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rfioanornrrilanmffsnr:Birffonjdsudordrnrstu 24 ffalur

Result of Femoral Nerve Block with o.|Vo Levobupivacaine to Reduced

Pain after Total Knee Replacement within z+ hrs

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uYIUfiglufluu Original article

Thanin Pinyopornpanit** M.D.

Sumana Watcharadirekrat* B.N.S.

* Nursing Department

** Department of anesthesiology

Sawanpracharak Hospital

Nakhon Sawan

Sawanpracharak Medical Journalda v d

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To study that femoral nerve block can reducing severity of pain in

patients who received total knee replacement and how.

Perioperative room Sawanpracharak Hospital.

A double blind, prospective randomized control trial.

A d , o 9r, j v t u ty I o I v?or:outeygltj : -lu4il?flffrur:unr:il'tFrnflatm

n1:Yl1 femoral nerve block T2ilnu spinalq{

anesthesia 6{1 }J1Tn a n:uaiu nfiil? nm fllu r o d'rla.r.:ra a-l nt::siu nfl e6fi ngrdAd[0r El il:cotu fl 1Til'] na nn.: 1 .7-3.6 Lru o tYt Elufl u n1:?11 spinal anesthesia

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nnuLdo'rLafluLFr

I femoral nerve block levobupivacaine n1:il'lol nr:ndulfi 01t6flu nlTFiuoov

Fr-tfl]flalq

Abstract

Objective

Setting

Design

-.) - )ilYt 8 0uun 1 il.n.-Lx.u. 2554

tuoirornl:rir femoral neroe block deq o.r nJoir{uri levqbupivacainerfiooaornr:ilenrrd.rnr:ritffnrJ6auianirnrt,lu zl ieli.r

Result of Femoral Nerve Block with o.57o Levobupiyacaine to Reduced Pain

after Total Knee Replacement within zl hrs 37

Method

Results

Study in patients in patients who received total knee replacement in

Sawanpracharak Hospital between November 2008 to May 2009, there

were ASA physical status l-ll and spinal anesthesia was technique of

choice. 60 patients were divided to two groups; i.e. a spinal anesthesia

O.5% bupivacaine 3.0 cc addition with femoral nerve block O.5"h

levobupivacaine 20 cc amount 30 cases and a spinal anesthesia

O.5% bupivacaine 3.0 cc alone amount 30 cases. Demographic data,

VAS before and after spinal anesthesia at 8t', 12th,16h and 24h hr were

recorded, identified with mild pain = VAS 0-3, moderate pain = VAS

4-7, severe pain = VAS 8-10. The side effects, nausea vomiting and

hospital length of stay were also recorded. Significant of different

between two groups were using T-test and exact probability test.

Patients who received spinal anesthesia addition with femoral nerve

block were mean age 64.9 yrs (SD : 6.3), body weight 65.7 kg

(SD = 10.0), height 156.9 cm (SD = 6.2). The most of patients haci

ASA class ll (93.3%), 16.7y" were male and 83.3% were female, mean

the operation time 112 min (SD = 32.1), blood loss 101.7 ml (SD = 83.5).

ln spinal anesthesia addition with femoral nerve block group were

mean VAS before spinal anesthesia 7.1 (SD = 1.4) not significant

between spinal anesthesia alone group (p-value = 0.409), mean VAS

at 8h hr after spinal anesthesia in addition femoral nerve block group

was 2.1 (SD = 0.6), at 12'h hr 3.5 (SD = 1.8), at 16b hr 4.5 (SD = 2.0)

and pain scale significantly lower in spinal anesthesia alone group

(p_value < 0.00'l). Mean VAS at 24h hr after spinal anesthesia in spinal

anesthesia alone group was 4.4 (SD = 1.4), not significant between

groups (p_value < 0.147). Mean first time to received pehidine significantly

longer 16.4 hr.(SD = 1.0, p-value < 0.001), mean total dose of pethidine

in 24 hrs significantly lesser 29.2 mg (SD = 4.8, p-value < 0.001) and

number of patients no nausea and vomiting significantly lower (56.7"/",

p-value < 0.001) in addition femoral nerve block group versus spinal

anesthesia alone group. No significant difference in nausea vomiting

and hospital length of stay.

E!

I

Conclusion

Key words

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n21 ril o L1j:UU [n fl U n1Tfl Ft U'l{',] t?\ U{ nT{ tFt U?v oe , i ols-nnnrrlfiurriariiatmaan 24 drlru.,:(") fl't:av , J'triur Fia rfi ai,6t1 il1Tn n?L nNa1n1:rhorlfifi il:rAAdIAYdAdU61110'R1y\lFtn?1(''"'' LLFIIJ?lO[6lEl FtO tTlilAn:1

A X ett A \ \yy An1:mnlfl a L[aur,Jl]? rlrnaau 114??1 Lnuafl rua{{

Xdaaa41fl block motor u1u?u iln1:Flftl*''l?fl 3 in 1

Obct< 6arir femoral nerve blocX irruniu lumbar

plexus block tLdv sciatic block6l1il1:n:c.1'!, lfgd d

L?nLAOn?1n1:Yl'l femoral nerve block tflfl.,]t d 5lI O o

a u1{ tFl El? ttFr ttt? n1 [u nlTnlu1iln?1 yrufl't?c.Y t t A.Y t r

ttflTndauil1nn'j1 [acFirlfiqirufltn'jrtl+ro d X va e v eaLunlTFlnl*lufi A{ lfi n1:Tu{U n?1}J:dn

tu e d'drJ.r u:n tri 1^r u fr rh nyY{ a a.: n ei ru fi ar nr:{q

,JEil?OtUA.,lA1nqnfiZA{ spinal anesthesia

fl,-:n,:ad durnr a-r o'i'rh,:'Lufrrh und:JdtfiIUIUq

-.A -)ilm I auun 1 il.n.-ru.u. 2554

irn'r:rir femoral nerve block fiarnr:rlrrt

riafln'ir rfiatarnaT trdlfi block femoralt,adt

nerve uuLl:velst?n1n1:aanql]f,u1un?1@ \e Avq lYv

a'.: tn ntdar n:vEjv L? n1 n r.tllr a Ln :u peth idi nea,,

ni.,:u:novulun'j1 Ltnu?lu1n?a{ pethidine

{i frrh alfiiutu 24 d"ilsJ{asfia u n'jr frrJr un{ru

dtfiiunr::v$u nmr.rifi nfirs spinal anesthesiad r d u 5l9/ v 9/4

tfr g.:a Ei'rt ud Elr fl a{n1T[x n1T:vnu n?1il:6lnA &r- v\ Y 4-,-fi z+ t'rh.,: rirhavLraa.:nrirufr arnl:ilxFl

,tqvrr@a4-- -JLrj oir.,:nu Lua{a'1fl n1:fi il nqno'fl a{ u'lt1Yl

block femoral nerve rrnr{rJrulfiiu?J1 pehidine

rfia:s$url2n(15)) tY d --'Lunriila1fl'l:nau[6{alLaguilutJ'Ifl q

drdAspinal anesthesia LYIU{Afl1{LAU') tUA{A1na t, , $tr -- re jfrrlrunduiild:u pethidine rl3rurrufrsq

il1nn'i1(16) drviuarnr:6'u kirrnneir.:riuJ qv a c

[Ua.]a1nn1TLl{ pethidine ttt.:maantaann,l

1,{u 01 n1:Fiuria a n'ir ud a nli uu rfi a u fiu nr:"lfr)d,

morphine fit rfl un-r:'Lfrurmr.: central opiod(17)

Result of Femoral Nerve Block with 0.5% LevobuPivacaine to Reduced Pain

after Total Knee Replatement within 24 lus

I

d:tJt,o 9r, ai u t v aY I o

[u zuu?EIY|tJl:U n-l:zu1&lnfl a[?1 n1:n1cl

femoral nerve block iruriu spinal

anesthesia 611u1:nan:sriunr:il?nmu1u 1 6J,c u u va f d v{? LrJ{fi a{ n1::v.0u n?1N:dfl LFI El tJ:vFlU fl ',l:

q

ilroraoa'l 1 .7-3.G rfi arfi erlrilnr:rir spinal

anesthesia tfi u',:adr',:tdgr dflfr:;urL?nld'tfr pethidine nr{.,:u:nuru{u o.e d'dru{ aot

n1:'[fi pethidine'[u z+ #rlru{a'o 42.6 finfinilA qv a tv

Lra16l'r tJ1:61 n n a1 fl 1: n nu Ldal ta fl u LFI

aaanflnn::illJtsR'lfl

abv d anrucallQ ufl o?au nfu u1 El Ltl\Yl fl LAAil

gq

- E v eo I Idnha:ts narursnl:h{Y{tl1u1ad?lrn

. u I €a a a

ri:flnind, unv u't EILLl\mg IYlEl1 o'Tlf,"ilAqmilQnu y t ^.Lf

da ) oYo

mrmir n ri il.,1'lu1 dru rurn ur traurur n [mrr

;;;;;',,u",uu,,iifi"*,u q u

,u

tondl:o'l{oil1. Benyamin R, Trecot AM, Datta S. Opioid complications and side effects pain physician.

Opiod special issue 2008; 1 1 : 105-20.

Z. Edkin B, Spindler K, Flanagan J. Femoral nerve block as an altemative to parenteral

narcotics for pain control after anterior cruciate ligament reconstruction Arthroscopy.

The Journal of Arthroscopic & Related surgery 2001; 11: 404-9.

3. Tondrae AS, Nadkarni AV. Femoral nerue block for fractr-rred shaft of femur. Can Anestt

Soc J 1982; 29:270-1.

-E

d,vCfl?::nL:ut1:nut?ufi1:

4. Tierney E, LewisG, Hurtig JB, Johnson D. Femoral nerve block with bupivacaine0.25 percent for postoperative analgesia after open knee surgery. Can J Anaesth1987;5: 455-8.

Richman JM, Liu sS, courpas G, wong R, Rowlingson AJ, McGready J, et al.

Does continuous peripheral nerve block provide superior pain control to opioids?a meta-analysis. Anesth Analg 2006; 102. Z4B-ST.

Fanelli G, Casati A, Garancini P, Torri G. Nerve stimulator and multiple injection

technique for upper and lower limb blockade: failure rate, patient acceptance, andneurologic complications. Anesth Analg l ggg; BB: g47-50.

Hugh wA, spencer sL, Paul DW, craig sN, Brain Do. peripheral nerve blockimprove analgesia after total knee replacement surgery. Anesth Analg 1g9g; g7:

93-7.

Roxane F, Elisabeth VG, Giovanni G, Silv'ere B, Alain F,Zdravko G. Postoperative

analgesia with "3-in-1" femoral nerve block after prosthetic hip surgery. CanadianJournal of Anesthesia 1998; 45: S4-8.

9. Patel NJ, Flashburg MH, Parkin S, Grossman R. A regional anesthesia techenique

to general anesthesia for outpatient knee arthroscopy. Anesth Analg 1g86; 16 34-7.10. Heici F, Miiller N, Piepho T, Bares M, Giesa M, Dree p, et al. postoperative

analgesic efficacy of peripheral levobupivacaine and ropivacaine: a prospective,

randomized double-blind trial in patients after total knee arthroplasty. Anesth Analg

2OO8; 1 06:1 559-61 .

11. Francis VS, Spencer SL, Michael FM. The effect of single-injection femoral nerve

block versus continuous femoral nerve block after knee arthroplasty on hospital

length of stay and long-term function recovery within an established clinical pathway.

Anesth Analg 2006; 102: 1234-9.

12. Tarkkila P, Touminen M, Huntala J, Lindgren L. Comparison of intrathecal morphine

and continuous femoral 3-in 1 block for pain after major knee surgery under spinalanesthesia. European Journal of anesthesiology 2OO2: 15: 6-g.

13. Brian D, Michael B, Jhon DG, Robert AJ, Michael BS, Lundberg JF. A singleinjection ultrasound-assisted femoral nerue block provides side effect-sparing analgesia

when compared with intrathecal morphine in patients undergoing total knee

arthroplasty. Anesth Analg 2004;99: 1539-49.

14. Urbanek B, Duma A, Kimberger o, Huber G, Marhof er p, Zimpfer M, et al. onsettime, quality of blockade, and duration of three-in-one blocks with levobupivacaine

and bupivacaine. Anesth Analg 2003; 97: 8BB-92.

6.

7.

8.

Haxosnl:rir femoral nerve block daq o.r nJojr{uei levqbupivacainerfi oonornr:ilrqrdlnr:drffnnl6uuionirnrulu zl irlir.r

a,A v a Result of Femoral Nerve Blork with o.b% Levobupivacaine to Reduced Painilil 8 AUUm 1 il.F1.-ttJ.U. 2554 after Total Knee Replacement within zl hrs 4,)

15. Connor OA, Schug SA, Cardwell H. A comparison of the efficacy and safety of

morphine and pethidine as analgesia for suspected renal colic in the emergency

setting. Journal of Accident & Emergency Medicine 2000; 17: 261-4.

16. Unlugenc H, Vardar MA, Tetiker S. A Comparative study of the analgesic effect

of patient-controlled morphine, pethidine, and tramadol for postoperative pain

management after abdominal hysterectomy. Anesth Analg 2008; 106: 309-12.

17. Yosunkaya A, Tavlan A, Tuncer S, Rerslr R, Topal A, Okeslr S. Comparison of

the effects of intravenous and thoracic epidural patient-controlled analgesia with

morphine after upper abdominal surgery. Acta anesthesiologica Scandinavia 2003;

15: 271-9.

JvXn1fldfi t {aruafrufi1u?o.,:frd?el

{dd

Addition femoral block

(n=30)

mean (sD)

Spinal block alone

(n=30)

mean (sD)P value

o1q (fl)v

u1fiun (nn.)

drua.: (f,eJ.)

ASA classification (n,o/")

I

tr

tlt'lFI (n,%)

{'ru

u€,,:

:gEJ3[?A1nr:il'rriBr (u1fi )

nr:rfiarfian (ila.)

64.e (6.3)

65.7 (10.0)

156.e (6.2)

2 (6.7)

28 (e3.3)

5 (16.7)

25 (83.3)

112.2 (32.1)

1O1.7 (83.5)

63.3 (6.0)

62.7 (10.0)

155.3 (5.0)

2 (6.7)

28 (e3.3)

6 (20.0)

24 (80.0)

114.5 (2e.2)

88.3 (61.1)

0.349

o.247

0.306

1.000

0.739

o.772

0.483

jvmfl{fr 2 svnun'l?il?Ft

:vriunr:rhnAddition fernoral block

(n=30)

n (%)

Spinal block alone

(n=30)

n (Y")P value

vu9afi a.1fl1::s.1uFl?'t3JT6ln I {eJ.

mild pain ru

moderate pain

severe pain

mean (SD)vvy4

ila{n1::c.,tuFtl1tJTdn 1 2 ?tr.t.

mild pain {

, moderate pain

severe pain

mean (SD)uuya

fia{fl1TTs.:UFt?1il:6ln 1 6 {tJ.

mild pain

moderate pain

parn

mean (SD)vvlya

fi a{fl1::rnun?13J:61fl 24 AN.

mild pain {

moderate pain

severe pain

mean (SD)

0 (0)

16 (53.3)

14 (46.7)

7.1 (1.4)

30 (o)

0 (0)

0 (0)

2.1 (0.6)

24 (80.0)

4 (13.3)

2 (6.7)

3.5 (1.8)

16 (53.4)

13 (213.3)

1 (3.3)

4_5 (2.O)

16 (53.4)

13 (43.3)

1 (3.3)

3.e (1.3)

riaunr::sIunmru5fin

mild pain

moderate pain

severe pain

mean (SD)

0 (0)

18 (60.0)

12 (40.0)

6.8 (1.2)

17 (56.7)

e (30.0)

4 (13.3)

4.1 (2.1)

4 (13.3)

e (30.0)

17 (s6.7)

7.1 (2.1)

2 (6.7)

16 (53.3)

12 (40.0)

6.2 (2.3)

e (30.0)

1e (63.3)

2 (6.7)

4.4 (1.4)

0.409

<0.001

<0.00'l

0.003

o.'t47

ttd a ariud 1 il.n.-tx.fl. 2554Result of Femoul Nerve Blmk with o.e% Levobupivacaine to Reduced Pain

alter Total Knee Replacement within 2{ hrs

A oe e a rFt'l:1.0fi 3 nr:lfitrr pethidine A1n1T't1d[na.: UaE:rHut2aluau[:{ilUlulA

I

10il4{

Addition femoral block

(n=30)

mean (sD)

Spinal block alone

(n=30)

mean (sD)P value

nardlfr pethidine n{',:ur:n ltel';

?tu'rfr pethidine \u z+ tu. (iln.)A tv d

o1n1?nauld'aruiElu (n,%)

:rdu 0v

T&NU 1

:UFI"U 2

:ga"lj 3

a1n1:fru (n,%)fu

:sEtut'laluou LT{v{ u1u1n ('lu)

16.4 (1.0)

2e.2 (4.8)

17 (56.7)

0 (0)

1 (3.3)

12 (40.0)

0 (0)

6.2 (1.6)

e.6 (0.4)

71.8 (5.1)

3 (10.0)

2 (6.7)

3 (1o.0)

22 (73.3)

3 (10.0)

5.7 (1.4\

<0.001

<0.001

<0.001

o,237

0.233