A Staged Approach to Analgesia After Hip Arthroscopy Using Multimodal Analgesia & Elective Ultrasound Guided Fascia Iliaca Block

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1 A Staged Approach to Analgesia After Hip Arthroscopy Using Multimodal Analgesia & Elective Ultrasound Guided Fascia Iliaca Block James T. Beckmann MD Stephen K. Aoki MD Stephen Guyette MD Jeffrey Swenson MD Department of Orthopaedic Surgery THE UNIVERSITY OF UTAH

2 Disclosures James T Beckmann, MD: No financial relationships to disclose Stephen K Aoki, MD: Consultant: Smith & Nephew: educational consultant Arthrocare: surgical advisory board Royalties: None Salary: None Stephen Guyette, MD: No financial relationships to disclose Jeffery Swenson, MD: No financial relationships to disclose

3 Background Hip arthroscopy can result in severe postoperative pain Effective pain control after surgery can be challenging in the outpatient setting High dose opioids, an option to treat postoperative pain, are associated with respiratory depression, nausea, and other potentially dangerous side effects In combination with multimodal analgesia, elective postoperative ultrasound guided fascia iliaca block may provide safe and effective analgesia

4 Fascia Iliaca Block Less invasive alternative to lumbar plexus blockade as injected local anesthesia tracks along soft tissue plain to lumbar plexus Figure 1: Cadaveric specimen demonstrating tracking of injected dye along the iliac fascia to the lumbar plexus Safe and effective to perform 1-3 Technically feasible following hip arthroscopy despite capulotomy and extravasation of fluid Figure 2: Ultrasound image of successfully placed fascia iliacus block. Femoral Nerve (*), Iliac fascia (small arrows), Iliacus muscle (IM), Local Bolus (LB). Figure 1 LB * IM Figure 2

5 Objective Determine the safety and effectiveness of a protocol utilizing preoperative multimodal analgesia and elective postoperative ultrasound guided fascia iliaca block for pain management following hip arthroscopy

6 Subject Selection IRB approved 60 patients reviewed who were treated with a multimodal analgesia for pain management after hip arthroscopy, with and without fascia iliaca blockade All patients underwent osteochondroplasty and/or labral repair Patients with a history of chronic opioid use or obstructive sleep apnea were excluded prior

7 Analgesia Protocol Pre-op Informed consent for possible postoperative ultrasound guided fascia iliaca block obtained Celecoxib 400 mg and pregabalin 150 mg administered orally Intra-op TIVA administered with IV fentanyl doses recorded Post-op IV fentanyl titrated to respiratory rate >10 breaths/minute Option to receive ultrasound guided fascia iliaca block if primary pain complaint was in the anterior hip following surgery

8 Data Collection Total fentanyl received in mcg/kg (intraoperative and PACU) by each patient Pain scores (VAS 0-10) at admission and discharge from the PACU Aldrete score at PACU discharge Total PACU time For patients receiving fascia iliaca block: Pain scores immediately before and 30 minutes after block Nerve block complications

9 Results Baseline Data Demographic data (age, height, weight) did not differ between those electing for or against fascia iliaca block Age (yrs) Weight (kg) Height (cm) No Block 35.9 ± ± ± 9.92 Block 34.4 ± ± ± 8.88 Discharge All patients were successfully discharged with no readmissions for pain control Complications Nerve blocks were performed without difficulty or complications

10 Fascia Iliaca vs. Multimodal Analgesia Alone Of the 60 patients, 39 (64.4 %) requested a nerve block in the PACU Similar measures amongst patients receiving a block and those that did not include: Mean fentanyl (mcg/kg) dose Duration of PACU stay PACU Aldrete scores Total Fentanyl (mcg/kg) Duration of Stay (min) No Block No Block Block Block

11 VAS Scores 10 For patients requesting a block, the mean VAS score decreased from 7.5 to 2.2 ( 71% decrease), P < VAS Pre- Block Post- Block There was a significant difference observed in discharge VAS score between blocked and unblocked patients (2.2 vs 3.6, P < 0.01) Discharge VAS No Block Block

12 Conclusions Multimodal analgesia alone provides sufficient pain control in approximately one-third of patients following hip arthroscopy Fascia iliaca block was performed safely and effectively despite intraoperative capsulotomy and extravasation of fluid from hip arthroscopy Fascia iliaca block significantly reduced postoperative anterior hip pain following hip arthroscopy in those patients that elected for the procedure Discharge VAS scores were significantly lower in patients receiving fascia iliaca block than those who did not If anterior hip pain persists despite multimodal analgesia, fascia iliaca block can be considered as a safe and effective adjunct without the need for additional opioid narcotics in this study

13 References 1. Birnbaum K et al. The sensory innervation of the hip joint--an anatomical study. Surg Radiol Anat, Beaudoin FL et al. Ultrasound-guided femoral nerve blocks in elderly patients with hip fractures. Am J Emerg Med, Ilfeld BM et al. Continuous Femoral Versus Posterior Lumbar Plexus Nerve Blocks for Analgesia After Hip Arthroplasty: A Randomized, Controlled Study. Anesth Analg, 2011.