• Analgesic Efficacy of Adding Sciatic Blockade to the 3-in-1 Block Following Total Knee Arthroplasty: A Meta-analysis

      Holmes, Johnnie M.; Johantgen, Mary E.; Zangaro, George (2010)
      Background: Total knee arthroplasty (TKA) is one of the most common orthopedic procedures performed. It is also invasive and is associated with severe postoperative pain. The 3-in-1 block has been repeatedly demonstrated to provide effective postoperative analgesia. However, adding sciatic blockade to the 3-in-1 has become a growing practice as a result of residual pain to the posterior knee, although the additional benefit is unknown particularly in light of the potential risks. Purpose: To examine the analgesic efficacy and associated adverse events of adding sciatic blockade to the 3-in-1 block compared to the 3-in-1 alone for postoperative analgesia following TKA. Methods: A meta-analysis was conducted on relevant articles from 1993 to 2010. Methodological rigor was applied to each of the analytical procedures including: evaluation of between-study heterogeneity, pooling effects, subgroup analyses, sensitivity analysis, and assessment of publication bias. Results: Nine studies representing 1827 subjects were included. Pain outcomes were measured with the visual analog scale both at rest (VASr) and dynamic (VASd) and reported as the weighted mean difference (WMD). The addition of sciatic blockade demonstrated improved postoperative analgesia with the greatest effects up to 24 hours postoperatively: early (6-8hr) VASr WMD -2.039 (95% CI: -2.718, -1.360); 12hr VASr WMD -1.491 (95% CI: -2.174, -0.808); 24hr VASr WMD -0.767 (95% CI: -1.114, -0.421); 24hr VASd WMD -0.671 (95% CI: -1.301, -0.041). The 24hr opioid consumption was also lower [WMD -10.237 (95% CI: -20.029, -0.444)]. After 24 hours, effects were small and/or not significant. There was also a statistically significant advantage in maximum knee flexion on POD3 [WMD -7.102 (95% CI: -11.864, -2.339)]. A lack of consistent reporting precluded quantitative analysis on adverse events. Conclusion: Findings support the use of peripheral nerve blocks for postoperative analgesia following TKA. The addition of sciatic blockade appears to offer greater analgesic efficacy than a 3-in-1 block alone but only in the early postoperative period. However, until an accurate estimate of associated adverse events can be unveiled, the addition of a sciatic block cannot be recommended for all patients following TKA. It should, however, be considered in the postoperative period for those patients who continue to experience substantial pain to the posterior aspect of the knee on a case-by-case basis.
    • Effectiveness of an Electronic Pain Notification System on Postoperative Pain

      Paranilam, Sheeba Ouseph; Johantgen, Mary E. (2013)
      Background: Pain management is an important responsibility of the entire health care team. A 2008 nursing documentation audit at the study hospital showed inadequate pain assessment. In response, an Electronic Notification System (ENS) for Registered Nurses (RNs) was implemented in one surgical unit of the study hospital in 2008-2009. Purpose: The purpose of this study was to determine the effectiveness of the ENS on postoperative pain measurements, pain intensity, and total narcotic analgesic use. Furthermore, the association between pain control and patient outcomes such as physical therapy participation, length of hospitalization, and discharge disposition was examined. Methods: A retrospective, descriptive-correlational design used medical record data to compare postoperative pain and related outcomes before and during the ENS implementation. Hospitalized inpatients undergoing hip or knee joint replacement, laminectomy, or spinal fusion were studied. The pre-ENS group included 95patients, whereas the ENS group had 113 patients. Linear mixed modeling was used to account for the repeated pain observations clustered within patients, while controlling for potential covariates. Results: There were no significant differences in frequency of pain measurement nor in pain intensity between the pre-ENS and ENS time periods. However, other important covariates were found to significantly influence pain intensity including history of mental illness (t=2.028, p=.045), pre-operative opioids (t=3.307, p<.001), and age (t= -3.383. p<.001). Only age (t=3.406, p<.001) and pain level on day 2 (t=2.306, p= .025) were significant predictors of length of stay. Conclusion: While the use of an electronic notification system reflects a widely used technology, the effectiveness was not demonstrated in this population and setting. The findings showing that patients with a history of mental illness and opioid use report higher pain intensity, confirm the findings of previous studies and should be incorporated in developing customized pain management plans. Innovative new devices such as ENS could be a valuable tool to assist nurses in pain assessment and documentation but current evidence does not support their use.