SLR - December 2015 - Andrew Pavelescu
Reference: Elkassabany N, Cai L, Mehta S, Ahn J, Pieczynski L, Polomano RC, Picon S, Hogg R, Liu, J. Does Regional Anesthesia Improve the Quality of Postoperative Pain Management and the Quality of Recovery in Patients Undergoing Operative Repair of Tibia and Ankle Fractures? J Orthop Trauma. 2015 Sep; 29(9): 404-409.Scientific Literature Review
Reviewed By: Andrew Pavelescu, DPM
Residency Program: NewYork-Presbyterian/Queens
Podiatric Relevance: Postsurgical pain is an inherent risk associated with all operative procedures. It influences patients in various ways and causes undesirable effects ranging from physical and emotional distress to cardiovascular implications such as hypertension and tachycardia, increased oxygen consumption, impaired bowel function, delayed immobilization, and even immune and endocrine function alterations that can cause delayed healing. The overall goals of postoperative pain management are to achieve optimal patient comfort, improve quality of life, reduce morbidity, facilitate timely discharge, and allow for a quick recovery and return to function. Regional anesthesia has been shown to improve postoperative pain control, provide site-specific analgesia, and decrease opioid-related adverse effects when compared with opioid-based analgesia protocols. Therefore, the purpose of this study was to determine whether the use of peripheral nerve blocks as part of an analgesic protocol for operative repair of tibia and ankle fractures can improve the quality of postoperative pain management and the quality of recovery. Of importance is the ability to extrapolate the study’s conclusion to a podiatric perspective of regional anesthesia in the setting of both trauma and ambulatory surgery of the foot and ankle.
Methods: This is a prospective cohort study which enrolled 93 patients into two groups (59 regional group, 34 no-regional group) between January 2013 and April 2014. All patients were admitted by the orthopaedic trauma service with isolated tibial or ankle fractures and underwent operative repair by two surgeons. Exclusion criteria included multisystem or limb trauma, pregnancy, allergy to local anesthetics or any of the study medications, and patients who were deemed high risk for development of acute compartment syndrome or at risk of nerve injury. All patients received general anesthesia, with or without ultrasound guided popliteal and/or saphenous nerve blocks.
Results: Patient satisfaction score was significantly higher (P = 0.005) in the regional group, score of nine, when compared with the no-regional group, score of seven. The sum of adverse effects and the impact of pain on negative emotions were significantly higher in the no-regional group when compared with the regional group (P = 0.02 and 0.018, respectively). Least, average, and worst pain score in the 24-hour period was lower in the regional group. The average and least pain scores were not significantly different between the 2 groups (P = 0.07 and 0.09, respectively). However, the median of the worst pain score in 24 hours was significantly lower in the regional group (9 vs. 10, P = 0.04). The no-regional group reported a median higher percentage of time spent in severe pain (50 percent) when compared with the regional group (40%), P = 0.04. Patients in the no-regional group were ordered intravenous patient-controlled analgesia (IV PCA) as a supplement to postoperative analgesia more frequently than patients in the regional group (19/35 vs. 19/59, P = 0.03). Predictors significantly correlated with higher satisfaction scores were the percentage of overall pain relief, participation in the decision making, and QOR score at 24 hours. However, the sum of negative emotions and percentage of time spent in severe pain were negatively correlated with satisfaction with pain management (P = 0.001 and 0.002, respectively).
Conclusion: In conclusion, patients who received regional anesthesia as part of their analgesic protocol after surgery for injuries below the knee had higher satisfaction scores and scored better in three of the five domains assessed by the APS-POQ-R questionnaire compared to those who received only systemic analgesia. The regional anesthesia group had a better QOR when assessed 24 hours after surgery with no significant difference between the groups at 48 hours.
Limitations to this study include heterogeneity of fracture types potentially resulting in different pain trajectory for each fracture, selection criteria, potential for unknown confounders, limited follow up period and limited data collected in regards to home opioid consumption, and finally the fact that opioid management during and after surgery was not standardized.