The Effect of Regional Analgesia on Vascular Tone in Hip Arthroplasty Patients

Abstract

Background

While it is assumed that neuraxial analgesia and pain management may beneficially influence perioperative hemodynamics, few studies provided data quantifying such effects and none have assessed the potential contribution of the addition of a nerve block.

Questions/Purposes

This clinical trial compared the visual analog scale (VAS) scores and measurement of arterial tone using augmentation index of patients who received combined spinal–epidural (CSE) only to patients who received both CSE and lumbar plexus block.

Methods

After obtaining written consent, 92 patients undergoing total hip arthroplasty were randomized to receive either CSE or CSE with lumbar plexus block (LPB). Perioperative pain and arterial tone were measured using VAS scores and augmentation index (AI) respectively, at baseline and at various times postoperatively.

Results

After the exclusion of 2 patients, 44 patients received CSE alone and 46 patients received CSE and LPB. Patient demographics and perioperative characteristics were similar in both groups. AI continuously decreased after placement of a CSE with or without LBP, beyond full resolution of neuraxial and peripheral blockade. Although the LPB group demonstrated a statistically significant reduction of VAS pain scores in the postanesthesia care unit (PACU; P < 0.05), overall, the addition of a LPB did not significantly reduce the AI when compared to the control group.

Conclusion

The addition of a LPB provided better pain control in the PACU but did not reduce the AI, compared to the control group. We conclude that the addition of a LPB may have limited ability to affect arterial tone in the presence of a continuous infusion of epidural analgesics. In summary, the addition of a LPB in patients undergoing total hip arthroplasty is clinically effective and provided better pain control, especially in the immediate postoperative period. The continuous decrease on the AI in both groups beyond the full resolution of the neuroaxial and LPB will require further studies.

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References

  1. 1.

    American Society of Anesthesiologists. ASA physical status classification system. http://www.asahq.org/Home/For-Members/Clinical-Information/ASA-Physical-Status-Classification-System.

  2. 2.

    Block BM, Liu SS, Rowlingson AJ, et al. Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA. 2003; 18: 2455-2463.

    Article  Google Scholar 

  3. 3.

    Capdevila X, Coimbra C, Choquet O. Approaches to the lumbar plexus: success, risks, and outcome. Reg Anesth Pain Med. 2005; 2: 150-6213.

    Google Scholar 

  4. 4.

    de Oliveira RM, Tenorio SB, Tanaka PP, et al. Control of pain trough epidura328 l block and incidence of cardiac dysrhythmias in postoperative period of thoracic and major abdominal surgical procedures: a comparative study. Rev Bras Anestesiol. 2012; 1: 10-18.

    Article  Google Scholar 

  5. 5.

    Ginosar Y, Weiniger CF, Kurz V, et al. Sympathectomy-mediated vasodilatation: a randomized concentration ranging study of epidural bupivacaine. Can J Anaesth. 2009; 3: 213-221.

    Article  Google Scholar 

  6. 6.

    Goytizolo E, Marcello D. Hospital for special surgery clinical trial registry: effect of optimal regional analgesia on arterial tone after total hip arthroplasty. http://www.hss.edu/clinical-trials_arthroplasty-hip-arterial-tone-optimal-regional-analgesia.asp. Accessed July 2012.

  7. 7.

    Horlocker TT. Pain management in total joint arthroplasty: a historical review. Orthopedics. 2010; 9(Suppl): 14-19.

    Article  Google Scholar 

  8. 8.

    Ilfeld BM. Continuous peripheral nerve blocks: a review of the published evidence. Anesth Analg. 2011; 4: 904-925.

    Article  Google Scholar 

  9. 9.

    Ilfeld BM, Mariano ER, Madison SJ, et al. Continuous femoral versus posterior lumbar plexus nerve blocks for analgesia after hip arthroplasty: a randomized, controlled study. Anesth Analg. 2011; 4: 897-903.

    Article  Google Scholar 

  10. 10.

    Jans O, Bundgaard-Nielsen M, Solgaard S, et al. Orthostatic intolerance during early mobilization after fast-track hip arthroplasty. Br J Anaesth. 2012; 3: 436-443.

    Article  Google Scholar 

  11. 11.

    Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002; 6: 630-641.

    Article  Google Scholar 

  12. 12.

    Ledowski T, Reimer M, Chavez V, et al. Effects of acute postoperative pain on catecholamine plasma levels, hemodynamic parameters, and cardiac autonomic control. Pain. 2012; 4: 759-764.

    Article  Google Scholar 

  13. 13.

    Ledowski T, Stein J, Albus S, et al. The influence of age and sex on the relationship between heart rate variability, haemodynamic variables and subjective measures of acute post-operative pain. Eur J Anaesthesiol. 2011; 6: 433-437.

    Article  Google Scholar 

  14. 14.

    Logan JG, Barksdale DJ, Carlson J, et al. Psychological stress and arterial stiffness in Korean Americans. J Psychosom Res. 2012; 1: 53-58.

    Article  Google Scholar 

  15. 15.

    Lowe A, Harrison W, El-Aklouk E, et al. Non-invasive model342 based estimation of aortic pulse pressure using suprasystolic brachial pressure waveforms. J Biomech. 2009; 13: 2111-2115.

    Article  Google Scholar 

  16. 16.

    Memtsoudis SG, Ma Y, Gonzalez Della Valle A, et al. Demographics, outcomes, and risk factors for adverse events associated with primary and revision total hip arthroplasties in the United States. Am J Orthop. 2010; 8: E72-E77.

    Google Scholar 

  17. 17.

    Munir S, Guilcher A, Kamalesh T, et al. Peripheral augmentation index defines the relationship between central and peripheral pulse pressure. Hypertension. 2008; 1: 112-118.

    Article  Google Scholar 

  18. 18.

    Ni Choileain N, Redmond HP. Cell response to surgery. Arch Surg. 2006; 11: 1132-1140.

    Article  Google Scholar 

  19. 19.

    Park S, Lakatta EG. Role of inflammation in the pathogenesis of arterial stiffness. Yonsei Med J. 2012; 2: 258-261.

    Article  Google Scholar 

  20. 20.

    Richman JM, Liu SS, Courpas G, et al. Does continuous peripheral nerve block provide superior pain control to opioids? A meta-analysis. Anesth Analg. 2006; 1: 248-257.

    Article  Google Scholar 

  21. 21.

    Sharrock NE, Salvati EA. Hypotensive epidural anesthesia for total hip arthroplasty: a review. Acta Orthop Scand. 1996; 1: 91-107.

    Article  Google Scholar 

  22. 22.

    Stevens RA, Frey K, Liu SS, et al. Sympathetic block during spinal anesthesia in volunteers using lidocaine, tetracaine, and bupivacaine. Reg Anesth. 1997; 4: 325-331.

    Article  Google Scholar 

  23. 23.

    Wilkinson IB, MacCallum H, Flint L, et al. The influence of heart rate on augmentation index and central arterial pressure in humans. J Physiol. 2000; 263–70.

  24. 24.

    YaDeau JT, Liguori GA, Zayas VM. The incidence of transient neurologic symptoms after spinal anesthesia with mepivacaine. Anesth Analg. 2005; 3: 661-665.

    Article  Google Scholar 

  25. 25.

    Zieman SJ, Melenovsky V, Kass DA. Mechanisms, pathophysiology, and therapy of arterial stiffness. Arterioscler Thromb Vasc Biol. 2005; 5: 932-943.

    Article  Google Scholar 

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Acknowledgments

We thank Ms. Tara Thompson, RN, BN, for her help with late-night follow-up examinations.

Compliance with Ethical Standards

Conflict of Interest

Enrique A. Goytizolo, MD, Ottokar Stundner, MD, Sandra Hurtado Rúa, PhD, Dorothy Marcello, BA, Valeria Buschiazzo, Ansara M Vaz, MD and Stavros G Memtsoudis, MD, PhD have declared that they have no conflict of interest.

Human/Animal Rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5).

Informed Consent

Informed consent was obtained from all patients for being included in the study.

Funding

This study was supported with funds from the Research and Education Fund of the Department of Anesthesiology at the Hospital for Special Surgery. Dr. Sandra Hurtado Rúa was partially supported by the following grant: Clinical Translational Science Center (CTSC) (UL1- RR024996).

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Correspondence to Enrique A. Goytizolo MD.

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Level of Evidence: Therapeutic study, level II.

Work performed at Hospital for Special Surgery.

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Goytizolo, E.A., Stundner, O., Rúa, S.H. et al. The Effect of Regional Analgesia on Vascular Tone in Hip Arthroplasty Patients. HSS Jrnl 12, 125–131 (2016). https://doi.org/10.1007/s11420-015-9477-1

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Keywords

  • hip arthroplasty
  • arterial stiffness
  • vascular resistance
  • lumbar plexus block