Total Diz Artroplastisi Sonrası Ağrı Kontrolü İçin Femoral Sinir Bloğu ya da Adduktor Kanal Bloğu Yapılmış Hastalarda Rebound Ağrı ve Postoperatif Tramadol Gereksiniminin Karşılaştırılması

Amaç: Genel anestezi altında total diz protezi cerrahisi sonrası femoral sinir veya adduktor kanal bloğu uygulanan hastalarda rebound ağrı ve postoperatif tramadol gereksiniminin karşılaştırılması amaçlanmıştır. Yöntem: Total diz protezi cerrahisi geçiren ve postoperatif analjezi amacıyla anestezi indüksiyonu sonrası bu blokların yapıldığı 18-80 yaş, ASA I-III 50 hasta postoperatif dönemde incelendi. Hastalar FSB (femoral sinir bloğu) ve AKB (adduktor kanal bloğu) yapılanlar olarak 2 gruba ayrıldı (Grup F ve Grup AK). Tüm hastalara kurtarıcı analjezik olarak intravenöz tramadol ile Hasta kontrollü analjezi (HKA) uygulandı. Ek analjezik ihtiyacı için 75 mg diklofenak sodyum intramusküler uygulandı. Postoperatif ağrı skorları, tramadol tüketimi, ek anal- jezik ihtiyacı, rebound ağrı insidansı ve gelişen diğer komplikasyonlar kaydedildi. Postoperatif dönemde ağrı ve motor güç takibi için Vizuel Analog Skala (VAS) ve Bromage skalaları kullanıldı. Veriler SPSS 20.0 istatistik prog- ramı ile analiz edildi. Bulgular: Rebound ağrı görülen 7 hastanın üçü femoral blok grubundayken diğer 4 hasta adduktor kanal bloğu grubundaydı. Rebound ağrı süreleri sırasıyla grup F ve grup AK olmak üzere 50, 60, 120 ve 60, 60, 90, 110 dk olarak izlendi. Rebound ağrı görülme sıklığı ve süreleri benzerdi. 0., 2., 4. ve 8. saatlerdeki postoperatif ağrı skorları femoral blok grubunda adduktor kanal bloğu uygulananlara göre anlamlı derecede düşük bulundu. Femoral blok grubunda 0., 2., 4. saatlerdeki Bromage skorları adduktor kanal bloğu grubuna göre istatistiksel olarak daha düşüktü. HKA ile tramadol tüketimi femoral blok grubunda adduktor blok grubuna göre anlamlı olarak daha düşüktü. Toplam tramadol tüketimi ve ek analjezik ihtiyacı ile postoperatif komplikasyonlar karşılaştırıldığında gruplar arasında istatistiksel olarak anlamlı bir fark görülmedi. Her iki gruptaki hasta memnuniyet puanları benzerdi. Sonuç: Her iki gruptaki rebound ağrı görülme sıklığı ve süresi benzerdi. Femoral blok ile 0., 2., 4. ve 8. saatlerde adduktor kanal bloğuna göre daha etkin analjezi sağlandığını gördük. HKA kullanma isteği femoral blok gru- bunda anlamlı olarak daha düşüktü. Postoperatif komplikasyon ve ek analjezik ihtiyaçları arasında da istatistik- sel olarak anlamlı fark bulunmadı.

Comparison of Rebound Pain and Postoperative Tramadol Requirement in Patients Who Had Femoral Nerve Block or Adductor Canal Block for Pain After Total Knee Arthroplasty

Objective: It was aimed to compare the rebound pain and postoperative tramadol requirement in patients who underwent femoral nerve or adductor canal block after total knee replacement surgery under general anesthesia. Methods: Fifty ASA I-III patients, 18-80 years of age, who underwent total knee replacement surgery and underwent these blocks after induction of anesthesia for postoperative analgesia, were examined in the postoperative period. The patients were divided into 2 groups as FNB (femoral nerve block) and ACB (adductor canal block) (Group F and Group AC). Patient controlled analgesia (PCA) was applied to all patients with intravenous tramadol as a rescue analgesic. 75 mg diclofenac sodium was administered intramuscularly for additional analgesic requirement. Postoperative pain scores, tramadol consumption, additional analgesic requirement, incidence of rebound pain and other complications were recorded. Visual Analogue Scale (VAS) and Bromage scales were used to monitor pain and motor weakness in the postoperative period. The data were analyzed with the SPSS 20.0 statistical program. Results: Three of the 7 patients with rebound pain were in the femoral block group, while the other 4 patients were in the adductor canal block group. Rebound pain durations were followed as 50, 60, 120 and 60, 60, 90, 110 minutes, in group F and group AK, respectively. The frequency and duration of rebound pain were similar. It was found that postoperative pain scores at 0. 2. 4. and 8. hours were statistically significantly lower in patients who underwent femoral block than those who received adductor canal block. Bromage scores at 0, 2 and 4 hours in the femoral block group were statistically lower than the adductor canal block group. Tramadol consumption with PCA was significantly lower in the femoral block group than in the adductor block group. When total tramadol consumption and additional analgesic requirement were compared with postoperative complications, no statistically significant difference was found between the two groups. Patient satisfaction scores in both groups were similar. Conclusion: The frequency and duration of rebound pain in both groups were similar. We found that femoral block provides more effective analgesia in the first 8 hours compared to adductor canal block. Request to use PCA was significantly lower in the femoral block group. There was no statistically significant difference between postoperative complications and additional analgesic needs.

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1. Tietje T, Davis AB, Rivey MP. Comparison of 2 Methods of Local Anesthetic-Based Injection as Part of a Multimodal Approach to Pain Management After Total Knee Arthroplasty. J Pharm Pract. 2015;28:523-8. https://doi.org/10.1177/0897190014544815
2. Sort R, Brorson S, Gogenur I, Nielsen JK, Moller AM. Rebound pain following peripheral nerve block anaesthesia in acute ankle fracture surgery: An exploratory pilot study. Acta Anaesthesiol Scand. 2019;63:396- 402. https://doi.org/10.1111/aas.13290
3. Jaeger P, Koscielniak-Nielsen ZJ, Schroder HM, et al. Adductor canal block for postoperative pain treatment after revision knee arthroplasty: a blinded, randomized, placebo-controlled study. PLoS One. 2014;9:e111951. https://doi.org/10.1371/journal.pone.0111951
4. Lavand’homme P. Rebound pain after regional anesthesia in the ambulatory patient. Curr Opin Anaesthesiol. 2018;31:679-84. https://doi.org/10.1097/ACO.0000000000000651
5. Hussain N, Costache I, Kumar N, et al. Is Supraclavicular Block as Good as Interscalene Block for Acute Pain Control Following Shoulder Surgery? A Systematic Review and Meta-analysis. Anesth Analg. 2020;130:1304-19. https://doi.org/10.1213/ANE.0000000000004692
6. Barry GS, Bailey JG, Sardinha J, Brousseau P, Uppal V. Factors associated with rebound pain after peripheral nerve block for ambulatory surgery. Br J Anaesth. Br J Anaesth. 2021;126:862-71. https://doi.org/10.1016/j.bja.2020.10.035
7. Galos DK, Taormina DP, Crespo A, et al. Does Brachial Plexus Blockade Result in Improved Pain Scores After Distal Radius Fracture Fixation? A Randomized Trial. Clin Orthop Relat Res. 2016;474:1247-54. https://doi.org/10.1007/s11999-016-4735-1
8. Abdallah FW, Halpern SH, Aoyama K, Brull R. Will the Real Benefits of Single-Shot Interscalene Block Please Stand Up? A Systematic Review and Meta-Analysis. Anesth Analg. 2015;120:1114-29. https://doi.org/10.1213/ANE.0000000000000688
9. Dong CC, Dong SL, He FC. Comparison of Adductor Canal Block and Femoral Nerve Block for Postoperative Pain in Total Knee Arthroplasty: A Systematic Review and Meta-analysis. Medicine (Baltimore). 2016;95:e2983. https://doi.org/10.1097/MD.0000000000002983
10. Alves WM, Jr., Migon EZ, Zabeu JL. Pain Following Total Knee Arthroplasty - a Systematic Approach. Rev Bras Ortop. 2010;45:384-91. https://doi.org/10.1016/S2255-4971(15)30424-9
11. Vora MU, Nicholas TA, Kassel CA, Grant SA. Adductor canal block for knee surgical procedures: review article. J Clin Anesth. 2016;35:295-303. https://doi.org/10.1016/j.jclinane.2016.08.021
12. Abdallah FW, Mejia J, Prasad GA, et al. Opioid- and Motor-sparing with Proximal, Mid-, and Distal Locations for Adductor Canal Block in Anterior Cruciate Ligament Reconstruction: A Randomized Clinical Trial. Anesthesiology. 2019;131:619-29. https://doi.org/10.1097/ALN.0000000000002817
13. Patterson ME, Bland KS, Thomas LC, et al. The adductor canal block provides effective analgesia similar to a femoral nerve block in patients undergoing total knee arthroplasty--a retrospective study. J Clin Anesth. 2015;27:39-44. https://doi.org/10.1016/j.jclinane.2014.08.005
14. Gadsden JC, Sata S, Bullock WM, Kumar AH, Grant SA, Dooley JR. The relative analgesic value of a femoral nerve block versus adductor canal block following total knee arthroplasty: a randomized, controlled, doubleblinded study. Korean J Anesthesiol. 2020;73:417- 24.
15. Shah NA, Jain NP. Is continuous adductor canal block better than continuous femoral nerve block after total knee arthroplasty? Effect on ambulation ability, early functional recovery and pain control: a randomized controlled trial. J Arthroplasty. 2014;29:2224-9. https://doi.org/10.1016/j.arth.2014.06.010
16. Grevstad U, Mathiesen O, Valentiner LS, Jaeger P, Hilsted KL, Dahl JB. Effect of adductor canal block versus femoral nerve block on quadriceps strength, mobilization, and pain after total knee arthroplasty: a randomized, blinded study. Reg Anesth Pain Med. 2015;40:3-10. https://doi.org/10.1097/AAP.0000000000000169
17. Ganta A, Ding D, Fisher N, Lavery J, Jain S, Tejwani NC. Continuous Infraclavicular Brachial Block Versus SingleShot Nerve Block for Distal Radius Surgery: A Prospective Randomized Control Trial. J Orthop Trauma. 2018;32:22-6. https://doi.org/10.1097/BOT.0000000000001021
18. Williams BA, Bottegal MT, Kentor ML, Irrgang JJ, Williams JP. Rebound pain scores as a function of femoral nerve block duration after anterior cruciate ligament reconstruction: retrospective analysis of a prospective, randomized clinical trial. Reg Anesth Pain Med. 2007;32:186-92. https://doi.org/10.1097/00115550-200705000-00003
19. Munoz-Leyva F, Cubillos J, Chin KJ. Managing rebound pain after regional anesthesia. Korean J Anesthesiol. 2020;73:372-83. https://doi.org/10.4097/kja.20436
20. Goldstein RY, Montero N, Jain SK, Egol KA, Tejwani NC. Efficacy of popliteal block in postoperative pain control after ankle fracture fixation: a prospective randomized study. J Orthop Trauma. 2012;26:557-61. https://doi.org/10.1097/BOT.0b013e3182638b25
21. Gordon SM, Chuang BP, Wang XM, Hamza MA, Rowan JS, Brahim JS, et al. The differential effects of bupivacaine and lidocaine on prostaglandin E2 release, cyclooxygenase gene expression and pain in a clinical pain model. Anesth Analg. 2008;106:321-7. https://doi.org/10.1213/01.ane.0000296474.79437.23
22. Kaiser U, Liedgens H, Meissner W, Weinmann C, Zahn P, Pogatzki-Zahn E. Developing consensus on core outcome domains and measurement instruments for assessing effectiveness in perioperative pain management after sternotomy, breast cancer surgery, total knee arthroplasty, and surgery related to endometriosis : The IMI-PainCare PROMPT protocol for achieving a consensus on core outcome domains. Trials. 2020;21:773. https://doi.org/10.1186/s13063-020-04665-9
23. Fang J, Shi Y, Du F, et al. The effect of perineural dexamethasone on rebound pain after ropivacaine singleinjection nerve block: a randomized controlled trial. BMC Anesthesiol. 2021;21:47. https://doi.org/10.1186/s12871-021-01267-z
24. Cao X, White PF, Ma H. An update on the management of postoperative nausea and vomiting. J Anesth. 2017;31:617-26. https://doi.org/10.1007/s00540-017-2363-x
25. Matava MJ, Prickett WD, Khodamoradi S, Abe S, Garbutt J. Femoral nerve blockade as a preemptive anesthetic in patients undergoing anterior cruciate ligament reconstruction: a prospective, randomized, double-blinded, placebo-controlled study. Am J Sports Med. 2009;37:78-86. https://doi.org/10.1177/0363546508324311
26. Coderre TJ, Katz J, Vaccarino AL, Melzack R. Contribution of central neuroplasticity to pathological pain: review of clinical and experimental evidence. Pain. 1993;52:259-85. https://doi.org/10.1016/0304-3959(93)90161-H