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Proximal Versus Distal Continuous Adductor Canal Blocks

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Proximal Versus Distal Continuous Adductor Canal Blocks Proximal Versus Distal Continuous Adductor Canal Blocks: Does Varying Perineural Catheter Location Influence Analgesia? A Randomized, Subject-Masked, Controlled Clinical Trial Jacklynn F. Sztain, MD, Bahareh Khatibi, MD, Amanda M. Monahan, MD, Engy T. Said, MD, 06/24/2018 on HRKGxsQg0SuoZn4utVXOmk5z97Ja58gACMhy7Bn6J3AP6ghkXyb1tI+UeqR7yrM9qMCtumnaZizf7u+BFX+JxKfAaCZ2GwhaiucBBv+CqffnLy74g548/g== by https://journals.lww.com/anesthesia-analgesia from Downloaded Wendy B. Abramson, MD, Rodney A. Gabriel, MD, MAS, John J. Finneran IV, MD, Richard H. Bellars, MD,* Patrick L. Nguyen, MD,* Scott T. Ball, MD, Francis† B. Gonzales, MD,* Downloaded Sonya S. Ahmed, MD, Michael* C. Donohue, PhD, Jennifer*‡ A. Padwal, BS, and *‡ Brian M. Ilfeld, MD, MS *(Clinical Investigation) * § § from § ∥ ¶ https://journals.lww.com/anesthesia-analgesia BACKGROUND: A continuous adductor canal*‡ block provides analgesia after surgical procedures of the knee. Recent neuroanatomic descriptions of the thigh and knee led us to speculate that local anesthetic deposited in the distal thigh close to the adductor hiatus would provide superior analgesia compared to a more proximal catheter location. We therefore tested the hypothesis that during a continuous adductor canal nerve block, postoperative analgesia would be improved by placing the perineural catheter tip 2–3 cm cephalad to where the femoral artery descends posteri- orly to the adductor hiatus (distal location) compared to a more proximal location at the midpoint between the anterior superior iliac spine and the superior border of the patella (proximal location). by HRKGxsQg0SuoZn4utVXOmk5z97Ja58gACMhy7Bn6J3AP6ghkXyb1tI+UeqR7yrM9qMCtumnaZizf7u+BFX+JxKfAaCZ2GwhaiucBBv+CqffnLy74g548/g== METHODS: Preoperatively, subjects undergoing total knee arthroplasty received an ultrasound- guided perineural catheter inserted either in the proximal or distal location within the adductor canal in a randomized, subject-masked fashion. Subjects received a single injection of lidocaine 2% via the catheter preoperatively, followed by an infusion of ropivacaine 0.2% (8 mL/h basal, 4 mL bolus, 30 minutes lockout) for the study duration. After joint closure, the surgeon infiltrated the entire joint using 30 mL of ropivacaine (0.5%), ketorolac (30 mg), epinephrine (5 μg/mL), and tranexamic acid (2 g). The primary end point was the median level of pain as measured on a numeric rating scale (NRS) during the time period of 8:00 AM to 12:00 PM the day after surgery. RESULTS: For the primary end point, the NRS of subjects with a catheter inserted at the proxi- mal location (n = 24) was a median (10th, 25th–75th, 90th quartiles) of 0.5 (0.0, 0.0–3.2, 5.0) vs 3.0 (0.0, 2.0–5.4, 7.8) for subjects with a catheter inserted in the distal location (n = 26; P = .011). Median and maximum NRSs were lower in the proximal group at all other time points, but these differences did not reach statistical significance. There were no clinically relevant or statistically significant differences between the treatment groups for any other secondary end point, including opioid consumption and ambulation distance. CONCLUSIONS: For continuous adductor canal blocks accompanied by intraoperative periar- ticular local anesthetic infiltration, analgesia the day after knee arthroplasty is improved with a catheter inserted at the level of the midpoint between the anterior superior iliac spine and the superior border of the patella compared with a more distal insertion closer to the adductor hiatus. (Anesth Analg 2018;127:240–6) KEY POINTS • Question: Neuroanatomy of the thigh and knee has led to speculation that local anesthetic deposited in the distal thigh close to the adductor hiatus would provide superior analgesia compared to a more proximal location, yet this supposition remains unexamined. • Findings: For continuous adductor canal blocks, analgesia the day after knee arthroplasty is on improved with a catheter inserted at the level of the midpoint between the anterior superior 06/24/2018 iliac spine and the superior border of the patella, compared with a more distal insertion closer to the adductor hiatus. • Meaning: For perineural local anesthetic infusion within the adductor canal, a more proximal catheter insertion site improved analgesia the day after knee arthroplasty compared with a more distal insertion point. From the Department of Anesthesiology, University of California Accepted for publication March 27, 2018. San Diego, San Diego, California; Department of Anesthesiology, Funding: This work was supported by the Department of Anesthesiology, * University of Pittsburgh, Pittsburgh, Pennsylvania; Outcomes Research University of California San Diego (San Diego, CA). Consortium, Cleveland, Ohio; Department† of Orthopedics, University of California San Diego, San Diego, California; Division‡ of Biostatistics The authors declare no conflicts of interest. and Bioinformatics, University§ of Southern California, Los Angeles, The contents of this article are solely the responsibility of the authors and do California; and School of Medicine, University∥ of California San Diego, not necessarily represent the official views of the funding entity. San Diego, California. Institutional review board: University California San Diego Human Research ¶ Copyright © 2018 International Anesthesia Research Society Protections Program at (858) 657–5100, 9500 Gilman Dr, La Jolla, CA 92093- DOI: 10.1213/ANE.0000000000003422 0052. E-mail: [email protected]. 240 www.anesthesia-analgesia.org July 2018 • Volume 127 • Number 1 Copyright © 2018 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited. ontinuous adductor canal nerve blocks provide post- CA). Written informed consent was obtained from all sub- operative analgesia after surgical procedures of the jects participating in the trial. The trial was prospectively Cknee.1,2 Inserting the perineural catheter distal to registered at clinicaltrials.gov (NCT02523235, Principal the location of a traditional inguinal femoral nerve block Investigator: B.M.I., date of registration: August 14, 2015) decreases induced quadriceps femoris weakness while retain- before initiation of enrollment. ing similar analgesic potential.3–5 Remaining undetermined is Enrollment was offered preoperatively to adults (age the optimal location for catheter insertion within the thigh. 18 years or older) undergoing primary tricompartment The most commonly reported level of insertion is the knee arthroplasty with a preplanned adductor canal midpoint between the anterior superior iliac spine and catheter and local anesthetic infusion for postoperative the cephalad border of the patella (commonly referred to analgesia. Exclusion criteria included neuropathy of as the “midthigh” approach),1–14 although a more cepha- the operative extremity, chronic opioid use (daily use lad placement has been reported.15–18 Recent investigation for >4 weeks before surgery of at least the equivalent of and description of the relevant neuroanatomy of the thigh 20 mg oxycodone), body mass index >40 kg/m2; allergy and knee had led us to speculate that superior postopera- to lidocaine or ropivacaine, renal insufficiency, inabil- tive analgesia might be produced with deposition of local ity to communicate with the investigators, pregnancy, anesthetic further caudad in “the distal thigh within the AC and incarceration. The study was conducted at Hillcrest [adductor canal] where the femoral artery is sonographi- Hospital (San Diego, CA) as well as Thornton and Jacobs cally seen to descend posteriorly toward the adductor hia- Medical Center (La Jolla, CA), both academic institutions tus, as described by Manickam et al in 2009.”19–21 In contrast, associated with the University of California San Diego other investigators have provided anatomically based rea- Medical Center. sons for why the more proximal insertion site might pro- vide optimal analgesia after knee surgery.12 Perineural Catheter Insertion Unfortunately, no published data exist comparing the Subjects were positioned supine with slight external rota- midthigh and a more distal perineural catheter location. tion of the leg at the hip. Standard monitors were applied, Considering >700,000 knee arthroplasty procedures are per- and oxygen was administered by facemask at 8 L/min. formed within the United States annually, and continuous Intravenous (IV) midazolam (1–2 mg) and fentanyl (50–100 adductor canal blocks are frequently used to provide anal- μg) were administered, titrating for anxiolysis and anal- gesia after these procedures, there is value in identifying the gesia, with verbal responsiveness maintained at all times. optimal perineural catheter location.22 Procedures were completed by regional anesthesia fel- We therefore conducted this randomized, subject- lows under the direct supervision of an attending regional masked, controlled, parallel-arm clinical trial to test the anesthesiologist. hypothesis that during a continuous adductor canal nerve Using a 13–6 MHz 38-mm linear array ultrasound trans- block, postoperative analgesia after knee arthroplasty will ducer (M-Turbo; SonoSite, Bothell, WA) in the short-axis be improved with the perineural catheter tip inserted in a view, the 2 possible catheter insertion locations were iden- distal location 2–3 cm cephalad to where the femoral artery tified. The proximal location was defined as, “… halfway descends posteriorly to the adductor hiatus compared to a between the superior anterior iliac spine and the [superior 23 more
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