Brief Summary
Over 300,000 hip arthroplasties are performed each year in the United States.1 This number has been steadily increasing over the last two decades, likely due to increased life expectancy and, more significantly, the obesity epidemic. Traditionally, this procedure has been performed under general anesthesia. However, neuraxial and regional anesthesia have become more commonly utilized to aid in postoperative analgesia. Postoperative pain control has a significant impact on earlier ambulation, initiation of physical therapy, better functional recovery, and overall patient satisfaction.2 Moreover; optimal pain management can reduce the duration of hospitalization and the risk of adverse events, such as deep vein thrombus. The use of regional anesthesia reduces the postoperative opioid requirement, thereby decreasing the degree to which patients suffer the side effects of opioids, namely sedation and constipation, and less frequently nausea, vomiting, respiratory depression, pruritus, and retention. In the past, femoral nerve block, fascia iliaca compartment block, lumbar plexus block and the quadratus lumborum block have been shown efficacious for pain relief for hip arthroplasty. However there are several risk factors such as quadricep weakness and difficulty of the block that causes a limitation in the used of this blocks. Recently, the erector spinae plane block has been introduced as an alternative to the blocks above. This block was first described in the literature in 2016 when it was used to treat chronic neuropathic thoracic pain. Since then, there have been studies demonstrating its efficacy with a thoracic approach for analgesia in breast surgery and rib fractures.9 Only two case reports to date have demonstrated a lumbar approach to achieve analgesia for hip arthroplasty.10,11 The purpose of the study is to determine whether or not a lumbar erector spinae plane block is effective at improving postoperative pain in patients receiving hip arthroplasty.
Brief Title
The Use of Lumbar Erector Spinae Plane Block for Hip Arthroplasty at the L4 Interspace
Detailed Description
Hypothesis:
The erector spinae plane block will decrease opioid requirements in patients undergoing hip arthroplasty as compared to patients that do not receive the block.
Primary Objective:
To compare the opioid consumption in the post-anesthesia care unit (PACU) and at 24 hours postoperative (in morphine equivalents) in patients receiving regional anesthesia with spinal vs. spinal alone.
Secondary Endpoints:
To evaluate the pain scores at discharge from PACU, at 2 hours post PACU discharge, at 24 hours and at 48 hours postoperative; to evaluate the sensory distribution of the block (T10-L5); to evaluate whether or not patients that receive the block have evidence of quadricep muscle weakness
Design and methods This is a randomized, prospective study in patients receiving hip arthroplasty. Patients will be assigned to receive a lumbar erector spinae block versus no block. There will be no change in the primary anesthetic technique (spinal anesthesia with sedation) since these patients routinely get spinal anesthesia for hip arthroplasty. Consent for the study will be obtained in the preoperative area upon arrival for surgery. Patients will then be randomized into one of the two groups above. One group will receive a lumbar erector spinae block at L4 with 30ml of 0.375% ropivacaine with 50 mcg of dexmedetomidine before the procedure using ultrasound guidance. The second group will receive no peripheral nerve block to serve as the control. Patients to receive a nerve block will receive mild sedation (1-2mg midazolam ± ≤100mcg fentanyl). All patients receiving nerve blocks will have a printed image of the block thus to confirm proper spread of local anesthetic both cranially and caudally.
Postoperatively, the PACU nurse will be asked to document pain scores according to the Visual Analog Scale (VAS) and total dose of opioids given. The distribution of the sensory block and motor weakness will be documented in the anesthesiologist's PACU discharge note. For patients that receive the block, the Physical therapist note will be assessed for any report of quadriceps muscle weakness (i.e., evidence of buckling while walking).
For postoperative data collection, opioid consumption totals and the pain scores at 2 hours post admission, at 24 hours and 48 hours post-procedure will be collected from the electronic medical record (EMR) as documented by nurses on the admitting floor. Additionally, the Acute Pain service, who rounds on all patients that receive nerve blocks, will make a note of the pain scores of the patient and any residual muscle weakness or decreased sensation at 24- and 48-hours post-procedure. All data will then be extracted from the EMR by the research assistant.
The erector spinae plane block will decrease opioid requirements in patients undergoing hip arthroplasty as compared to patients that do not receive the block.
Primary Objective:
To compare the opioid consumption in the post-anesthesia care unit (PACU) and at 24 hours postoperative (in morphine equivalents) in patients receiving regional anesthesia with spinal vs. spinal alone.
Secondary Endpoints:
To evaluate the pain scores at discharge from PACU, at 2 hours post PACU discharge, at 24 hours and at 48 hours postoperative; to evaluate the sensory distribution of the block (T10-L5); to evaluate whether or not patients that receive the block have evidence of quadricep muscle weakness
Design and methods This is a randomized, prospective study in patients receiving hip arthroplasty. Patients will be assigned to receive a lumbar erector spinae block versus no block. There will be no change in the primary anesthetic technique (spinal anesthesia with sedation) since these patients routinely get spinal anesthesia for hip arthroplasty. Consent for the study will be obtained in the preoperative area upon arrival for surgery. Patients will then be randomized into one of the two groups above. One group will receive a lumbar erector spinae block at L4 with 30ml of 0.375% ropivacaine with 50 mcg of dexmedetomidine before the procedure using ultrasound guidance. The second group will receive no peripheral nerve block to serve as the control. Patients to receive a nerve block will receive mild sedation (1-2mg midazolam ± ≤100mcg fentanyl). All patients receiving nerve blocks will have a printed image of the block thus to confirm proper spread of local anesthetic both cranially and caudally.
Postoperatively, the PACU nurse will be asked to document pain scores according to the Visual Analog Scale (VAS) and total dose of opioids given. The distribution of the sensory block and motor weakness will be documented in the anesthesiologist's PACU discharge note. For patients that receive the block, the Physical therapist note will be assessed for any report of quadriceps muscle weakness (i.e., evidence of buckling while walking).
For postoperative data collection, opioid consumption totals and the pain scores at 2 hours post admission, at 24 hours and 48 hours post-procedure will be collected from the electronic medical record (EMR) as documented by nurses on the admitting floor. Additionally, the Acute Pain service, who rounds on all patients that receive nerve blocks, will make a note of the pain scores of the patient and any residual muscle weakness or decreased sensation at 24- and 48-hours post-procedure. All data will then be extracted from the EMR by the research assistant.
Completion Date
Completion Date Type
Actual
Conditions
Hip Arthropathy
Regional Anesthesia
Eligibility Criteria
Inclusion Criteria:
* Patients undergoing primary hip arthroplasty
* American Society of Anesthesiologists (ASA) Category 1, 2, and 3
* Patients age ≥18 years
Exclusion Criteria:
* Patient refusal
* Inability to understand and sign consent
* Infection at the injection site
* Known allergy or hypersensitivity to ropivacaine or other amide local anesthetics
* Contraindication or patient refusal to get spinal anesthesia
* Thrombocytopenia (platelets \< 100,000)
* Coagulopathy (INR \> 1.4)
* Use of anticoagulant drugs that have not been discontinued in an appropriate amount of time before the surgery
* ASA Category 4 and 5
* Patients undergoing primary hip arthroplasty
* American Society of Anesthesiologists (ASA) Category 1, 2, and 3
* Patients age ≥18 years
Exclusion Criteria:
* Patient refusal
* Inability to understand and sign consent
* Infection at the injection site
* Known allergy or hypersensitivity to ropivacaine or other amide local anesthetics
* Contraindication or patient refusal to get spinal anesthesia
* Thrombocytopenia (platelets \< 100,000)
* Coagulopathy (INR \> 1.4)
* Use of anticoagulant drugs that have not been discontinued in an appropriate amount of time before the surgery
* ASA Category 4 and 5
Inclusion Criteria
Inclusion Criteria:
* Patients undergoing primary hip arthroplasty
* American Society of Anesthesiologists (ASA) Category 1, 2, and 3
* Patients age ≥18 years
* Patients undergoing primary hip arthroplasty
* American Society of Anesthesiologists (ASA) Category 1, 2, and 3
* Patients age ≥18 years
Gender
All
Gender Based
false
Keywords
Erector Spinae Plane Block
Ropivacaine
Ultrasound guided nerve block
Healthy Volunteers
No
Last Update Post Date
Last Update Post Date Type
Actual
Last Update Submit Date
Maximum Age
99 Years
Minimum Age
18 Years
NCT Id
NCT03801863
Org Class
Other
Org Full Name
Montefiore Medical Center
Org Study Id
2018-9687
Overall Status
Terminated
Primary Completion Date
Primary Completion Date Type
Actual
Official Title
The Use of Lumbar Erector Spinae Plane Block for Hip Arthroplasty at the L4 Interspace- a Randomized Controlled Study Comparing the 24-hour Opioid Requirements.
Primary Outcomes
Outcome Description
To compare the opioid consumption in the post-anesthesia care unit (PACU) and at 24 hours postoperative (in morphine equivalents) in patients receiving regional anesthesia with spinal vs. spinal alone.
Outcome Measure
Opioid Consumption in PACU and 24 hours post surgery
Outcome Time Frame
24 hours
Secondary Outcomes
Outcome Description
To evaluate the pain scores at 2 hours post PACU discharge
Outcome Time Frame
2 hours. Pain scores from 1 to 10. 10 being the worse pain and 1 being the least pain
Outcome Measure
Pain scores at 2 hours post PACU discharge
Outcome Description
Will test for temperature difference using ice cube.
Outcome Time Frame
2 hours post-surgery
Outcome Measure
To evaluate the sensory distribution of the block (T10-L5).
Outcome Description
Will have patient walk and Physical Therapist will assess for buckling of knee or potential falls while ambulating.
Outcome Time Frame
30 hours post-surgery
Outcome Measure
To evaluate whether or not patients that receive the block have evidence of quadricep muscle weakness
Outcome Description
To evaluate the pain scores at 24 hours post PACU discharge
Outcome Time Frame
24 hours. Pain scores from 1 to 10. 10 being the worse pain and 1 being the least pain
Outcome Measure
Pain scores at 24 hours post PACU discharge
Outcome Description
To evaluate the pain scores at 48 hours postoperative.
Outcome Time Frame
48 hours post-surgery. Pain scores from 1 to 10. 10 being the worse pain and 1 being the least pain
Outcome Measure
Pain scores at 48 hours postoperative
Start Date
Start Date Type
Actual
Status Verified Date
First Post Date
First Post Date Type
Actual
First Submit Date
First Submit QC Date
Study Population
Patients undergoing primary total hip replacement under neuraxial anesthesia
Std Ages
Adult
Older Adult
Maximum Age Number (converted to Years and rounded down)
99
Minimum Age Number (converted to Years and rounded down)
18
Investigators
Investigator Type
Principal Investigator
Investigator Name
Iyabo Muse
Investigator Email
imuse@montefiore.org
Investigator Phone