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The impact of popliteal block on postoperative medication administration and time to discharge from the post-anesthesia care unit.

As the demand for outpatient surgery in the treatment of foot and ankle fractures increases, anesthesia and postoperative pain management have become increasingly popular topics among those involved in caring for patients. (1) Although surgical fixation has often been performed with general anesthesia, the use of regional blocks has gained popularity for benefits, such as avoiding airway manipulations, (2) intra-operative analgesia, (2) and muscle relaxation. (3) In addition to these benefits, several studies of the use of regional anesthesia in various lower extremity procedures found that regional anesthesia improves postoperative recovery by decreasing postoperative nausea and vomiting, administration of anti-emetic medications, (4) postoperative narcotic administration, (1,3,5,6) overnight hospitalizations secondary to pain, (7) and length of post-anesthesia care unit stay. (3-5,8,9) Improving postoperative care and ultimately minimizing the duration of hospitalization are critical as costs of prolonged hospital stays continue to be a major concern.

Several studies reported in the literature examine the efficacy of a popliteal regional block in addition to spinal anesthesia. Popliteal nerve blocks provide prolonged analgesia, (10) decreasing the need for narcotic administration and diminishing adverse side effects associated with these opiods. (11) Postoperative recovery is improved and length of stay in these patients is often shorter than that of patients who receive general or spinal anesthesia alone. (10) White and coworkers also reported an increase in patient satisfaction in pain management amongst those who received popliteal blocks after elective foot and ankle surgery. (11) Furthermore, Rongstad and associates reported that 95% of patients were satisfied with their postoperative care and would have the popliteal block again. (12)

Effective postoperative management is a critical issue in patients who undergo operative treatment for ankle fractures as well, since these patients often require narcotic administration and overnight hospitalization after ankle fracture fixation. Although there have been many reports on the use of localized popliteal regional blocks for foot and ankle surgeries, there is a lack of information on the use of popliteal regional blocks for postoperative management of ankle fractures. (13)

Post-anesthesia care unit stay details in patients treated surgically for ankle fractures who receive popliteal blocks remain underreported in the literature. The purpose of this IRB approved study was to compare the amount of narcotic pain medication administered, the need for anti-emetic medication, and PACU length of stay, including discharge status, in patients treated surgically for ankle fractures who receive popliteal blocks with those who received general anesthesia alone.

Patients and Methods

Institutional Review Board approval was obtained prior to proceeding with this study. All patients who underwent open reduction and internal fixation of an ankle fracture at New York University Medical Center or the Hospital for Joint Diseases by three attending traumatologists from December 28, 2009, to February 14, 2011, were asked to participate in this study. All anesthesia was administered by the same anesthesia group at both institutions. Patients were excluded from the study if they were under 18 years old, did not speak and read English, were unable to answer phone calls during the first 48 hours after surgery, or refused to consent to participate. All patients were operated on electively in a delayed fashion.

Patients who met inclusion criteria and agreed to participate were asked to provide informed consent. Those who consented were randomized to one of two anesthesia protocols: general anesthesia without any regional anesthesia or general anesthesia with a single injection popliteal block. Randomization was carried out by opening consecutive sealed opaque envelopes generated using random number tables to assign each patient to one of the two groups. These were prepared by one of the authors who did not take part in recruitment. The study was not blinded, so that both staff and patients were aware of the type of anesthesia used. This was necessary in order to assess the acceptability to the staff of the type of anesthesia. Demographic data, including age, sex, type of ankle fracture, and time to the operating room, were recorded for all consenting patients. Patients were followed up for at least 6 months and until fracture union (clinically or radiologically) to confirm the presence or lack of any complications including infection or persistent neurological deficit.

Anesthesia Technique

All patients were brought to the operating room. After the placement of standard ASA monitors and an intravenous line, all patients were sedated with a combination of midazolam (1 to 4 mg), fentanyl (25 to 50 pg) or ketamine (10 to 20 mg). Patients randomized to popliteal block were then placed in the prone position. The sciatic nerve was visualized with an ultrasound at approximately 10 cm proximal to the popliteal crease. Thirty cc of 0.25% bupivacaine with a 1:200,000 solution of epinephrine was injected; negative aspiration was confirmed every 5 cc. If a medial malleolar fracture was present, anesthesiologists were given the option of providing a saphenous block as well. A 25-gauge needle was placed into the proximal tibia and 6 cc of 0.25% bupivacaine was injected in the region of the saphenous nerve. After placement of the popliteal block, an 18-gauge needle was used to assess the efficacy of the block. Once adequate anesthesia was ensured, general anesthesia was administered. General anesthesia was induced, and a laryngeal mask airway (LMA) or an endotracheal tube was used at the discretion of the anesthesiologist.

In the perioperative period, patients were assessed for signs of toxic or allergic reactions, duration of procedure, duration of pneumatic tourniquet use, location of surgical incisions, time from entering the room to incision, and time from dressing placement to extubation. In addition, American Society of Anesthesiologists (ASA) Physical Status classification, as determined by the attending anesthesiologist performing the anesthesia, was recorded for each patient. Postoperatively, all patients were admitted to the Post-Anesthesia Care Unit (PACU). Data was collected on the duration of time in the PACU before discharge to home or to a hospital floor. Additional information was collected on the need for and amount of anti-emetic and pain medication in the PACU. Dosage of pain medications were converted into morphine dosing (10 mg of morphine equals 1.5 mg of dilaudid equals 100 [micro]g of fentanyl) to allow for comparison of various narcotics types.

Statistics

Data was analyzed using Statistical Program for the Social Sciences (SPSS), version 19.0 (IBM, Somers, NY). Descriptive statistics were compiled for all data points. Means and ranges were calculated for visual analog scale scores. Chi-square analyses were used to compare the categorical variables of sex and the presence of postoperative nausea. Independent samples Student's t-tests were used to compare continuous variables between the two groups. Analysis of Variance (ANOVA) tests were utilized to compare continuous variables amongst multiple groups. Prior to initiation of the study, a power analysis was conducted. It was determined that 25 patients would need to be included in each group to demonstrate a difference of three points on the visual analogue scale. A stepwise multivariate linear regression analysis was performed using the variables of interest in order to determine which variables contributed to the amount of pain medication received and the duration of time in the PACU. A stepwise multivariate logistic regression analysis was performed in order to determine which variables contributed to overnight hospitalization.

Results

Fifty-five consecutive patients with operative, unstable ankle fractures were asked to participate in the study. Four patients refused to participate, and 51 patients were enrolled in the study. Twenty-five patients were randomized to receive popliteal block, while 26 patients were randomized to receive no block. There was no significant difference between the two groups with regards to age, sex, type of ankle fracture, number of days from injury to surgical intervention, surgeon, or hospital in which the surgery took place (Table 1). There was no significant difference between the two groups with regards to ASA classification (Table 2).

Intra-operatively, there was no significant difference between the two groups with regards to location of incision(s) or total tourniquet time. There was a significant difference between the popliteal block and the no block groups with regards to amount of time to incision. The patients who received popliteal block averaged 52.4 [+ or -] 12.5 minutes from the time they were brought to the operating room until incision was made, while those who did not receive a popliteal block averaged 42.2 [+ or -] 8.9 minutes (p = 0.001). There was no difference between the two groups with regards to the amount of time from placement of the dressing until the patient was ready for transfer to the recovery room (Table 3). No patients sustained complications related to the anesthesia.

In the PACU, 14 patients who had a popliteal block and 18 patients who had general anesthesia received 4 mg of odanestron for nausea. One patient in the popliteal block group required an additional 4 mg dose of odansetron for continued nausea. There was no significant difference between the two groups with regards to the need for anti-emetic medication (p = 0.99). Only one patient was noted to have postoperative nausea or vomiting at 2 hours postoperatively. This patient was in the general anesthesia alone group.

All of the patients in the study group received medication for pain during their PACU stay. In the popliteal block group, patients received an average of 9.2 [+ or -] 7.1 mg of morphine. Those patients who had general anesthesia received an average of 9.6 [+ or -] 4.3 mg of morphine. There was no significant difference between the two groups with regards to the amount of pain medication received in the PACU (p = 0.83).

Patients in the study spent an average of 216.1 [+ or -] 95.1 minutes in the PACU before transfer to a hospital floor or discharge to home. There was no significant difference between the group who received a popliteal block (203.2 [+ or -] 91.4 minutes) and those who received general anesthesia (228.3 [+ or -] 98.3 minutes; p = 0.36). In addition, patients who received a popliteal block were no more likely to be discharged to home from the PACU than those who received general anesthesia (Table 3) (p = 0.09).

A stepwise multivariate linear regression analysis was used to determine the variables significantly associated with increased pain medication administration in the PACU. In this model, the only significant contributor to pain medication administration was age. For every year increase in age, the patient received 0.16 units less of pain medication (CI: 0.01-0.32, p < 0.001). This model accounted for 14.9% of the variability in pain medication administered in the PACU.

A similar analysis was used to determine the variables significantly associated with duration of stay in the PACU. However, no variables could be identified that were significantly associated with duration of stay in the PACU. A stepwise multivariate logistic regression analysis was used to determine the variables significantly associated with overnight hospitalization after open reduction and internal fixation of an ankle fracture. A logistic regression model found that ASA classification and age were predictors of overnight hospitalization. For every unit increase in ASA classification, there was a 13.8 times increased risk for overnight hospitalization (CI: 1.5-125.67, p = 0.020). For every year increase in age, there was a 1.1 times increased risk for overnight hospitalization (CI: 1.01-1.2, p = 0.036).

There were no postoperative anesthesia-related complications in either group.

Discussion

Previous studies of regional anesthesia have cited numerous postoperative benefits over general anesthesia alone. Authors argue that regional anesthesia improves postoperative recovery by decreasing postoperative nausea and vomiting and administration of anti-emetic medications. (4) Moreover, studies have demonstrated that regional anesthesia decreases postoperative narcotic administration, (1,3,5,6) overnight hospitalizations secondary to pain, (7) and length of post-anesthesia care unit stay. (3-5,8,9)

Our study did not find a significant difference between the patients receiving general anesthesia alone and those who received popliteal block with regards to the need for postoperative anti-emetic. A majority of the study patients received 4 mg of odansetron in the PACU. Only one patient in the study required an additional dose of anti-emetic, and that patient had received a popliteal block. Additionally, on assessment at 2 hours postoperatively, only one patient was noted to have nausea or vomiting. This patient was in the general anesthesia alone group. It is possible that this finding may be secondary to the anesthesiologists' practice of administering prophylactic anti-emetic medication during surgery.

Moreover, our study also found that single injection popliteal block administration did not decrease postoperative narcotic medication administration in the PACU. The amount of narcotic administered in the PACU was nearly identical between the two groups. A previous study of this cohort of patients demonstrated that patients receiving general anesthesia alone had significantly more pain as measured on the Visual Analog Scores (VAS) in the first 8 hours postoperatively. (13) However, in this study, the increased pain score did not translate into increased narcotic administration.

This lack of association between the narcotic administration and visual analog score may be attributed to a lack of understanding of regional anesthesia by PACU staff. In a multi-specialty hospital, many services do not use regional anesthesia. Therefore, staff may not be as familiar with regional anesthesia and as a result may be more likely to administer narcotic medication to postoperative patients in the recovery room as they emerge from anesthesia.

In addition, we found that popliteal block anesthesia did not decrease the length of stay in the PACU. Patients in both groups spent an average of 3.5 hours in the PACU before being released to home or being admitted to the floor. Moreover, while there did appear to be a trend towards patients with a block being discharged directly from the PACU, this difference was not statistically significantly different. This is an important finding that is dissimilar to previous studies; we are unable to explain the reason for lack of difference in length of stay or discharge home status. This may be due to patient expectations in their management including stay in the hospital. More studies are underway at our institution to understand whether this is secondary to our institutional culture or patient expectations.

This study was limited in that there were no standard criteria for the administration of anti-emetics or analgesia administration. Thus, medication administration is only one marker of postoperative nausea or pain and was subjective based on the nurse taking care of the patient in the recovery room.

Conclusion

In conclusion, this study found no difference between patients receiving regional anesthesia and those receiving general anesthesia alone with regards to the need for postoperative anti-emetic medication, narcotic requirements, time to discharge from the PACU, or the need for overnight admission. Our findings differ from the findings of previous studies, which often tout the advantages of regional anesthesia in orthopaedic surgeries.

Disclosure Statement

Rachel Y. Goldstein, M.D., received a Resident Research Grant from the Orthopaedic Trauma Association. None of the other authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.

References

(1.) Pearce CJ, Hamilton PD. Current concepts review: regional anesthesia for foot and ankle surgery. Foot Ankle Int. 2010 Aug; 31(8):732-9.

(2.) Singelyn FJ, Gouverneur JM, Gribomont BF. Popliteal sciatic nerve block aided by a nerve stimulator: a reliable technique for foot and ankle surgery. Reg Anesth. 1991 Sep-Oct; 16(5):278-81.

(3.) Chelly JE, Greger J, Al Samsam T, et al. Reduction of operating and recovery room times and overnight hospital stays with interscalene blocks as sole anesthetic technique for rotator cuff surgery. Minerva Anestesiol. 2001 Sep; 67(9):613-9.

(4.) Hadzic A, Williams BA, Karaca PE, et al. For outpatient rotator cuff surgery, nerve block anesthesia provides superior same-day recovery over general anesthesia. Anesthesiology. 2005 May; 102(5):1001-7.

(5.) Collins L, Halwani A, Vaghadia H. Impact of a regional anesthesia analgesia program for outpatient foot surgery. Can J Anaesth. 1999 Sep; 46(9):840-5.

(6.) Singelyn FJ, Aye F, Gouverneur JM. Continuous popliteal sciatic nerve block: an original technique to provide postoperative analgesia after foot surgery. Anesth Analg. 1997 Feb; 84(2):383-6.

(7.) Lichtenfeld NS. The pneumatic ankle tourniquet with ankle block anesthesia for foot surgery. Foot Ankle. 1992 Jul-Aug; 13(6):344-9.

(8.) McCartney CJ, Brull R, Chan VW, et al. Early but no long-term benefit of regional compared with general anesthesia for ambulatory hand surgery. Anesthesiology. 2004 Aug; 101(2):461-7.

(9.) la Grange P, Foster PA, Pretorius LK. Application of the Doppler ultrasound bloodflow detector in supraclavicular brachial plexus block. Br J Anaesth. 1978 Sep; 50(9):965-7.

(10.) Mendicino RW, Statler TK, AR C. Popliteal sciatic nerve blocks after foot and ankle surgery: an adjunct to postoperative analgesia. J Foot Ankle Surg. 2002; 41(5):338-41.

(11.) White PF, Issioui T, Skrivanek GD, et al. The use of a continuous popliteal sciatic nerve block after surgery involving the foot and ankle: does it improve the quality of recovery? Anesth Analg. 200 Nov 3; 97(5):1303-9.

(12.) Rongstad K, Mann RA, Prieskorn D, et al. Popliteal sciatic nerve block for postoperative analgesia. Foot Ankle Int. 1996 Jul; 17(7):378-82.

(13.) Goldstein RY, Montero N, Jain SK, et al. Efficacy of popliteal block in postoperative pain control after ankle fracture fixation: a prospective randomized study. J Orthop Trauma. 2012 Oct; 26(10):557-61.

Rachel Y. Goldstein, M.D., M.P.H., Ji Hae Park, B.A., Sudheer Jain, M.D., and Nirmal Tejwani, M.D.

Rachel Y Goldstein, M.D., M.P.H., Ji Hae Park, B.A., and Nirmal Tejwani, M.D., Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU-Langone Medical Center, New York, New York. Sudheer Jain, M.D., Department of Anesthesia, NYU Langone Medical Center, New York, New York.

Correspondence: Nirmal Tejwani, M.D., NYU Langone Medical Center, Hospital for Joint Diseases, 301 East 17th Street, Suite 1403, New York, New York 10003; nirmal.tejwani@nyumc.org.
Table 1 Demographic Data

                       Popliteal        No Block      Significance
                         1 Block

Age                        14              13            0.428
  Male                     11              13
  Female
Age (Years)           38.9 [+ or -]   41.7 [+ or -]      0.586
Side                       15.7            18.8
  Right                    14              18            0.561
  Left                     11               8
Time to OR                10.5            11.74          0.290
Type of Fracture
  Lateral Malleolus         9               9            0.507
  Bimalleolar              10               9
  Trimalleolar              6               8
  Medial Malleolus          0               2

Table 2 ASA Classification

ASA Class   Popliteal Block   No Block

1                 14             9
2                 10             15
3                  1             2

Comparison of medians p = 0.106.

Table 3 Duration of Admission

                       Block   No Block   Total

Admission               13        22       35
Discharged from PACU    10        6        16

Chi squared p = 0.091.
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Article Details
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Author:Goldstein, Rachel Y.; Park, Ji Hae; Jain, Sudheer; Tejwani, Nirmal
Publication:Bulletin of the NYU Hospital for Joint Diseases
Article Type:Report
Geographic Code:1USA
Date:Jan 1, 2015
Words:3118
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