American Society of Regional Anesthesia and Pain Medicine May 2018 - 7

a retrospective review of the National Trauma Data Bank (NTDB).
More than a million records were screened, and patients were
included based on the presence of an ICD-9 code indicating rib
fractures. Patients were excluded for age less than 18 years or
the presence of concurrent sternal, tracheal, or laryngeal trauma.
A total of 194,766 patient records were selected, of which 1,110
received paravertebral blocks, 1,073 received epidural analgesia,
and 192,583 received no interventions. Patients were then
propensity matched twice (scoring the probability of receiving
a PVB and probability of requiring any procedure) to eliminate
potential confounding variables. This allowed two comparisons:
(1) epidural versus paravertebral and (2) procedure (EA or PVB)
versus nonprocedure. After
1:1 propensity matching, 557
patients in the EA and PVB
groups and 1,114 patients
in the nonprocedure group
remained for analysis. No
significant differences
between EA and PVB were
found regarding in-hospital
mortality, length of stay (LOS),
intensive care unit (ICU) admission, ICU LOS, duration of mechanical
ventilation, development of pneumonia, or other complications.
In contrast, the nonprocedure group suffered increased mortality
compared with patients receiving either EA or PVB (odds ratio =
2.25; 95% confidence interval: 1.14-3.84). However, the procedure
group experienced an increase in hospital LOS and more frequent
ICU admissions. Study limitations included dependency on accuracy
and completeness of data, the inability to evaluate for comorbidities
from the procedures themselves, and the potential for selection
bias (despite propensity matching) of more severely injured patients
because of the characteristics of the hospitals participating in the
NTDB.

patient-controlled analgesia, and placebo. Trials included in the
analysis spanned 30 years, represented 12,530 patients from 35
countries, and included 17 different treatment modalities. Pain
at rest, pain with movement, opioid consumption, and range of
motion in the first 72 hours after operation were used as primary
outcome measures. As with other meta-analyses, the included
trials varied in quality, risk of bias, patient population, and types
of data present, as well as surgical anesthetic technique and
adjuvant analgesic medications. The authors sought to rank the 17
identified treatments for each of the four primary outcomes using a
surface under the cumulative ranking curve method of analysis to
compare interventions against a theoretical optimal regimen. What
emerged was a ranking
of interventions. Their
conclusions suggested
that multiple nerve blocks
work better than any
single nerve block and are
superior to neuraxial or
periarticular techniques.
The combination of femoral
and sciatic nerve blocks
was rated the best overall option, although that conclusion masks a
great deal of nuance.

"The article should serve as an
invaluable aid to those designing a total
joint protocol or contemplating their
institution's current practices."

Terkawi AS, Mavridis D, Sessler DI, et al. Pain management
modalities after total knee arthroplasty: a network
meta-analysis of 170 randomized controlled trials.
Anesthesiology 2017;126(5):923-937. https://doi.org/10.1097/
ALN.0000000000001607
Terkawi et al performed a network meta-analysis of 170 trials
of analgesic regimens for TKA to evaluate efficacy and rank the
various modalities available to control pain. A network metaanalysis aggregates study data across multiple studies in much
the same way as a conventional meta-analysis, but instead
of comparing two treatment arms, it seeks to use direct and
indirect comparisons between multiple groups to stratify and rank
treatments. Terkawi et al made comparisons between neuraxial
analgesia, various combinations of peripheral nerve blocks,
periarticular local anesthetic infiltration, auricular acupuncture,

Kopp SL, Børglum J, Buvanendran A, et al. Anesthesia and
analgesia practice pathway options for total knee arthroplasty.
Reg Anesth Pain Med 2017;42(6):683-697. https://doi.
org/10.1097/AAP.0000000000000673
Kopp et al approached the complexity of literature surrounding
analgesic options in TKA by structuring their investigation as a
scoping review. This technique focuses more on describing the
literature, in this case the breadth of analgesic options available
for TKA, rather than providing any quantitative analysis. Although
the expert panel that authored this study initially sought to define
optimal practice and create a practice pathway, the approach
changed when the heterogeneity in clinical practice became
apparent. Instead, the authors compiled and evaluated the risks
and benefits of currently available treatment options. Different
modalities discussed included neuraxial anesthesia, general
anesthesia, peripheral nerve blocks, local anesthetic infiltration,
wound catheters, and various oral and intravenous analgesics.
The TKA protocol goals are detailed. A sample TKA pathway is
provided to illustrate integration of preoperative, intraoperative,
and postoperative care. The article highlights the advantages of
neuraxial over general anesthesia, and decreases in mortality;
reduction of pulmonary, renal, and gastrointestinal complications;
and improvements of length of stay and cost are discussed. The
article should serve as an invaluable aid to those designing a total
joint protocol or contemplating their institution's current practices.

American Society of Regional Anesthesia and Pain Medicine
2018

https://doi.org/10.1097/AAP.0000000000000673 https://doi.org/10.1097/AAP.0000000000000673 https://doi.org/10.1097/ALN.0000000000001607 https://doi.org/10.1097/ALN.0000000000001607

Table of Contents for the Digital Edition of American Society of Regional Anesthesia and Pain Medicine May 2018