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1. Regional Anesthesia forTotal Joint ArthroplastyDAVID A. PROVENZANO, MDExecutive DirectorInstitute for Pain Diagnostics and CareOhio Valley General HospitalMcKees Rocks, PennsylvaniaEUGENE R. VISCUSI, MDDirector, Acute Pain ManagementDepartment of AnesthesiologyThomas Jefferson UniversityPhiladelphia, PennsylvaniaDr. Provenzano has consulted for Janssen GlobalServices, LLC, and Medtronic, and receivedhonoraria from Cadence Pharmaceuticals.Dr. Viscusi has received research funding fromAcelRx, Adolor/Cubist, Cumberland, and Salix;consulted for AcelRx, Cadence, Cubist, Incline,and Pacira; and received honoraria from Cadenceand Merck.Patients undergoing total joint arthroplasty (TJA) experiencehigh levels of pain after surgery that often interferes withtheir functional recovery and sleep patterns in the postoperativeperiod.1In one study, patients undergoing total hip arthroplasty (THA)and total knee arthroplasty (TKA) reported mean worst pain severities of7.6 and 8.1 on a 10-point scale, respectively.1Numerous techniques havebeen developed for anesthesia and analgesia in an effort to optimizeperioperative pain control, patient satisfaction, and functional recovery.Because clinician preference strongly influences patient selection anddecision making, anesthesiologists and orthopedic surgeons mustunderstand the current literature and level of evidence for each technique.2This article provides an updated review of the evidence for regionalanesthesia for TJA surgery with an emphasis on the risks and benefits ofeach technique for intraoperative anesthesia and postoperative analgesia.PRINTER-FRIENDLY VERSION AVAILABLE AT ANESTHESIOLOGYNEWS.COM59INDEPENDENTLY DEVELOPED BY MCMAHON PUBLIS HING ANE ST HE S IOLOGY NE WS S P E CIAL E DIT ION • OCTOB E R 2012Copyright©2012McMahonPublishingGroupunlessotherwisenoted.Allrightsreserved.Reproductioninwholeorinpartwithoutpermissionisprohibited.
TJA is performed with either a primary regional orgeneral anesthetic technique. Many methods exist forcontinued perioperative pain control (Table 1). In somecases, various modalities will be combined in an effortto optimize pain management. Each method for paincontrol is associated with specific benefits, risks, sideeffects, economic implications, patient satisfaction lev-els, and labor requirements for the health care team.General Versus Regional Anesthesia for TotalJoint ArthroplastySeveral advantages have been suggested for the useof neuraxial anesthesia for TJA surgery. These includemodification of the hypercoagulable surgical state,improvements in regional blood flow, improvement inpain control, and reduction in the surgical neuroendo-crine stress response (Table 2). From the surgeon’s per-spective, spinal anesthesia also provides ideal operatingconditions—profound muscle relaxation—moderatehypotension, which reduces blood loss, and the poten-tial for faster room turnover.Recent systematic reviews have examined the influ-ence of the anesthetic choice for TJA surgery on out-comes. Reviews that included dates from 1966 onwardsuggest that neuraxial anesthesia improves specific end-organ outcomes and postoperative pain control. In ameta-analysis specifically examining neuraxial regionalanesthesia for TJA, regional anesthesia was associatedwith significant reductions in operating time, need fortransfusions, nausea and vomiting, and incidence ofthromboembolic disease including deep vein thrombosis(DVT) and pulmonary embolism (PE).3It is important tonote that many of the studies in this review that favoredregional anesthesia over general anesthesia in the reduc-tion of vascular events were earlier trials that examinedindividuals who were not receiving anticoagulation pro-phylaxis. A review of general and regional anesthesiafor THA that contained research from 1966 to August2005, suggested that neuraxial block decreased the inci-dence of radiographically diagnosed DVT and PE, anddecreased operative time by 7.1 minutes and intraopera-tive blood loss by 275 mL.4Contemporary reviews that examined only papersfrom 1990 onward have provided evidence for improve-ment in pain control but do not always demonstrateimprovements in cardiovascular outcomes and mortal-ity. One systematic review of studies published since1990 found insufficient evidence from randomized con-trolled trials to conclude that anesthetic techniqueaffected mortality, cardiovascular morbidity or inci-dence of DVT and PE in patients undergoing THA.5In addition, regional anesthesia did not reduce hospi-tal length of stay or facilitate rehabilitation. In 2009, asystematic review that examined contemporary litera-ture on randomized controlled trials of TKA publishedsince 1990 found insufficient evidence to conclude thatanesthesia technique influenced mortality, cardiovascu-lar morbidity, or incidence of DVT and PE when usingthromboprophylaxis.6Anesthetic choice also has been shown to affectother important outcomes, in addition to pain control,including rates of surgical site infection (SSI) and med-ical costs. In a retrospective review of more than 3,000knee or hip arthroplasty surgeries, Chang and col-leagues, demonstrated a significant reduction in 30-daySSI rates—1.2% for epidural or spinal anesthesia versus2.8% for general anesthesia.7The odds of an SSI occur-ring in a patient receiving general anesthesia were 2.2times greater than when neuraxial anesthesia was used.Proposed mechanisms for possible reduction in surgicalsite infections with neuraxial anesthesia include modu-lation of the inflammatory response, vasodilation andimprovement in tissue oxygenation, and improvementsin postoperative analgesia.8Spinal anesthesia has been shown to be more cost-effective for TJA. Gonano and colleagues randomized40 patients to receive either spinal anesthesia or gen-eral anesthesia and examined the costs of drugs andsupplies for both the chosen anesthetic and associatedrecovery.9They found that spinal anesthesia was asso-ciated with lower fixed and variable costs, resulting ina 48% savings (excluding expenditures for personnel)compared with general anesthesia.Regional Techniques for PostoperativeAnalgesia for Total Joint ArthroplastySeveral analgesic techniques exist for postoperativepain management for TJA surgery. Each regional anes-thetic technique has specific advantages and disadvan-tages. Selection of the appropriate technique is bestTable 1. Methods of PostoperativePain Control for Total JointArthroplastyIntravenous opioids (IV-PCA)Oral opioidsNonopioid analgesicsNeuraxial anesthesia and analgesia• Spinal–intrathecal opioids• Epidural–continuous infusion• Epidural–single-injection EREMSingle and continuous peripheral nerve blocks• Femoral nerve block• Sciatic nerve block• Lumbar plexus blockEREM, extended-release epidural morphine;PCA, patient-controlled analgesiaINDEPENDENTLY DEVELOPED BY MCMAHON PU B LIS HING60Copyright©2012McMahonPublishingGroupunlessotherwisenoted.Allrightsreserved.Reproductioninwholeorinpartwithoutpermissionisprohibited.
guided through an understanding of the associatedrisk–benefit profile of each technique and the pain man-agement needs for the specific clinical situation.INTRATHECAL OPIOIDSOne analgesic approach that requires only minormodifications in the anesthetic plan is the addition ofintrathecal opioids to the spinal injection of local anes-thetic. Typically, intrathecal morphine will be added in adose range from 0.2 to 0.3 mg. For THA and TKA, intra-thecal morphine has been shown to improve patientsatisfaction compared with IV patient-controlled anal-gesia (IV-PCA) with opioids. However, intrathecal mor-phine only reduced the supplemental postoperativePCA morphine requirements for the patients undergo-ing THA.10When intrathecal opioids are administered, additionalforms of pain control are needed to control “break-through pain” and for pain that outlasts the durationof the therapy. Respiratory monitoring also is requiredwhen intrathecal opioids are administered.EPIDURAL ANALGESIAEpidural analgesia with a single injection of extended-release epidural morphine (EREM) or continuous epi-dural infusions with local anesthetics can be effectivemethods of pain control in patients undergoing jointsurgery. When specifically examining the use of epidur-als for TJA compared with IV-PCA, epidural analgesiahas been shown in high-quality studies to improve painrelief and recovery time.11,12A Cochrane Collaborationreview demonstrated that epidural analgesia for painrelief following TJA in comparison to systemic analge-sia was beneficial, but its effects may be limited only tothe early postoperative period, 4 to 6 hours.13Use of EREM has been studied in patients undergo-ing TKA and THA. Compared with IV-PCA, the patientstreated with EREM for TKA required significantly lesspostoperative opioids and had reduced mean painintensity recall scores.14For THA surgery, EREM demon-strated improved pain control at rest to 48 hours post-dose and improvement in pain control ratings15; 25% ofTHA patients who received EREM did not require sup-plemental analgesia.Regional Techniques for PostoperativeAnalgesia for Total Hip ArthroplastyTHA is associated with a high level of postopera-tive pain, although perhaps less than TKA. Many tech-niques for administering regional anesthesia have beenexplored for THA to improve pain control.16Theseinclude neuraxial analgesia, peripheral nerve blocks(PMBs), and EREM. Singelyn and colleagues comparedIV-PCA with morphine, continuous epidural analgesia,and continuous femoral nerve sheath block for post-operative analgesia in THA.17The authors found nodifference in quality of pain relief, postoperative hiprehabilitation, and duration of hospital stay for any ofthese approaches. The continuous femoral block wasassociated with a lower incidence of side effects, includ-ing nausea and vomiting, urinary retention, and arte-rial hypotension. Single and continuous lumbar plexusblocks also have been employed for postoperativeanalgesia. A lumbar plexus block is performed with thegoal of anesthetizing additional nerve branches (lateralfemoral cutaneous, femoral, and obturator nerves) thatinnervate the surgical area. A continuous lumbar plexusblock was found to be superior to IV-PCA for pain man-agement, with a reduction in morphine consumption,improvement in pain control, and patient satisfaction.18Although the lumbar plexus nerve block provideseffective analgesia, recently published guidelines fromthe American Society of Regional Anesthesia and PainMedicine for patients receiving antithrombotic therapycircumscribe its use.19The new guidelines state that thesame precautions should be applied to deep periph-eral nerve catheters as neuraxial techniques. Alterna-tives to the lumbar plexus block have been investigated,including a continuous femoral nerve block (CFNB). Inone study, Ilfeld and colleagues compared a continuousposterior lumbar plexus nerve block with a CFNB.20Thefemoral nerve-stimulating catheter was advanced up to15 cm beyond the tip with the goal of obtaining cov-erage of the obturator and lateral femoral cutaneousnerves. Pain control was equivalent for these 2 meth-ods. The CFNB was associated with shorter ambulationdistances the morning after surgery, suggesting greaterimpairment in the quadriceps femoris muscle.Regional Anesthesia for Total KneeArthroplastyPERIPHERAL NERVE BLOCKSPNBs, including single-injection and continuous PNBcatheters (CPNBC), have received substantial atten-tion as alternatives to neuraxial analgesia and systemicopioids for TKA. Some of the emphasis on PNBs arisesfrom concerns about concurrent anticoagulation andTable 2. Physiologic Sequelae of theNeuroendocrine Stress ResponseHyperactivity of the autonomic nervous systemIncreased cardiovascular stressDysfunction in respiratory mechanicsDecreased muscle protein synthesisElevated metabolic rate with an associated pro-tein catabolic stateIncreased formation of blood clotsSlower return of bowel functionImpaired immune functionANE ST HE S IOLOGY NE WS S P E CIAL E DIT ION • OCTOB E R 2 012 61Copyright©2012McMahonPublishingGroupunlessotherwisenoted.Allrightsreserved.Reproductioninwholeorinpartwithoutpermissionisprohibited.
neuraxial anesthesia. The employment of low-molecu-lar-weight heparin for DVT prophylaxis has limited theuse of epidurals for postoperative analgesia. AlthoughCPNBCs have been advocated as a means of prolong-ing the duration of action of single-injection nerveblocks, debate still continues on their advantages anddisadvantages compared with single-injection blocks.FEMORAL AND SCIATIC NERVE BLOCKSThe most commonly used PNBs for TKA are femo-ral and sciatic (Figure). In 2010, Paul et al performed ameta-analysis of randomized controlled trials that com-pared a femoral block with or without a sciatic nerveblock with PCA or epidural analgesia.21Compared withPCA alone, a femoral block reduced morphine con-sumption at 24 and 48 hours, pain scores with activity(but not at rest) at 24 and 48 hours, and the incidenceof nausea. No further improvements were found withthe addition of a CFNB. Although the femoral nervedoes not innervate the posterior portion of the knee, inthis meta-analysis a single-jnjection sciatic nerve blockdid not offer a pain control advantage.In a recent trial comparing a single-injection femo-ral block to CFNB for TKA, pain-intensity ratings wereimproved during the first and second days after sur-gery.22Opioid consumption and pain-intensity ratingsduring physical therapy also were significantly lowerwith a CFNB.Although a femoral block does improve postopera-tive pain control for TKA, 60% to 80% of patients stillwill complain of clinically significant pain. In an attemptto improve pain control, single and continuous sciaticnerve blocks can be administered. Evidence is mixedfor the analgesic benefits of adding a single-injectionor continuous catheter sciatic nerve block to a femoralnerve block technique. In addition, no consensus hasbeen reached on whether a sciatic nerve block shouldbe performed for all TKA cases in which a femoral nerveblock also is performed.23Neither a single-injection nora continuous catheter sciatic nerve block is without the-oretical risks and possible disadvantages, including theprevention of the early detection of compartment syn-drome or neurologic injury resulting from surgery andthe further impairment of motor function, thus imped-ing physical therapy during its duration of action. Someof the hesitation to perform sciatic nerve blocks isrelated to the risk profile of the procedure and the sur-gical vulnerability of the nerve. Sciatic nerve injury afterTKA, not related to regional anesthetic technique, is aknown complication.Two randomized controlled trials24,25and a recentsystematic review26have attempted to address whetherblocking the sciatic nerve is advantageous for post-operative pain control and other related clinical out-comes following TKA. In one trial, patients undergoingTKA were randomized to 1 of 3 groups: a femoral nervecatheter, a femoral catheter combined with a singleinjection, or a femoral catheter plus a continuous sci-atic nerve block.25The addition of a single-injectionsciatic nerve block to the CFNB reduced postopera-tive pain on the day of surgery. The continuous sciaticnerve block reduced moderate pain during mobilizationon the first 2 postoperative days. A sciatic nerve blockdid not influence time to discharge readiness. In a sec-ond study, Pham Dang and colleagues demonstratedimprovements in pain control with a continuous sciaticnerve block during the first 36 postoperative hours.24A recent systematic review, examining 4 interme-diate-quality randomized and 3 observational studies,established that there is inadequate evidence to definethe role of adding a sciatic nerve block, and could notdemonstrate a benefit in analgesia beyond 24 hours.26Unlike a CFNB, continuous sciatic nerve blocks havenot been shown to improve functional outcomes ordecrease time until discharge readiness.23,25With the current level of evidence for a sciatic nerveblock, one method to determine its implementationcould be to observe the patient during early recoveryto see if he or she is experiencing significant pain fromthe posterior aspect of the knee that is not relieved bythe femoral nerve block. If so, the analgesia could beaugmented with a single-injection sciatic nerve block.ComplicationsOther factors that must be incorporated into deci-sion making for the anesthetic and analgesic techniquefor TJA include complications and adverse events. AllFigure. An ultrasound-guided right-sided femoral nerve block. The redarrows delineate the placed needle.The triangle-shaped femoral nerve islateral to the femoral artery (FA).INDEPENDENTLY DEVELOPED BY MCMAHON PUB LIS HING62Copyright©2012McMahonPublishingGroupunlessotherwisenoted.Allrightsreserved.Reproductioninwholeorinpartwithoutpermissionisprohibited.
the regional anesthetic techniques described abovehave the following risks, including but not limited tobleeding, nerve damage, vascular injury, block failure,and infection. Neuraxial techniques and deep peripheralnerve catheters have been associated with devastatingbleeding complications. When opioids are incorporatedinto neuraxial anesthesia, respiratory depression mayoccur. Other opioid-related side effects also may result,including sedation, pruritus, urinary retention, and post-operative nausea and vomiting.27The risks and compli-cations specifically associated with CPNBCs are shownin Table 3.Although bacterial colonization may be commonwith certain catheters, the overall risk for infection islow. In one study, the incidence of bacterial colonizationfor femoral catheters was reported to be as high as 57%when catheters were removed at 48 hours.28Although3 cases of transitory bacteremia likely related to thefemoral catheters were reported, no patients developedan abscess or cellulitis.Abscesses, cellulitis, and transient bacteremia havebeen reported with CPNBCs. The presence of diabetesmellitus may increase the risk for infection. Appropri-ate steps to reduce the risk for infection include lim-iting the duration of catheter use and following strictaseptic guidelines. Another potential hazard of CPN-BCs that has received significant recent attention isthe association between lower-extremity blocks andpatient falls.29-31Continuous PNBs are associated withmuscle weakness that may lead to falls or that can delayrehabilitation. Lower-extremity nerve blocks have beenshown to impair the maintenance of limb stiffness, alterproprioception, and decrease lateral stability.32Post-operative protocols should be in place to safely andappropriately manage quadriceps weakness associatedwith femoral nerve blocks in the postoperative period.In addition, the selected postoperative pain manage-ment technique should be tailored to allow for earlyrehabilitation following TJA. Early intensive rehabili-tation following TKA (ie, starting rehabilitation within24 hours) has been shown to improve muscle strength,range of motion, and pain by the time of discharge fromthe hospital.33ConclusionTJA is associated with significant levels of postop-erative pain. An appropriately selected anesthetic andanalgesic plan will positively influence pain levels andfunction after the procedure. To obtain optimal resultswith regional anesthetic and analgesic techniques,these therapies should comprise one facet of a multi-modal perioperative treatment plan that includes non-opioid analgesics and the inclusion of a structuredrehabilitation program. A massive increase in the num-ber of patients undergoing TJA surgery in the UnitedStates is expected to occur over the next 2 decades;by 2030, it is estimated that nearly 3.5 million primaryTKA surgeries alone will be performed in this coun-try.34Research must continue to define and refine theselection of perioperative pain treatment based on effi-cacy, safety, and patient satisfaction. The economicimplications and labor requirements of each techniquealso should be further explored.References1. Strassels SA, Chen C, Carr DB. Postoperative analgesia: economics,resource use, and patient satisfaction in an urban teaching hospi-tal. Anesth Analg. 2002;94(1):130-137.2. Webster F, Bremner S, McCartney CJ. Patient experiences asknowledge for the evidence base: a qualitative approach tounderstanding patient experiences regarding the use of regionalanesthesia for hip and knee arthroplasty. Reg Anesth Pain Med.2011;36(5):461-465.3. Hu S, Zhang ZY, Hua YQ, Li J, Cai ZD. A comparison of regionaland general anaesthesia for total replacement of the hip or knee:a meta-analysis. J Bone Joint Surg Br. 2009;91(7):935-942.4. Mauermann WJ, Shilling AM, Zuo Z: A comparison of neuraxialblock versus general anesthesia for elective total hip replacement:a meta-analysis. Anesth Analg. 2006;103(4):1018-1025.5. Macfarlane AJ, Prasad GA, Chan VW, Brull R. Does regional anaes-thesia improve outcome after total hip arthroplasty? A systematicreview. Br J Anaesth. 2009;103(3):335-345.6. Macfarlane AJ, Prasad GA, Chan VW, Brull R. Does regional anes-thesia improve outcome after total knee arthroplasty? Clin OrthopRelat Res. 2009;467(9):2379-2402.7. Chang CC, Lin HC, Lin HW, Lin HC. Anesthetic management andsurgical site infections in total hip or knee replacement: a popula-tion-based study. Anesthesiology. 2010;113(2):279-284.8. Sessler DI. Neuraxial anesthesia and surgical site infection.Anesthesiology. 2010;113(2):265-267.Table 3. Complications/AdverseEvents Associated With CPNBCs andTime Frame of OccurrenceInsertionInfusionRemovalNeurologic injury XaX XVascular injury X XLocal anesthetic toxicity X XMigration/dislodgment XInfection X X XCatheter knotting X XCatheter retention XSecondary block failure XMuscle weaknessbXaX denotes most likely time frame of occurrence orpresentation.bMuscle weakness may put patients at risk for falls or delayphysical therapy after a knee or hip arthroplasty.CPNBCs, continuous peripheral nerve blocksANE ST HE S IOLOGY NE WS S P E CIAL E DIT ION • OCTOB E R 2 012 63Copyright©2012McMahonPublishingGroupunlessotherwisenoted.Allrightsreserved.Reproductioninwholeorinpartwithoutpermissionisprohibited.
9. Gonano C, Leitgeb U, Sitzwohl C, Ihra G, Weinstabl C, Kettner SC.Spinal versus general anesthesia for orthopedic surgery: anesthe-sia drug and supply costs. Anesth Analg. 2006;102(2):524-529.10. Rathmell JP, Pino CA, Taylor R, Patrin T, Viani BA. Intrathecal mor-phine for postoperative analgesia: a randomized, controlled,dose-ranging study after hip and knee arthroplasty. Anesth Analg.2003;97(5):1452-1457.11. Singelyn FJ, Deyaert M, Joris D, Pendeville E, Gouverneur JM.Effects of intravenous patient-controlled analgesia with morphine,continuous epidural analgesia, and continuous three-in-one blockon postoperative pain and knee rehabilitation after unilateral totalknee arthroplasty. Anesth Analg. 1998;87(1):88-92.12. Capdevila X, Barthelet Y, Biboulet P, Ryckwaert Y, Rubenovitch J,d’Athis F. Effects of perioperative analgesic technique on the sur-gical outcome and duration of rehabilitation after major kneesurgery. Anesthesiology. 1999;91(1):8-15.13. Choi PT, Bhandari M, Scott J, Douketis J. Epidural analgesia forpain relief following hip or knee replacement. Cochrane DatabaseSyst Rev. 2003;(3):CD003071.14. Hartrick CT, Martin G, Kantor G, Koncelik J, Manvelian G. Eval-uation of a single-dose, extended-release epidural morphineformulation for pain after knee arthroplasty. J Bone Joint Surg Am.2006;88(2):273-281.15. Viscusi ER, Martin G, Hartrick CT, Singla N, Manvelian G, EREMStudy Group. Forty-eight hours of postoperative pain relief aftertotal hip arthroplasty with a novel, extended-release epiduralmorphine formulation. Anesthesiology. 2005;102(5):1014-1022.16. Indelli PF, Grant SA, Nielsen K, Vail TP. Regional anesthesia in hipsurgery. Clin Orthop Relat Res. 2005;441:250-255.17. Singelyn FJ, Ferrant T, Malisse MF, Joris D. Effects of intravenouspatient-controlled analgesia with morphine, continuous epiduralanalgesia, and continuous femoral nerve sheath block on rehabili-tation after unilateral total-hip arthroplasty. Reg Anesth Pain Med.2005;30(5):452-457.18. Siddiqui ZI, Cepeda MS, Denman W, Schumann R, Carr DB. Con-tinuous lumbar plexus block provides improved analgesia withfewer side effects compared with systemic opioids after hiparthroplasty: a randomized controlled trial. Reg Anesth Pain Med.2007;32(5):393-398.19. Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthe-sia in the patient receiving antithrombotic or thrombolytic therapy:American Society of Regional Anesthesia and Pain Medicine Evi-dence-Based Guidelines (Third Edition). Reg Anesth Pain Med.2010;35(1):64-101.20. Ilfeld BM, Mariano ER, Madison SJ, et al. Continuous femoral ver-sus posterior lumbar plexus nerve blocks for analgesia afterhip arthroplasty: a randomized, controlled study. Anesth Analg.2011;113(4):897-903.21. Paul JE, Arya A, Hurlburt L, et al. Femoral nerve blockimproves analgesia outcomes after total knee arthroplasty: ameta-analysis of randomized controlled trials. Anesthesiology.2010;113(5):1144-1162.22. Salinas FV, Liu SS, Mulroy MF. The effect of single-injection femoralnerve block versus continuous femoral nerve block after total kneearthroplasty on hospital length of stay and long-term functionalrecovery within an established clinical pathway. Anesth Analg.2006;102(4):1234-1239.23. Ilfeld BM, Madison SJ. The sciatic nerve and knee arthroplasty: toblock, or not to block—that is the question. Reg Anesth Pain Med.2011;36(5):421-423.24. Pham Dang C, Gautheron E, Guilley J, et al. The value of addingsciatic block to continuous femoral block for analgesia after totalknee replacement. Reg Anesth Pain Med. 2005;30(2):128-133.25. Wegener JT, van Ooij B, van Dijk CN, Hollmann MW, Preckel B,Stevens MF. Value of single-injection or continuous sciatic nerveblock in addition to a continuous femoral nerve block in patientsundergoing total knee arthroplasty: a prospective, randomized,controlled trial. Reg Anesth Pain Med. 2011;36(5):481-488.26. Abdallah FW, Brull R. Is sciatic nerve block advantageous whencombined with femoral nerve block for postoperative analgesiafollowing total knee arthroplasty?: a systematic review. Reg AnesthPain Med. 2011;36(5):493-498.27. Neal JM, Rathmell JP. Complications in Regional Anesthesia & PainMedicine. Philadelphia, PA: Saunders Elsevier; 2007.28. Cuvillon P, Ripart J, Lalourcey L, et al. The continuous femoralnerve block catheter for postoperative analgesia: bacterial col-onization, infectious rate and adverse effects. Anesth Analg.2001;93(4):1045-1049.29. Ilfeld BM, Duke KB, Donohue MC. The association between lowerextremity continuous peripheral nerve blocks and patient falls afterknee and hip arthroplasty. Anesth Analg. 2010;111(6):1552-1554.30. Kandasami M, Kinninmonth AW, Sarungi M, Baines J, Scott NB.Femoral nerve block for total knee replacement—a word of cau-tion. Knee. 2009;16(2):98-100.31. Sharma S, Iorio R, Specht LM, Davies-Lepie S, Healy WL.Complications of femoral nerve block for total knee arthroplasty.Clin Orthop Relat Res. 2010;468(1):135-140.32. Muraskin SI, Conrad B, Zheng N, Morey TE, Enneking FK. Fallsassociated with lower-extremity-nerve blocks: a pilot investigationof mechanisms. Reg Anesth Pain Med. 2007;32(1):67-72.33. Labraca NS, Castro-Sánchez AM, Matarán-Peñarrocha GA, Arroyo-Morales M, Sánchez-Joya Mdel M, Moreno-Lorenzo C. Benefits ofstarting rehabilitation within 24 hours of primary total knee arthro-plasty: randomized clinical trial. Clin Rehabil. 2011;25(6):557-566.34. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primaryand revision hip and knee arthroplasty in the United States from2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780-785.INDEPENDENTLY DEVELOPED BY MCMAHON PU B LIS HING64Copyright©2012McMahonPublishingGroupunlessotherwisenoted.Allrightsreserved.Reproductioninwholeorinpartwithoutpermissionisprohibited.