La analgesia epidural mejora la rehabilitación post reemplazo total de rodilla.

Ehab Farag MD, FRCAa, Fellow, John Dilger MDa, b, Senior Associate Consultant, Peter Brooks MDc, Staff and John E. Tetzlaff MDa, d, e, , , Professor of Anesthesiology, Director

aDivision of Anesthesiology and Critical Care Medicine, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA bDepartment of Anesthesiology, Mayo Clinic, Rochester, MN 55905, USA cDepartment of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA dCleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH 44195, USA eCenter for Anesthesiology Education, Cleveland Clinic, Cleveland, OH 44195, USA

Abstract

Study Objective To compare epidural anesthesia and analgesia with spinal anesthesia with intravenous morphine analgesia for its effect on range of motion (ROM) and early rehabilitation after total knee replacement.

Design Randomized prospective study.

Setting Tertiary care, academic medical center.

Patients Thirty-eight patients scheduled for total knee replacement.

Interventions Patients were randomized into 2 groups. One group received spinal anesthesia with 0.5% bupivacaine and analgesia with intravenous patient-controlled analgesia morphine, demand mode only. The other group was given epidural anesthesia with 1.0% ropivacaine with 1:200 000 epinephrine and analgesia with 0.2% ropivacaine at 8 mL/h, maintained for 7 days. Both groups had compression stocking for deep venous thrombosis (DVT) prophylaxis, urinary catheter for the first 24 hours, and duplex scanning at days 3 and 10. The spinal group received low molecular-weight heparin for DVT prophylaxis.

Measurements Data collected included pain scores at rest, and with ROM, frequency of DVT, and patient satisfaction. Data were evaluated with Wilcoxon rank sum test for continuous variables and Fisher exact test for categorical variables. Data were considered significant at P < .05.

Main Results All 38 patients finished the study, 22 in the spinal group and 16 in the epidural group. There was no difference in demographics between groups. The pain sores at rest and with ROM were significantly less in the epidural group. ROM was better in the epidural group compared with the spinal group after day 1. No DVT was detected on day 3 or 10 in either group. No patient in either group required reinsertion of bladder catheter for urinary retention.

Conclusion By using epidural analgesia in the first 7 days postoperatively, we achieved improved early rehabilitation due to excellent pain relief effect and an antithrombotic effect with an efficacy comparable to low molecular-weight heparin.