Editorial article
Why to use peripheral nerve blocks in orthopedic surgery?
¿Por qué utilizar los bloqueos nerviosos periféricos en cirugía ortopédica?
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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "181" "paginaFinal" => "184" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "M.Á. Gómez-Ríos" "autores" => array:1 [ 0 => array:4 [ "nombre" => "M.Á." "apellidos" => "Gómez-Ríos" "email" => array:1 [ 0 => "magoris@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Anestesiología y Medicina Perioperatoria, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Head of the Anaesthesiology and Pain Management Research Group, Institute for Biomedical Research of A Coruña (INIBIC), A Coruña, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Por qué utilizar los bloqueos nerviosos periféricos en cirugía ortopédica?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Orthopaedic surgery has increased dramatically over the past decades. It is now the most widely performed surgery in the world, and will continue to increase in parallel with population ageing.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">1</span></a> Orthopaedic procedures are associated with severe acute postoperative pain<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">2</span></a> that can have profound implications and potentially severe consequences. It causes stress, suffering and patient dissatisfaction, and undermines progress, recovery and surgical outcomes,<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">3</span></a> delays rehabilitation, prolongs hospitalization and impairs functionality. It can develop into chronic pain and can contribute to the progression of certain cancers, and it also increases the risk of morbidities, including cognitive impairment, deep venous thrombosis, myocardial infarction, and postoperative infections.<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">4,5</span></a> Together, these factors significantly increase healthcare spending, which is why adequate postoperative pain management should be a top priority. However, despite advances in the understanding of postoperative pain and the development of new drugs and techniques, inadequate management of postoperative pain is still commonplace in orthopaedic surgery.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Orthopaedic surgery, like any other surgical procedure, involves tissue damage. Injured tissues release local inflammatory mediators that activate different peripheral nociceptors (C fibres and A fibres). Thus, the nociceptive information is transmitted from the primary afferent neuron to the central nervous system. Intense and persistent nociceptive afferent inputs can lead to changes that may be difficult to reverse, such as peripheral and central sensitization, neurochemical and neuroanatomical changes or “neural plasticity”, prolonged neuronal discharge and sensitivity, and the development of chronic pain.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">6</span></a> However, the impact is not limited to acute or long-term pain. The release of inflammatory mediators and the stimulation of afferent neurons activate central effectors of the stress response, i.e., the locus coeruleus–noradrenergic or sympathetic systems situated in the brainstem, and the corticotropin-releasing hormone. The latter is released by the hypothalamus and activates the sympathetic nervous system and the hypothalamic–pituitary–adrenal axis.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">7</span></a> Therefore, tissue damage secondary to surgery and the resulting pain trigger a cascade of systemic events that lead to profound neuroendocrine, metabolic, inflammatory and immunological responses. These in turn trigger pathophysiological events related to postoperative morbidity, including cardiac ischaemia and haemodynamic instability, renal and pulmonary decompensation, increased catabolism, impaired immunity, and hypercoagulability syndrome.<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">1,8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Opioids continue to be the mainstay of acute postoperative pain management. However, their many disavantages<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">9</span></a> include multiple deleterious effects on the immune system. Thus, opioid use can increase the incidence of infection,<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">10</span></a> promote cancer recurrence in the case of oncological orthopaedic surgery,<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">11</span></a> or interfere in the healing process,<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">12</span></a> although there is insufficient evidence to change clinical practice.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">13</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Fast-track or “enhanced recovery” programmes are based on these concepts.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">14</span></a> Their main goal is to control postoperative pain and inflammation by means of effective multimodal opioid-sparing analgesic regimens aimed at limiting adverse outcomes secondary to organ dysfunction in the context of surgical stress.<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">14,15</span></a> Peripheral nerve block (PNB) plays a key role in this setting by providing an afferent neural blockade.<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">3,15</span></a> In 2004, the American Society of Anesthesiologists task force on Acute Pain Management published the first set of guidelines dealing with perioperative pain management, in which they strongly recommended the routinely incorporation of peripheral regional analgesic techniques within a multimodal analgesia protocol, particularly in patients undergoing lower extremity and upper extremity surgical procedures. These recommendations remain valid today.<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">16</span></a> Given the existence of high-quality evidence of the beneficial outcome of PNB,<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">17,18</span></a> it is surprising that these techniques are hardly ever used.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The advantages of PNB in orthopaedics cover a wide spectrum of perioperative outcomes. The analgesic efficacy of PNB for acute pain management has been demonstrated extensively. Thus, PNB is as effective as epidural analgesia for postoperative pain management, and is associated with significantly fewer postoperative complications in patients undergoing total knee joint replacement.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">19</span></a> PNB can provide effective unilateral analgesia with a low incidence of opioid-related and autonomic side effects.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">19</span></a> PNB is considered a therapeutic tool that can limit organ dysfunction secondary to surgical stress.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">15</span></a> A recent study demonstrated that the use of ultrasound-guided interscalene brachial plexus block in shoulder surgeries significant reduced intraoperative and postoperative stress response.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">20</span></a> The incidence of postoperative nausea and vomiting is lower with opioid-free regional anaesthesia<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">21,22</span></a> because it does not require the use of volatile anaesthetics, nitrous oxide, and postoperative opioids. Therefore, PNB is recommended as an antiemetic prophylaxis.<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">23</span></a> Multiple studies have confirmed that PNB reduces hospital stay.<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">24–26</span></a> In fact, perineural infusions are the mainstay of acute postoperative pain management in outpatient orthopaedic surgery.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">5</span></a> Likewise, PNB significantly reduces direct and indirect costs per procedure, and is therefore a cost-effective technique.<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">27–29</span></a> PNB allows patients to achieve a higher range of motion in less time, and speeds up rehabilitation.<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">30–32</span></a> Moreover, satisfaction with anaesthesia is generally high (up to 97% satisfied or highly satisfied)<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">33,34</span></a> and most patients (more than 90%) state they would be willing to repeat PNB.<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">35</span></a> Nerve block may also downregulate proinflammatory cytokines in the hippocampus after surgery.<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">37</span></a> Inflammation of the central nervous system (shown by inflammatory markers in cerebrospinal fluid) may be part of the pathogenesis of postoperative cognitive changes,<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">36</span></a> suggesting that PNB may reduce the risk of postoperative cognitive dysfunction,<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">37</span></a> cognitive decline, delirium and sleep disturbances.<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">38,39</span></a> Recently published data show that short-term postoperative continuous PNB may reduce the incidence and/or severity of chronic, persistent postoperative pain.<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">31,32</span></a> Likewise, it has been hypothesized that the use of regional anaesthesia to reduce surgical stress and opioid and volatile anaesthetic consumption would prevent perioperative immune suppression and angiogenesis, and ultimately cancer recurrence.<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">40</span></a> The results of studies in breast, gastrointestinal, and genitourologic cancers are controversial.<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">41</span></a> However, regional anaesthesia in the context of orthopaedic oncologic surgery has not been investigated.<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">41</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">PNB has certain limitations that should be taken into account. The duration of single dose block is limited. Nevertheless, perineural catheter infusion in continuous nerve block and the use of adjuvants can increase the duration of anaesthesia.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">5</span></a> Like any treatment modality, PNB carries the risk of complications. Serious adverse events include infection, bleeding, nerve injury, local anaesthetic toxicity, and neural blockade sequelae.<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">42</span></a> However, serious and permanent PNB-related complications are rare and most are self-resolving,<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">43</span></a> and the technique has an excellent risk/benefit ratio.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Multicentre RCTs are needed to determine the exact role of PNB in surgical stress response, functional outcomes, chronic postoperative pain, recurrence-free and overall survival after oncologic surgery, and postsurgical morbidity and mortality. Nonetheless, peripheral regional analgesic techniques are a useful intraoperative adjunct to general or neuroaxial anaesthesia and an essential element of multimodal analgesia in the postoperative period. Incorporating these techniques into pain management protocols may reduce or even prevent adverse postoperative outcomes. To achieve the best outcomes in orthopaedic surgery, PNB must be a part of the multidisciplinary approach.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Gómez-Ríos MÁ. ¿Por qué utilizar los bloqueos nerviosos periféricos en cirugía ortopédica? 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