To observe the effect of dexamethasone complex ropivacaine on reducing lateral side pain in patients undergoing total hip arthroplasty.
120 patients aged 45 to 75 years who were recommended to undergo unilateral total hip replacement treatment were selected and randomly divided into 4 groups of 30 each and receive treatment as following: 5 μg sufentanyl injection was injected before lumbar anesthesia in Group A, ropivacaine and saline in group B; dexmedetomidine combined with ropivacaine in group C; dexamethasone plus ropivacaine in group D. Electrocardiogram and pulse oxygen saturation were routinely monitored (SpO2), invasive mean arterial pressure (MAP), heart rate (HR), and pain visual analogue score (VAS) at 0, 5, 10 and 15 minutes after administration ( T0, T1, T2 and T3) were assessed for the patients in the operating room. The operation duration, anesthesia operation duration, intraoperative bleeding volume, patient anesthesia satisfaction, adverse reactions such as hypotension, bradycardia, chills and nausea and vomiting, and the number of postoperative intravenous analgesia pump dosage presses were recorded.
Comparison of the hemodynamic changes between the groups: at T2, the fluctuations in HR and arterial blood pressure in group D (10 minutes after dose) were smaller than those of the other 3 groups, with statistically significant differences (P < 0.05); at T3, the arterial blood pressure and HR fluctuations in groups B, C and D were smaller than those in group A, with A statistically significant difference (P < 0.05). VAS scores at T2 and T3 Time points were statistically significant reduced than T0 in group B, C and D (P < 0.05); in group C and D, VAS score at T1 were significantly lower than T0, which was not observed in other groups; none of the 4 groups had adverse event such as hypotension, bradycardia, nausea and vomiting, and local anesthetic poisoning (P > 0.05). In groups C and D, the number of postoperative analgesic pump dosage presses was significantly less than that in groups A and B, with a significant difference (P < 0.05).
Ultrasound-guided dexamethasone compound ropivacaine fascia iliaca space block can significantly reduce the pain caused by lateral lumbar anesthesia in total hip replacement surgery, and facilitate the hemodynamic stability of patient, better patient comfort and higher satisfaction with anesthesia. Combined dexmedetomidine and dexamethasone had better postoperative analgesia and less opioid use in the analgesic pump. Compared with the dexamethasone compound ropivacaine group, the nerve block was faster and patients were more satisfied with anesthesia, which was conducive to postoperative rehabilitation and worthy of clinical promotion and application.
With the aging of China’s population, coupled with people’s living habits, dietary changes, and other factors, an increasing number of patients suffer from hip joint diseases. Due to the increase in the number of elderly patients, the condition of patients with hip disease is more complicated, which is often combined with hypertension, diabetes, coronary heart disease, and other basic diseases.1–3 Total hip replacement (total hip anthroplasty, THA) is the most representative treatment for end-stage hip disease.4 Searching for interventions to reduce the perioperative risk has become a clinical focus, and anesthesia and analgesia are an important link.5 Therefore, safe and effective anesthesia methods and comfortable analgesia measures play an increasingly important role in THA treatment programs, and have a direct impact on the functional recovery of surgical patients and the satisfaction of the surgical effect. Waist anesthesia (spinal anesthesia, SA) has gradually become one of the main methods of anesthesia for hip replacement surgery because of its rapid effect, accurate anesthesia effect, and good muscle relaxation.6–8 Duration of SA anesthesia is not long, which has certain postoperative analgesic effects conducive to early functional exercise and promoting rapid rehabilitation.9,10 However, the pain caused by the change of patient body position (i.e., from supine to lateral position) during SA operation is unbearable for most patients, and severe pain has a great impact on the hemodynamics of patients. Therefore, the pain of SA operation body position change brings many difficulties to safe and comfortable anesthesia.11 In recent years, there have been reports of acute pain in patients with hip injury, fascia iliac compartment block (FICB) analgesia in emergency departments, and positive analgesic effects.12 The anatomical iliofascia space is the potential space between the iliofascia and outer membrane of the iliopsoas muscle, which is the iliac fascia in front and iliac muscles in the pelvis in the back. The beginning of the femoral nerve, obturator nerve, and the beginning of the lateral femoral cutaneous nerve were traversed behind the iliac fascia. Therefore, successful FICB can block the femoral nerve, obturator nerve, and femoral lateral cutaneous nerve, achieving the analgesic effect of blocking the innervated area.13 The anesthetic drugs were injected into the fascia during the FICB procedure. It can simultaneously block the femoral nerve, obturator nerve, and lateral femoral skin nerve in the fascia layer, which is safe and has better analgesic effect than the femoral nerve block alone. Ropivacaine is used clinically in several ways for postoperative analgesia.15 It was found that the use of 0.2% to 0.5% ropivacaine in the peripheral nerve block was more effective.16 Shariat et al,17 using 30 mL volume of ropivacaine at a concentration of 0.375%, gave ultrasound-guided FICB to patients undergoing THA surgery, with positive outcomes with postoperative analgesia. Several studies have shown that dexamethasone can enhance the analgesic effect of local anesthetic and prolong analgesic time.18–22 In recent years, some scholars used dexamethasone as an adjuvant for brachial plexus block, and observed that it could significantly shorten the onset time of local anesthetic.23 At present, the mechanism is not clear, and the possible mechanism is that dexamethasone, as an exogenous glucocorticoid, can increase sensitivity of local blood vessels to catecholamines, increasing the tension of blood vessels; and dexamethasone may strengthen the combination of local anesthetic and neuroaxon, so as to enhance and prolong effects of nerve block time.24 This study observed the clinical analgesic effect of dexamethasone complex ropivacaine in FICB and compared it with ropivacaine alone and dexmedetomidine complex ropivacaine, aiming to provide theoretical and data support for hip postoperative analgesia options.
Data and Methods
Study subjects
General information
The study was approved by the Ethics Committee of Guilin Medical College, and the informed consent was signed with the patient or family members before the start of the study. In this study, 120 patients with unilateral hip replacement were selected and divided into 4 groups: A, B, C, and D, with 30 patients in each group.
Inclusion criteria
ASA ∼ level;
Age: 45–75 years old;
Patients with unilateral total hip replacement;
Sign the informed consent form.
Exclusion criteria
Patients with obvious bleeding tendency or blood coagulation disorder;
Puncture site infection;
Severe symptoms of systemic infection;
History of allergy to local anesthetic;
History of trauma and surgery at the puncture site;
Long-term history of taking psychotropic drugs;
Mental development disorders or mental abnormalities cannot cooperate.
Elimination criteria
Patients who change to general anesthesia due to difficulty in puncture of lumbar anesthesia or poor anesthesia effect;
Failure of fascia iliaca block for various reasons.
Drugs, Materials and Equipment
Main drugs
The names, specifications, registration numbers, and manufacturers of the major drugs used in this study are shown in Table 1.
Materials and instruments and equipment
Names and manufacturers of the main materials and instruments used in this study are shown in Table 2 below.
Experimental Method
Group grouping method
Using the random number table method, 120 patients were randomly divided into 4 groups A, B, C, and D, with 30 patients in each group. In group A, sufentanyl was given intravenously before lumbar anesthesia; in groups B, C, and D an ultrasound block was performed before lumbar anesthesia.
Group A: 5 ug of intravenous sufentanyl injection before lumbar anesthesia;
Group B iliofascia space block combination drug: 15 mL 0.75% ropivacaine mixed with 15 mL of normal saline into 0.375% ropivacaine 30 mL mixture;
Group C iliofascia space block combination: 15 mL 0.75% ropivacaine + 0.5 μg/kg dexmedetomidine 15 mL saline mixed into 0.375% ropivacaine dexromedetomidine 30 mL mixture;
Group D iliofascia space block: 15 mL of 0.75% ropivacaine + 5 mg dexamethasone 15 mL of normal saline into 0.30 mL of 0.375% ropivacaine dexamethasone mixture.
Anesthesia method
According to the anesthesia routine, the patient reached the preoperative fasting and drinking time. After entering the operating room, the nurse was instructed to open the venous channel and nasal catheter for oxygen, and routinely performed electrocardiogram, blood pressure, heart rate, respiratory rate and blood oxygen saturation (SpO2) guardianship. Under local infiltration anesthesia, the radial artery catheterization was uniformly selected to establish invasive artery monitoring. Patients in Group A underwent lumbar anesthesia after intravenous injection of 5 μ sufentanyl for analgesia; patients in Group B, C, and D were given the FICB before a single SA.
Ultrasound-guided operation method of FICB
The patient lay supine and routinely sterilized. Using a portable color 2-dimensional ultrasound instrument, high-frequency line array probe, the probe was positioned in the sagittal plane beside the inguinal ligament. It found the iliopsoas muscle and femoral artery, moved the probe laterally, and adjusted the ultrasound probe to obtain the best position. Use one-use injection needle (0.750 mm), to observe the tip position and enter the needle layer by layer. When the tip reached the iliac fascia space and had no gas or blood, a small amount of normal saline was injected to observe its diffusion. If saline spreads well in the iliofascia space, inject 30 mL of the previously prepared drug into the iliofascia space. The iliac fascia space was expanded by injecting large volume fluid, then the probe was rotated to the transverse position to find the femoral and femoral nerves, and observe the local anesthetic along the femoral artery and the diffusion in the fascia space. Ultrasound is shown in Figures 1 and 2.
Ultrasonic imaging of iliac fascia cavity (1) femoral artery; (2) iliac fascia; (3) iliopsoas muscle.
Ultrasonic imaging of iliac fascia cavity (1) femoral artery; (2) iliac fascia; (3) iliopsoas muscle.
Successful imaging of iliac block (4) puncture needle tip; (5) medicinal solution.
Successful imaging of iliac block (4) puncture needle tip; (5) medicinal solution.
Observing indicators
Record the general condition of patients: age, height, weight, and gender. Duration of anesthesia operation and operation duration were recorded, and the blood loss was counted.
Monitoring and recording of the following parameters of all patients when admitted to the operating room at 0, 5, 10, and 15 minutes (T0, T1, T2 and T3) after administration: HR, MAP, and SpO during movement and at rest, VAS and score.
Observe the intraoperative adverse reactions and number of postoperative analgesic pump dosage presses: including bradycardia, hypotension, respiratory depression (RR less than 12 times/minutes), local anesthetic poisoning, nausea and vomiting, chills, and low oxygen (SpO2 < 90%) and other occurrence of adverse reactions.
The VAS pain score has 10 scales: 0 for the absence of any pain, and 10 for intolerable severe pain. 3 points below: represents the patient, with mild pain, tolerable. 4∼6, the patient has significant pain and affects the quality of sleep, but can tolerate it. 7∼10, the patient appears to have strong pain that affects sleep quality and appetite, unbearable. The VAS scoring scale is shown in the following figure.
Statistical Methods
In this study, SPSS 23.0 was used for statistical data processing, measurement data were expressed as mean ± standard deviation (± S), 1-way analysis of variance was used for intragroup and intergroup comparisons, and P < 0.05 was considered statistically significant.
Results
Comparison of general data
Present clinical observation data are divided into 4 groups. The ASA grade, gender, age, height, weight, anesthesia operation time, operation time, and bleeding volume were not significantly different in the 4 groups (P > 0.05). See Table 3 for further details.
Comparison of hemodynamic changes
Within Group: In Group D, comparisons of the T1 heart rate, mean arterial pressure, and T0 revealed significant differences that were statistically significant (P < 0.05). Additionally, when comparing T2 and T3 heart rates and mean arterial pressure across Groups B, C, and D, significant differences were also noted (P < 0.05).
Between Groups: At the T1 time point, Group D showed statistically significant differences in heart rate and mean arterial pressure (P < 0.05). For T2 and T3, Groups B, C, and D demonstrated statistically significant variations compared to Group A (P < 0.05). Oxygen saturation showed almost no differences, as detailed in Table 4.
Comparison of VAS scores
Within-group comparison: At the T0 time point, comparisons among Groups B, C, and D at T2 and T3 revealed significant changes in VAS scores, with statistically significant differences (P < 0.05). Additionally, at the T0 time point, Group D showed a statistically significant change in VAS scores at T1 (P < 0.05).
Between-group comparisons: Group D’s VAS scores at T1 were statistically significant when compared to Group A (P < 0.05). However, there were no significant differences in VAS scores at T1 between Groups B and C compared to Group A (P > 0.05). In contrast, at T2 and T3, VAS scores for Groups B, C, and D showed statistically significant differences compared to Group A (P < 0.05), as detailed in Table 5.
Comparison of adverse anesthesia reactions and number of postoperative analgesic pump presses
None of the 4 groups experienced adverse anesthetic reactions, and there was no significant difference between the 4 groups (P > 0.05). However, Groups C and D showed statistically significant differences compared to Group B (P < 0.05), and there were significant differences between Groups B, C, and D as well (P < 0.05). Details are provided in Table 6.
Discussion
In recent years, with the popularization of enhanced recovery after surgery concept in the surgical system, surgery has paid more attention to reducing surgery-related complications, shortening hospital stay and reducing medical costs. Additionally, perioperative pain management is an important part of accelerating rehabilitation surgery. At present, use of opioid analgesia is the main means of providing perioperative analgesia, but its related side effects and adverse reactions are also quite obvious, which contributes to challenges concerning patients’ rapid rehabilitation and comfort experience. Multimodal analgesia can significantly reduce use of perioperative opioids, mainly including regional nerve block, intravenous analgesia, intraspinal analgesia, local infiltration anesthesia, etc. As an important means of multimodal analgesia, regional nerve block is increasingly favored by anesthesia and surgeons because of its simple and safe operation, few adverse effects, and definitive analgesic effect.
Application of regional nerve block in total hip replacement
At present, peripheral nerve block is lumbar plexus block, femoral nerve block, FICB, hip capsule peripheral nerve block, etc. The lumbar plexus nerve block can effectively target the femoral nerve, obturator nerve, lateral femoral cutaneous nerve, and all branches of the lumbar plexus, offering improved analgesia following total hip procedures. However, the lumbar plexus is located deep within the body, making the ultrasound-guided lower lumbar plexus block procedure more complex. If the operator lacks experience or skill, there is a risk of inadvertently injuring the intestines, kidneys, or even large blood vessels, as well as the potential for a bilateral block.24 There are even case reports of total spinal anesthesia,25 and security still needs to be further improved. In addition, the lumbar plexus block requires the patient to lie in the lateral position, without avoiding pain during the pendulum position. Therefore, although lumbar plexus block can provide precise postoperative analgesia, it does not provide good analgesia in the anterior lateral position of lumbar anesthesia in patients with THA. Studies have shown that the femoral nerve block can effectively relieve pain of patients with hip fracture, and can effectively reduce the pain caused by patients when changing their position.26 However, due to the limitation of the femoral nerve in the sensory area of the hip, blocking the femoral nerve can only relieve some pain in patients with hip fracture, and the limited duration of a single block is unable to control the effects of inflammatory mediators.27 Therefore, other analgesics are needed to make up for the lack of femoral nerve analgesia. Femoral nerve, obturator nerve joint branches, and other lines walk through the hip capsule, so the hip capsule peripheral nerve block can provide good analgesia.28 However, simple hip capsule block cannot block the lateral femoral cutaneous nerve, so a single ultrasound-guided hip capsule peripheral nerve block can effectively relieve the pain of patients with hip replacement, yet some patients cannot obtain satisfactory analgesia, so there are some limitations. FICB injects local anesthetic in the space between the iliac fascia and iliac muscle, which can block the femoral nerve, obturator nerve, and lateral femoral cutaneous nerve.29 Preoperative anesthesia with ultrasound-guided FICB in 40 elderly patients with hip fracture showed that ultrasound-guided FICB could provide well-established perioperative analgesia, which is consistent with the results of this study. The space of the iliofascia fascia is shallow, and there are no important organs and large vessels around. FICB can clearly distinguish the nerves and blood vessels in the iliofascia space, and the diffusion of the liquid can be observed under ultrasound, indicating that the ultrasound-guided FICB has good analgesic effect and high safety.
Clinical application and advantages of ultrasound-guided FICB
The FICB of traditional FICB mainly judges whether to reach the iliac fascia space through “breakthrough feeling” or “disappointed feeling.” The success rate of puncture is related to the operation of anesthesiologists, and blind wear is easy to damage nerves and blood vessels, and the success rate is low. Therefore, although the traditional method is simple and easy to learn, it has a certain failure rate.30
In this study, the fascia iliac space block used the ultrasound-guided single administration method. With the support of ultrasound visualization technology, the nerve block was descending, the puncture needle could be positioned under direct vision, and the successful puncture was judged by observing the diffusion of the liquid, which ensured the reliability of the selected patients’ FICB.31 Some studies have confirmed that ultrasound-guided FICB in THA patients has a high success rate and definite analgesia, which is related to the improvement of puncture accuracy by ultrasound guidance.32
In this study, for postoperative follow-up of the 4 groups, the analgesic pump presses in group B were less than group A, and the analgesia pumps in groups C and D were significantly less than group A and B, which was statistically significant. It can be inferred that ultrasound-guided FICB for THA can significantly reduce dosage of opioids, and that dexamethasone and dexmedetomidine as adjuvants for FICB could further reduce dosage of opioid analgesics. Studies have shown that regional nerve block analgesia can significantly reduce the amount of opioids, reducing adverse effects of opioid analgesia and increasing perioperative safety of patients.33 This was also confirmed by patients using FICB in this study who were using less opioids for postoperative analgesia.
Advantages of dexamethasone compound ropivacaine for FICB
This study was documented in the T1 (5 minutes after administration) Hemodynamics and VAS scores of the 4 patients at the time point, and found that the HR, MAP fluctuation, and VAS scores in Group D were significantly lower than groups A, B, and C, and the difference was statistically significant; the results showed that dexamethasone compound ropivacaine for FICB could significantly shorten the onset time of local anesthesia, to reduce THA and the pain caused by patients undergoing SA transformation, and maintain the hemodynamically stable; By comparison of this study, it was found that in T3, the VAS score (during lumbar anesthesia change) in the D group was lower than that of the remaining 3 groups, proving that dexamethasone compound ropivacaine enhanced the analgesic intensity of FICB and further improved the anesthesia comfort of patients. A more recent meta-analysis34 showed that ropivacaine combined with dexamethasone shortened the onset and prolonged the analgesic effect compared with dexmedetomidine, as demonstrated by the results of this study. In this study, by comparing the T2, the VAS score of patients at time point found that groups C and D were lower than groups A and B, which concluded that dexamethasone or dexmedetomidine compound ropivacaine applied to FICB had faster onset time and greater analgesic intensity than ropivacaine alone.
Limitations of this study
This study also has its own shortcomings. First, this study is a single-center study with a short study period and a small number of samples, so we hoped that more cases can be collected later. Secondly, this study focuses on how to quickly, safely, and effectively reduce the pain in the process of lumbar anesthesia, and observe the amount of postoperative opioid analgesic drugs used. Although it was confirmed that FICB can provide good postoperative analgesia, detailed postoperative follow-up and recording of postoperative analgesia were not performed in all patients, and it is impossible to confirm which drug provides longer analgesia in patients undergoing ultrasound-guided FICB. Finally, due to the limitations of clinical conditions, this study did not detect the content of catecholamine and cortisol in the blood of patients at each time point, which cannot directly reflect the stress status of patients in the perioperative period.
Conclusion
Ultrasound-guided dexamethasone combined with ropivacaine iliofascial space block for total hip replacement surgery faster, can reduce THA faster, pain caused by SA change, maintain the patient, hemodynamic stability. In addition, postoperative analgesic effect is positive, opioids are used less in the analgesic pump, and anesthesia satisfaction of patients is higher, which is conducive to the rapid postoperative recovery of patients, and is worthy of clinical promotion and application.
Acknowledgments
Manuscript is approved by all authors for publication. The data and materials of this experiment are available. No conflict of interest exists in this manuscript. The authors would like to thank the staff of the Department of Anesthesiology at the Affiliated Hospital of Guilin Medical University for their support and assistance throughout the study. Li Aiguo and Peng Lingyun contributed to the conception and design of the study. Zhang Xu oversaw the data collection and analysis. Li Aiguo and Zhang Xu drafted the manuscript. Peng Lingyun provided critical revisions. All authors read and approved the final version of the manuscript for submission.