and improve the localanaesthetic spread. • In one study the catheter was placed under direct visualization on the subcutaneous suprapatel ar space(Bianconi et al. 2003). In two studies the catheter wasplaced subcutaneously (Andersen KV et al. 2010,Andersen LØ et al. 2010c). Catheters were also placedintracapsularly (Andersen LØ et al. 2010b) andintra-articularly (Gomez-Cardero & Rodriguez-Merchan,2010). One study of bolus administration compared Number Catheter type Preclosure
Postoperative
Publication Grade* of
(1–13)
and location
administration
Outcomes
patients
24 h. High concentration:ropivacaine 1.0%, 10 mL at6 h and ropivacaine 0.5%,20 mL at 24 h Table 6. Summary of literature for total knee arthroplasty.
Publication Grade*
Catheter type Preclosure
Postoperative
(1–13) of
patients and location
administration
Outcomes
Table 6 cont. Summary of literature for total knee arthroplasty.
Number Catheter type Preclosure
Postoperative
Publication Grade* of
(1–13)
and location
administration
Outcomes
patients
Table 6 cont. Summary of literature for total knee arthroplasty.
*see page 15 for grading of publications.
progresses, according to a ‘moving needle technique’ to • At surgical closure, infiltration of the wound layers al avoid accidental intravascular drug injection. This seems to along the wound length with ropivacaine 0.5% (Bianconi offer improved postoperative analgesia when combined et al. 2003) or ropivacaine 2 µg/mL + epinephrine with continuous local anaesthetic infusion via a catheter. 10 mg/mL (Andersen LØ et al. 2010a; Andersen LØ et al. 2010b; Andersen LØ et al. 2010c) or ropivacaine2 mg/mL + ketorolac 30 mg/mL + epinephrine 1 mg/mL (Andersen KV et al. 2010, Dobrydnjov et al. • Continuous subcutaneous or intra-articular infusion of 2011), or ketorolac 1 mL + morphine 10 mg + ropivacaine 0.2% was performed at a flow rate of up to bupivacaine 100 mg (Ong et al. 2010) was performed, 5 mL/h for up to 60 h (Andersen KV et al. 2010, Bianconi before starting continuous infusion.
et al. 2003, Gomez-Cardero & Rodriguez-Merchan 2010).
Continuous intra-articular or extra-articular infusion of Large bolus infiltration of ropivacaine 0.5% results in safe ropivacaine 0.5% was performed at a flow rate of 2 mL/h plasma concentrations (assessed by pharmacokinetic for 48 h (Dobrydnjov et al. 2011). Continuous evaluation; Bianconi et al. 2003); its application is suggested.
subcutaneous and intra-articular infusion of bupivacaine Large perioperative bolus infiltration of ropivacaine 0.2%, 0.25% was performed for 48 h (Ong et al. 2010).
with adjuvant ketorolac and epinephrine into the posterior joint capsule and surrounding surgical layer, or with Continuous infusion of ropivacaine 0.2%, 5 mL/h has adjuvant ketorolac (without epinephrine) in the proved to be effective and safe. Intraoperative infiltration of subcutaneous tissues was performed as the operation the capsular joint with a mixture of ropivacaine, ketorolac and epinephrine was not associated with any significant complications or impairment of wound healing.
• Perioperative intra-articular infiltration and postoperative continuous infusion of ropivacaine improves postoperative pain relief and reduces opioid • Infusion duration was up to a maximum of 60 h.
requirements after major joint replacement surgery.
• There are no comparative studies on optimal duration • Additional wel -designed studies are needed to establish the effectiveness and safety of a combination of intra-articular and subcutaneous continuous surgical site infusion compared with Infusion duration of at least 48 h is suggested, but duration single-shot infiltration. Further investigations are should be tailored to the patient’s needs.
needed to determine the best catheter location, the optimal drug or combination of drugs, and the mostappropriate infusion duration. and wound infusion after anterior cruciate ligament reconstruction.
For a list of additional references and suggestions for further reading, Reg Anesth Pain Med 2009;34:95–9.
see Appendix 4. See also Chapter 7, LIA technique for TKA. Dobrydnjov I, Anderberg C, Olsson C, et al. Intraarticular vs Alford JW, Fadale PD. Evaluation of postoperative bupivacaine extraarticular ropivacaine infusion fol owing high-dose local infusion for pain management after anterior cruciate ligament infiltration analgesia after total knee arthroplasty. A randomized reconstruction. Arthroscopy 2003;19:855–61.
double-blind study. Acta Orthop 2011;82:692–698.
Andersen KV, Bak M, Christensen BV, et al. A randomized, Gomez-Cardero P, Rodriguez-Merchan EC. Postoperative analgesia control ed trial comparing local infiltration analgesia with epidural in TKA: ropivacaine continuous intraarticular infusion. Clin Orthop infusion for total knee arthroplasty. Acta Orthop 2010;81:606–10.
Andersen LØ, Gaarn-Larsen L, Kristensen BB, et al. Analgesic efficacy Hoenecke HR, Pulido PA, Morris BA, Fronek J. The efficacy of of local anaesthetic wound administration in knee arthroplasty: continuous bupivacaine infiltration fol owing anterior cruciate volume vs concentration. Anaesthesia 2010a;65:984–90.
ligament reconstruction. Arthroscopy 2002;18:854–8. Andersen LØ, Husted H, Kristensen BB, et al. Analgesic efficacy of Ong JCA, Lin CP, Fook-Chong SMC, et al. Continuous infiltration of subcutaneous local anaesthetic wound infiltration in bilateral knee local anaesthetic fol owing total knee arthroplasty. J Orthopaed Surg arthroplasty: a randomised, placebo-control ed, double-blind trial.
Acta Anaesthesiol Scand 2010c;54:543–8.
Parker RD, Streem K, Schmitz L, et al. Efficacy of continuous intra- Bianconi M, Ferraro L, Traina GC, et al. Pharmacokinetics and efficacy articular bupivacaine infusion for postoperative analgesia after of ropivacaine continuous wound instil ation after joint replacement anterior cruciate ligament reconstruction. Am J Sports Med surgery. Br J Anaesth 2003;91:830–5. Curry CS, Brown DL, Ruterbories L, et al. Localization of pain Vintar N, Rawal N, Veselko M. Intrarticular patient-control ed fol owing arthroscopic anterior cruciate ligament repair using regional anesthesia after arthroscopical y assisted anterior cruciate differential local anesthetic infiltration. Anesth Analg 1996;82:S81.
ligament reconstruction:ropivacaine/morphine/ketorolac versus ropivacaine/morphine.Anesth Analg 2005;101:573–8.
Dauri M, Fabbi E, Mariani P, et al. Continuous femoral nerve block provides superior analgesia compared with continuous intra-articular

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