Recovery Profile among Orthopedic Patients Receiving Peripheral Nerve Blocks. A Pilot Study.
Thuyvan H. Luu, BS, Matthew M. Roberts*, MD, Yuliya Gadulov, MD, Kara G. Fields†, MS, Richard L. Kahn, MD, Lawrence V. Gulotta*, MD, David M. Dines*, MD, David S. Levine*, MD, Vincent R. LaSala, MD, Michael A. Gordon, MD, Leonardo Paroli, MD, PhD, Jacques T. YaDeau, MD, PhD
Department of Anesthesiology, *Department of Orthopaedic Surgery, †Healthcare Research Institute, Weill Cornell Medical College, Hospital for Special Surgery, New York, NY
Introduction: Peripheral nerve blocks (PNBs) are often combined with intravenous sedation, general anesthesia, or neuraxial anesthesia. It is not clear which of these accompaniments most improves the patient experience. Neuraxial anesthesia is often considered to have better outcomes, such as minimized opioids, improved analgesia and reduced nausea.1,2 These presumed advantages may also be achieved by combining PNBs with general anesthesia. This study created a recovery profile based on factors comprising patient satisfaction. Postoperative nausea and vomiting is significantly associated with patient dissatisfaction,1 but evidence of nausea after regional anesthesia is not typically based on standardized assessment criteria. This study provides standardized assessment of nausea and postoperative quality of recovery after orthopedic surgery in patients receiving PNBs, with intravenous sedation, general anesthesia, or neuraxial anesthesia.
Methods: This observational, prospective cohort study received approval from the hospital Institutional Review Board. Patients were enrolled in three groups:
Sedation for blocks was midazolam, propofol and ketamine in all groups. All patients received ondansetron and dexamethasone. Groups were compared on the primary outcome of incidence and intensity of nausea at 1 and 2 hours after surgery on an 11-point Likert scale. Multidimensional recovery was measured by the Postoperative Quality Recovery Scale (PQRS) across physiological, nociceptive, emotive, cognitive and activities of daily living domains at 1 and 2 hours after surgery (T60 and T120) and on postoperative day (POD) 1.
Results: Forty-five patients (15 patients per group) were included in the study. There was no evidence of a difference in unadjusted incidence of nausea or severity of nausea between General/Block and Sedation/Block Groups (Table 1). No patients reported emesis. There were no significant differences in the percentage of patients who reported PQRS scores equal to baseline or better between General/Block and Sedation/Block Groups in any of the domains at 1 or 2 hours after surgery or on POD 1 (Figure 1).
Discussion: Peripheral nerve blocks, given with an opioid sparing anesthetic and prophylactic anti-emetics, are associated with a low incidence of nausea of mild to moderate intensity. This was seen regardless of whether combined with intravenous sedation, spinal anesthesia, or general anesthesia. Overall, PQRS score rates of recovery were high in all groups and followed trends based on complexity of surgery3 and type of anesthesia. Randomized controlled trials are needed to address whether the choice of sedation, spinal, or general anesthesia influences nausea or postoperative quality of recovery in the presence of adequate peripheral nerve blockade. One such study is underway at the authors’ institution, comparing readiness for discharge between ambulatory foot and ankle surgery patients receiving PNBs with either general or spinal anesthesia.