TKA: Postoperative opiate use lowered by intraoperative periarticular LIA .
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OrthoEvidence Journal (OE Journal) - ACE Report
OE Journal. 2015;3(6):3 Acta Orthop. 2014 Dec;85(6):614-9.60 patients undergoing primary total knee arthroplasty were randomized to receive either a periarticular local infiltration analgesia (LIA) with levobupivacaine, ketorolac, and adrenaline versus a placebo injection of saline. Oxycodone consumption, pain, and range of motion were measured over 48 hours postoperatively, and functional outcomes were evaluated 1 year following surgery. The results of this study suggest that LIA reduced cumulative oxycodone consumption over the first 24 postoperative hours, with effect mainly occurring within the first 6 hours after surgery. Knee range of motion was also greater at 6 hours in those who received LIA, though no significant differences were detected at 24 and 48h. Functional outcomes were similar between groups at 1 year.
Was the allocation sequence adequately generated?
Was allocation adequately concealed?
Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?
Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?
Blinding Patients: Was knowledge of the allocated interventions adequately prevented?
Was loss to follow-up (missing outcome data) infrequent?
Are reports of the study free of suggestion of selective outcome reporting?
Were outcomes objective, patient-important and assessed in a manner to limit bias (ie. duplicate assessors, Independent assessors)?
Was the sample size sufficiently large to assure a balance of prognosis and sufficiently large number of outcome events?
Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?
Sim = 1
Incerto = 0,5
Não relevante = 0
Não = 0
A Avaliação dos Critérios de Relato avalia a transparência com que os autores relatam as caraterísticas metodológicas e do ensaio na publicação. A avaliação está dividida em cinco categorias que são apresentadas de seguida.
4/4
Randomization
3/4
Outcome Measurements
4/4
Inclusion / Exclusion
4/4
Therapy Description
4/4
Statistics
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
O Índice de Fragilidade é uma ferramenta que auxilia na interpretação de achados significativos, fornecendo uma medida de força para um resultado. O Índice de Fragilidade representa o número de eventos consecutivos que precisam de ser adicionados a um resultado dicotómico para que o resultado deixe de ser significativo. Um número pequeno representa um resultado mais fraco e um número grande representa um resultado mais forte.
Porque é que este estudo era necessário agora?
Multimodal pain management in total knee arthroplasty aims to reduce opiate use and its inherent side effects. The role of local infiltration analgesia (LIA) in multimodal regimens has yet to be fully characterized within the knee arthroplasty arena. This study aimed to assess the effect of a single, intraoperative periarticular infiltration levobupivacaine, ketorolac, and adrenaline on postoperative pain and opioid consumption following TKA.
Qual era a principal questão de investigação?
Does a single, intraoperative periarticular infiltration of levobupivacaine, ketorolac, and adrenaline have a significant impact on oxycodone consumption following total knee arthroplasty?
- Cumulative oxycodone consumption for the first 24 hours after surgery was significantly lower in the LIA group than in the placebo group; oxycodone consumption in the LIA group was 17mg lower than the placebo group after 6h (p<0.001), 20mg lower after 12h (p<0.001), and 28mg lower after 24h (p=0.03).
- Time interval-based oxycodone consumption was significantly lower in the LIA group compared to the placebo group from 0-6h (p<0.001), though differences were not statistically significant for 6-12h (p=0.09), 12-24h (p=0.1), or 24-48h (p=0.04) time intervals.
- Median VAS scores of <3 were considered an adequate level of pain management. This was achieved in both groups 48 hours potsoperatively. Groups did not demonstrate statistically significant differences at any time point (all p>0.05).
- Mean range of motion (ROM) at 6 hours was significant greater in the LIA group compared to the placebo group (26deg difference; p<0.001). Groups did not significantly differ in knee ROM at 24h (p=0.08) or 48h (p=0.6).
- Functional outcomes between groups at 1 year follow up were not significantly different between groups, as measured by HAAS, OKS and 15D quality-of-life instrument.
De que é que me devo lembrar mais?
In total knee arthroplasty, total consumption of oxycodone over the first 24 hours postoperatively was significant lowered by the use of a single intraoperative infiltration containing levobupivacaine, ketorolac, and adrenaline when compared to those who received placebo. LIA effect was predominantly seen within the first 6 hours after surgery. LIA patients also improved early knee range of motion, although there was no functional difference between groups at 1 year postoperatively.
Como é que isto afectará o tratamento dos meus doentes?
The combined use of levobupivacaine, ketorolac, and adrenaline in a single, intraoperative paeriarticular infiltration in total knee arthroplasty appears to be beneficial in terms of lowering the use of patient-controlled opioids in the early postoperative period. The study suggests that local infiltration analgesia may be used as an adjunct to oral medical in patients undergoing total knee arthroplasty, though effects appear to be limited to analgesic outcomes immediately postoperatively. Future research should consider the possible impact of LIA in a multimodal regimen on rehabilitation progression and time to discharge.
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