Ravi Raj, R (2007) A Comparative study of Continuous Posterior Lumbar Plexus Block and Continuous Epidural Block in Total Hip Replacement Surgery: A Prospective Randomized Single Blind Controlled Clinical Trial. Masters thesis, Christian Medical College, Vellore.
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Abstract
INTRODUCTION: Total hip replacement (THR) is the most common joint replacement procedure that aims to relieve joint pain, increase mobility and improve the quality of life of the patients with, chronic degenerative disease of hip joint and patients with proximal femoral fracture. Anaesthesia and post operative analgesia for THR is a challenge, as the age of the patients presenting for THR varies, and 60% of the procedures are performed on patients above 65 years of age. Most of these elderly patients have significant comorbid conditions like hypertension, ischemic heart disease, renal dysfunction, diabetes mellitus and obstructive pulmonary disease, all of which can adversely affect the patient management in perioperative period. It is therefore important to choose an effective analgesic regimen with minimal side-effects to allow timely mobility, optimal functional recovery and decrease postoperative morbidity and mortality. The major intraoperative anaesthetic concerns during THR are blood loss, cardiovascular instability and hypoxemia. Blood loss is related to intraoperative tissue trauma, especially the reaming of medullary bone, and increases if an osteotomy of greater trochanteris performed to improve surgical exposure or with revision procedures. Blood loss is variable, averaging 0.5L to 1.5L intraoperatively and 300-500ml in the postoperative period. Intraoperative blood loss is significantly reduced with regional anaesthesia than general anaesthesia alone. Combination of general anaesthesia with regional techniques has revealed significantly lower blood loss than regional or general anaesthesia alone. Pain after total-hip replacement (THR), although variable and of unclear duration, is severe in half of the patients at rest and is often exacerbated by movement. Postoperative pain control can be achieved by a variety of techniques, such as intravenous Patient Control Analgesia (PCA), epidural analgesia, and lumbar plexus block. Intravenous PCA is inefficient in controlling pain during mobilization. The benefit of postoperative analgesia with epidural block is offset by adverse effects such as nausea, vomiting, pruritus, urinary retention and respiratory depression. Now-a-days, general anaesthesia with continuous lumbar epidural block is the standard anaesthetic technique. Because of the efficiency and relative safety of continuous neuraxial nerve blocks, the lower extremity received little attention during the early development of continuous nerve blockade7. Lumbar plexus block (LBP) is an effective but underused regional technique that was described nearly three decades ago. Since the introduction of peripheral nerve stimulators, ultrasound guided nerve localization and continuous peripheral nerve block technique, a growing interest in the field of regional anaesthesia has been established with more deep and unconventional nerve blocks being performed safely. AIM OF THE STUDY: Is Continuous lumbar plexus blockade, superior to continuous lumbar epidural blockade in total hip replacement? MATERIAL AND METHODS: The aim of the study was to assess if continuous lumbar plexus blockade was superior to continuous lumbar epidural blockade in total hip replacement surgery and compare the hemodynamic stability, pain relief and incidence of complications between the two groups. After obtaining institutional ethics committee approval and written informed consent, a single blinded randomized controlled trial was conducted on 60 patients scheduled for elective total hip replacement under general anaesthesia. The sample size was calculated as 30 in each group based on the previous study and a pilot study. Adults belonging to ASA grade I, II, III, body mass index less than 30 were included in the study. Those with ankylosing spondylitis, moderate to severe COPD, ASA grade IV, body mass index more than 30, were excluded from the study. Patients were randomly allocated to receive either general anaesthesia combined with a continuous lumbar plexus block (n=30 patients) or general anaesthesia combined with continuous lumbar epidural block. All patients were premedicated with diazepam 10mg and metaclopramide 10mg orally an hour before surgery. RESULTS: A total of 72 patients were assessed for eligibility. Among them, 12 patients were excluded from the study because 11 of them did not satisfy the inclusion criteria and one patient refused to participate in the study. 60 patients were enrolled and randomized to two groups of 30 each. In group-L all 30 were included in the analysis. Two patients were excluded from the post operative analysis as, one had pulmonary edema due to airway obstruction and inadequate reversal of neuromuscular blockade, and another patient’s post operative data was found missing. In group-E, two cases were excluded from the analysis due to failure of technique and six patients were excluded from the post operative period analysis due to discontinuation of infusion because of hypotension. CONCLUSION: Continuous lumbar plexus block is a superior alternative technique to continuous epidural block in the intra operative and post operative management of total hip replacement. It provides better hemodynamic stability, decreased incidence of urinary dysfunction and analgesia which is as good and sustained as epidural analgesia. The success rate is 100% with the use of a nerve stimulator, and the incidence of complications can be reduced by careful titrated doses of local anaesthetic, coupled with good vigilance and monitoring.
| Item Type: | Thesis (Masters) |
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| Uncontrolled Keywords: | Continuous Posterior Lumbar Plexus Block ; Continuous Epidural Block ; Total Hip Replacement Surgery ; Prospective Randomized Single Blind Controlled Clinical Trial ; Comparative study. |
| Subjects: | MEDICAL > Anaesthesiology |
| Depositing User: | Subramani R |
| Date Deposited: | 30 Apr 2018 02:52 |
| Last Modified: | 30 Apr 2018 02:52 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/7309 |
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