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Randomized Controlled Trial
. 2010 Oct;57(10):919-26.
doi: 10.1007/s12630-010-9364-7. Epub 2010 Aug 11.

Comparative efficacy of ultrasound-guided and stimulating popliteal-sciatic perineural catheters for postoperative analgesia

Edward R Mariano  1 , Vanessa J Loland, NavParkash S Sandhu, Michael L Bishop, Daniel K Lee, Alexandra K Schwartz, Paul J Girard, Eliza J Ferguson, Brian M Ilfeld
Affiliations
Randomized Controlled Trial

Comparative efficacy of ultrasound-guided and stimulating popliteal-sciatic perineural catheters for postoperative analgesia

Edward R Mariano et al. Can J Anaesth. 2010 Oct.

Abstract
in English, French

Purpose: Perineural catheter insertion using ultrasound guidance alone is a relatively new approach. Previous studies have shown that ultrasound-guided catheters take less time to place with high placement success rates, but the analgesic efficacy compared with the established stimulating catheter technique remains unknown. We tested the hypothesis that popliteal-sciatic perineural catheter insertion relying exclusively on ultrasound guidance results in superior postoperative analgesia compared with stimulating catheters.

Methods: Preoperatively, subjects receiving a popliteal-sciatic perineural catheter for foot or ankle surgery were assigned randomly to either ultrasound guidance (bolus via needle with non-stimulating catheter insertion) or electrical stimulation (bolus via catheter). We used 1.5% mepivacaine 40 mL for the primary surgical nerve block and 0.2% ropivacaine (basal 8 mL·hr(-1); bolus 4 mL; 30 min lockout) was infused postoperatively. The primary outcome was average surgical pain on postoperative day one.

Results: Forty of the 80 subjects enrolled were randomized to each treatment group. One of 40 subjects (2.5%) in the ultrasound group failed catheter placement per protocol vs nine of 40 (22.5%) in the stimulating catheter group (P = 0.014). The difference in procedural duration (mean [95% confidence interval (CI)]) was -6.48 (-9.90 - -3.05) min, with ultrasound requiring 7.0 (4.0-14.1) min vs stimulation requiring 11.0 (5.0-30.0) min (P < 0.001). The average pain scores of subjects who provided data on postoperative day one were somewhat higher for the 33 ultrasound subjects than for the 26 stimulation subjects (5.0 [1.0-7.8] vs 3.0 [0.0-6.5], respectively; P = 0.032), a difference (mean [95%CI]) of 1.37 (0.03-2.71).

Conclusion: For popliteal-sciatic perineural catheters, ultrasound guidance takes less time and results in fewer placement failures compared with stimulating catheters. However, analgesia may be mildly improved with successfully placed stimulating catheters. Clinical trial registration number NCT00876681.

Objectif: L’insertion de cathéters périnerveux à l’aide d’échoguidage seul est une approche relativement récente. Des études antérieures ont montré que les cathéters échoguidés requièrent moins de temps de positionnement et offrent un taux élevé de réussite du positionnement, mais nous ne savons pas comment leur efficacité analgésique se compare à celle d’une technique établie de cathéter stimulant. Nous avons testé l’hypothèse selon laquelle un cathéter périnerveux sciatique poplité inséré uniquement à l’aide d’échoguidage donne une meilleure analgésie postopératoire que les cathéters stimulants.

Méthode: Les patients chez lesquels on allait installer un cathéter périnerveux sciatique poplité pour une chirurgie du pied ou de la cheville ont été randomisés avant l’opération à une technique d’échoguidage (bolus via l’aiguille avec l’insertion d’un cathéter non stimulant) ou à la stimulation électrique (bolus via un cathéter). Nous avons utilisé 40 mL de mépivacaïne 1,5 % pour le bloc nerveux chirurgical primaire et de la ropivacaïne 0,2 % (analgésie de base 8 mL·h−1; bolus 4 mL; verrouillage de 30 min) a été perfusée après l’opération. La douleur chirurgicale moyenne au jour postopératoire un était le critère d’évaluation principal.

Résultats: Quarante des 80 patients inscrits à l’étude ont été randomisés dans chaque groupe de traitement. Le positionnement du cathéter selon le protocole a échoué chez un patient sur 40 (2,5 %) dans le groupe échoguidé comparativement à 9 sur 40 (22,5 %) dans le groupe cathéter stimulant (P = 0,014). La différence de durée de l’intervention (moyenne [intervalle de confiance (IC) 95 %]) était de –6,48 (−9,90 - −3,05), l’échoguidage nécessitant 7,0 (4,0-14,1) min contre 11,0 (5,0-30,0) min pour la technique de stimulation (P < 0,001). Les scores de douleur moyens des patients ayant fourni des données au jour postopératoire un étaient un peu plus élevés pour les 33 patients du groupe échoguidage comparativement aux 26 patients du groupe stimulation (5,0 [1,0-7,8] vs. 3,0 [0,0-6,5], respectivement; P = 0,032), soit une différence (moyenne [IC 95 %]) de 1,37 (0,03-2,71).

Conclusion: Lorsque cette technique est utilisée avec des cathéters périnerveux sciatiques poplités, l’échoguidage requiert moins de temps et entraîne moins d’échecs de positionnement que les cathéters stimulants. Toutefois, l’analgésie pourrait être légèrement meilleure avec un cathéter stimulant bien placé. Numéro d’enregistrement de l’étude clinique: NCT00876681.

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Figures

Fig. 1
Fig. 1
Illustration of a perineural catheter insertion technique employing electrical stimulation alone via a stimulating catheter; Panel 1: sciatic nerve and distal branches (tibial and common peroneal nerves) in the popliteal fossa; Panel 2: following nerve localization, the placement needle angle is lowered prior to catheter insertion; Panel 3: a stimulating catheter is deployed past the placement needle tip while maintaining the desired evoked motor response; Panel 4: the local anesthetic bolus is administered via the catheter
Fig. 2
Fig. 2
Illustration of a perineural catheter insertion technique employing ultrasound guidance alone with a non-stimulating catheter; Panel 1: the placement needle is directed in-plane toward the target nerve; Panel 2: the local anesthetic bolus is administered via the needle; Panel 3: a non-stimulating catheter may bypass the target nerve after insertion and require withdrawal; Panel 4: the non-stimulating catheter in proper position in proximity to the target nerve
Fig. 3
Fig. 3
Dot plot of average pain scores (numeric rating scale) by group on postoperative day one
See this image and copyright information in PMC

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