Rengin YILMAZ, Özlem Selvi CAN, Ali Abbas YILMAZ, Enver ÖZGENCİL, Funda SARGIN, Özgür CENGİZ, Ersin ADIGÜZEL, Feyhan ÖKTEN

Diz artroplastisinde postoperatif ağrı kontrolü için uygulanan femoral sinir bloğunda % 0,5’lik levobupivakaine tramadol ilavesinin etkiniği

Amaç: Bu çalışmada, spinal anestezi ile gerçekleştirilen total diz artroplastisi girişimlerinde postoperatif analjezi amacıyla tek enjeksiyon femoral 3-1 blok tekniğinde, levobupivakaine tramadol ilavesinin etkisi prospektif olarak araştırıldı. Gereç ve Yöntem: Total diz artroplastisi planlanan 24 hasta, rastgele 2 gruba ayrıldı. Tüm hastalara spinal anestezi öncesi tek enjeksiyon femoral blok; Levobupivakain Grubu’nda (Grup-L) 0,3 mL kg-1 % 0.5’lik levobupivakain, Levobupivakain + Tramadol Grubu’nda (Grup-LT) 0,3 mL kg-1 % 0.5’lik levobupivakain + 1,5 mg kg-1 tramadol ile yapıldı. Femoral blok sonrası tüm hastalara 15 mg hiperbarik bupivakainle selektif spinal anestezi uygulandı. Postoperatif dönemde ağrı değerlendirmesi Görsel Analog Skala (VAS) ve Verbal Ağrı Skalası (VPRS) ile yapıldı. VAS 30’un üstüne çıktığında iv morfin ile hasta kontrollü analjezi (HKA) başlandı. Femoral blok öncesi, spinal anestezi öncesi, operasyon sonu, HKA başlangıcından sonra 2, 4, 6, 12 ve 24. saatlerdeki istirahat ve hareketle VAS ve VPRS değerleri, toplam morfin gereksinimi, ek analjezik ihtiyacı, kan basıncı, kalp hızı ve yan etkiler kaydedildi. Bulgular: Çalışmaya dahil edilen hastalarda istirahatte daha fazla olmak üzere tüm periyotlarda, VAS ve VPRS skorları düşük bulunmuştur. Bu blok tekniğinde levobupivakaine tramadol eklenmesi anlamlı olmasa da blok oluşma süresini kısaltmıştır (Her iki grupta VAS

Knee arthroplasty and femoral block

Objective: In this study, efficacy of single shot femoral block technique by adding tramodol to levobupivacaine in order to provide postoperative analgesia in patients undergoing total knee arthroplasty with spinal anesthesia was investigated, prospectively. Methods: Twenty four patients that were planned to undergo total knee arthroplasty were enrolled to study. Patients were randomly divided into 2 groups. Femoral block was performed with in Levobupivacaine Group (Group-L) 0.3 mL kg-1 0.5% levobupivacaine and Levobupivacaine+Tramadol (Group Group-LT) 0.3 mL kg-1 0.5% levobupivacaine + 1.5 mg kg-1 tramadol before spinal anesthesia performed. After that selective spinal anesthesia was performed with 15 mg hyperbaric bupivacaine. Pain evaluation was made with Visual Analog Scala (VAS) and Verbal Pain Rating scala (VPRS) postoperatively. Intravenous morphine PCA was begun when the VAS over 30. Activity and resting VAS and VPRS values, total morphine need, additional analgesic need, blood pressure, heart rate and side effects were recorded before femoral block, before spinal anesthesia, end of the surgery and 2, 4, 6, 12 and 24 hours following the initiation of the PCA. Results: In the patients enrolled to the study, while more prominent in the resting, VAS and VPRS scores were lower in all periods. However pain scores were detected quite better in favor of tramadol given group. Although it was not meaningful to add tramadol to this block technique, it decreased the time to occurrence of block (VAS <3 and VPRS < 1 in both groups). Although time for initiating PCA and total morphine consumption were the same in both groups, amount of needed morphine and additional analgesic need were significantly lower in tramadol given group. No side effects were detected in both groups originating form the usage of local anesthetic and Tramadol. Conclusion: Single shot femoral 3 in 1 block technique, performed preoperatively in order to provide postoperative analgesia following total knee arthroplasty was observed simple, safe and efficient block. Levobupivacaine, was observed to be used safely in single shot femoral block. Adding tramadol to levobupivacaine in this block technique detected quite better pain control at resting and activity period.

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1. Colwell CW, Morris BA: The İnfuence Of Continuous Passive Motion On The Results Of Total Knee Arthroplasty. Clin Orthop 1992; 276: 225-8
2. Kehlet H: Postoperatif Pain Relief. What İs The İssue? Br J Anaesth 1994; 72: 375-8
3. Capdevila X, Barthelet Y, Biboulet P, Ryckwaert Y, Rubenovitch J, d'Athis F. Effects Of Perioperative Analgesic Technique On The Surgical Outcome And Duration Of Rehabilitation After Major Knee Surgery. Anesthesiology. 1999; 91(1): 8-15.
4. Ganapathy S, Wasserman RA, Watson JT, Bennett J, Armstrong KP, Stockall CA, et al. Modified Continuous Femoral Three-İnOne Block For Postoperative Pain After Total Knee Arthroplasty. Anesth Analg. 1999; 89(5): 1197-202.
5. Allen HW, Liu SS, Ware PD, Nairn CS, Owens BD. Peripheral Nerve Blocks İmprove Analgesia After Total Knee Replacement Surgery. Anesth Analg. 1998; 87(1): 93-7.
6. Singelyn FJ, Gouverneur JM: Postoperative Analgesia After Total Hip Arthroplasty: İ.V. PCA With Morphine, Patient-Controlled Epidural Analgesia, Or Continuous "3-İn-1" Block?: A Prospective Evaluation By Our Acute Pain Service İn More Than 1.300 Patients. J Clin Anesth 1999; 11 (7): 550-54
7. Singelyn FJ, Deyaert M, Joris D, Pendeville E, Gouverneur JM. Effects Of İntravenous Patient-Controlled Analgesia With Morphine, Continuous Epidural Analgesia, And Continuous Three-İnOne Block On Postoperative Pain And Knee Rehabilitation After Unilateral Total Knee Arthroplasty. Anesth Analg. 1998; 87(1): 88-92
8. Chelly JE, Greger J, Gebhard R, et al. Continuous Femoral Blocks İmprove Recovery And Outcome Of Patients Undergoing Total Knee Arthroplasty. Arthroplasty 2001; 16: 436-45
9. Singelyn FJ, Ferrant T, Malisse MF, Joris D. Effects Of Intravenous Patient-Controlled Analgesia With Morphine, Continuous Epidural Analgesia, And Continuous Femoral Nerve Sheath Block On Rehabilitation After Unilateral Total-Hip Arthroplasty. Reg Anesth Pain Med. 2005; 30(5): 452-7.
10. Madej TH., Ellis FR., Halsal PJ:Evaluation Of 3-İn-1 Lumbar Plexus Block İn Patients Having Muscle Biopsy.Br J Anesth. 1989; 62: 515-517
11. Singelyn FJ, Gouverneur JM. Extended "Three-İn-One" Block After Total Knee Arthroplasty: Continuous Versus Patient-Controlled Techniques. Anesth Analg. 2000; 91(1): 176-80.
12. Winnie AP, Ramamurthy S, Durrani Z. The İnguinal Paravascular Technic Of Lumbar Plexus Anesthesia: The "3-İn-1 Block". Anesth Analg. 1973; 52(6): 989-96.
13. Ben-David B, Schmalenberger K, Chelly JE. Analgesia After Total Knee Arthroplasty: İs Continuous Sciatic Blockade Needed İn Addition To Continuous Femoral Blockade? Anesth Analg 2004; 98: 747–49
14. Shoji H, Solomonow M, Yoshino S. Factors Affecting Postoperative Şexion İn Total Knee Arthroplasty. Ortopedics 1990; 13: 643-9
15. Ryu J, Saito S,Yamamoto K, Sano S. Factors İnfluencing The Postoperative Range Of Motion İn Total Knee Arthroplasty. Bull Hosp Joint Dis 1993; 53: 35-40
16. Wang H, Boctor B, Verner J. The Effect Of Single-İnjection Femoral Nerve Block On Rehabilitation And Length Of Hospital Stay After Total Knee Replacement. Reg Anesth Pain Med 2002; 27: 139–44
17. F. V. Salinas, S. S. Liu, And M. F. Mulroy. The Effect Of Single-İnjection Femoral Nerve Block Versus Continuous Femoral Nerve Block After Total Knee Arthroplasty On Hospital Length Of Stay And Long-Term Functional Recovery Within An Established Clinical Pathway. Anesth. Analg. 2006; 102(4): 1234 -39.
18. Hirst GC, Lang SA, Dust WN, Et Al. Femoral Nerve Block: Single İnjection Versus Continuous İnfusion For Total Knee Arthroplasty. Reg Anesth 1996; 21: 292-7.
19. Enneking KF, Benzon H. Oral Anticoagulants And Regional Anesthesia: A Perspective. Reg Anesth 1998; 23: 140 –5.
20. Marhofer P, Nasel C, Sitzwohl C, Kapral S. Magnetic Resonance İmaging Of The Distribution Of Local Anesthetic During The Three İn One Block. Anesth Analg 2000; 90: 119-124.
21. Urbanek B, Duma A, Kimberger O, Huber G, Marhofer P, Zimpfer M, et al. Onset Time, Quality Of Blockade, And Duration Of Three-İn-One Blocks With Levobupivacaine And Bupivacaine. Anesth Analg. 2003; 97(3): 888-92.
22. Casati A, Fanelli G, Magistris L, Beccaria P, Berti M, Torri G. Minimum Local Anesthetic Volume Blocking The Femoral Nerve İn 50% Of Cases: A Double-Blinded Comparison Between 0.5% Ropivacaine And 0.5% Bupivacaine. Anesth Analg. 2001; 92(1): 205-8.
23. Marhofer P, Oismuller C, Faryniak B, Sitzwohl C, Mayer N, Kapral S. Three-İn-One Blocks With Ropivacaine: Evaluation Of Sensory Onset Time And Quality Of Sensory Block. Anesth Analg. 2000; 90(1): 125-8.
24. Casati A, Borghi B, Fanelli G. A Double-Blinded, Randomized Comparison Of Either 0.5% Levobupivacaine Or 0.5% Ropivacaine For Sciatic Nerve Block. Anesth Analg 2002; 94: 987-90
25. Santorsola R, Casati A, Cerchierini E. Levobupivakaine For Peripheral Blocks Of The Lower Limb: A Clinical Comparison With Bupivakain And Ropivacaine. Minerva Anestesiol 2001; 67: 33-36
26. Morgan GE, Jr.Maged S.Mikhail Michael J Murray. Clinical Anesthsiology, Third Edition 2002;233-240. Lange
27. Aberg G. Toxicological And Local Anaesthetic Effects Of Optically Active İsomers Of Two Local Anaesthetic Compounds. Acta Pharmacol Et Toxicol 1992; 31: 273-86.
28. Luduena FP, Bogado EF, Tullar BF. Optical İsomers Of Mepivacaine And Bupivacaine. Arch Int Pharmacodyn 1972; 200: 359-69.
29. Gristwood RW, Greaves JL. Levobupivacaine: A New Safer Long Acting Local Anaesthetic Agent. Expert Opin Invest Drug 1999; 8: 861-76.
30. Morrison SG, Dominguez JJ, Frascarolo P, et al. Cardiotoxic Effects Of Levobupivacaine, Bupivacaine And Ropivacaine - An Experimental Study İn Pentobarbital Anesthetized Swine [Abstract]. Region Anesth Pain Med 1998; 23 (3) Suppl.: 50.
31. Kanai Y, Tateyama S, Nakamura T, et al. Effects Of Levobupivacaine, Bupivacaine, And Ropivacaine On Tail-Şick Response And Motor Function İn Rats Following Epidural Or İntrathecal Administration. Region Anesth Pain Med 1999; 24: 444-52..
32. Budd K, Langford R. Tramadol Revisited. Br J Anaesth. 1999; 82(4): 493-5.
33. Kapral S, Gollmann G, Waltl B, Likar R, Sladen RN, Weinstabl C, et al. Tramadol Added To Mepivacaine Prolongs The Duration Of An Axillary Brachial Plexus Blockade. Anesth Analg. 1999; 88(4): 853-6
34. Mannion S, O’Callaghan S, Murphy D. Tramadol As Adjunct To Psoas Compartment Block With Levobupivacaine 0.5% : A Randomized Double-Blinded Study. British Journal Of Anaesthesia 2005; 94: 352-6.