ESRA Journal Club

ESRA UPDATES journal club invites leading experts in (regional) anesthesia to select one (or more) article(s) which for him/her were/are important, interesting or changed his/her clinical practice. This choice can be a general big randomized study but can also be very personal. For this edition our choice went to Professor Edward Mariano.

Edward R. Mariano, MD, MAS, FASA, is a graduate of Georgetown University School of Medicine. He completed his anesthesiology residency at Stanford University Medical Center and pediatric anesthesiology fellowship at Stanford’s Lucile Packard Children’s Hospital with a special interest in regional anesthesiology and acute pain medicine (RAAPM) for children. He is double board-certified by the American Board of Anesthesiology and is a Fellow of the American Society of Anesthesiologists.

One article that changed my practice years ago with regard to the care of knee arthroplasty patients was published by Professor Lavand’homme and colleagues [1]. This observational study showed that over half of knee arthroplasty patients may report persistent pain at 3 months postoperatively, with 11% of patients exhibiting symptoms of neuropathic pain, and even patients who do not develop persistent pain may have moderate pain postoperatively for a week or more [1]. This article really made me think about other published studies, including my own, that had failed to show long-term outcome benefits from regional anaesthesia in this patient population [2,3]. Maybe our interventions for knee arthroplasty patients are too brief and not well matched to the normal pain trajectory. The finding that 11% of patients go on to develop neuropathic pain was also notable in that these patients were characterized by an increase in movement-related pain on postoperative day 5. In the US, patients are typically discharged from the hospital and at home by this time point, and their follow-up appointments with the surgeons are often not scheduled until 2 weeks after surgery. This observation suggests that we need to do a better job with our outpatient surveillance of these patients since these first 2 weeks after surgery may reveal the onset of chronic pain and may require earlier intervention.

1. Lavand’homme PM, Grosu I, France MN, Thienpont E. Pain trajectories identify patients at risk of persistent pain after knee arthroplasty: an observational study. Clin Orthop Relat Res 2014; 472: 1409-15.
2. Ilfeld BM, Meyer RS, Le LT, et al. Health-related quality of life after tricompartment knee arthroplasty with and without an extended-duration continuous femoral nerve block: a prospective, 1-year follow-up of a randomized, triple-masked, placebo-controlled study. Anesth Analg 2009; 108: 1320-5.
3. Sun EC, Bateman BT, Memtsoudis SG, Neuman MD, Mariano ER, Baker LC. Lack of Association Between the Use of Nerve Blockade and the Risk of Postoperative Chronic Opioid Use Among Patients Undergoing Total Knee Arthroplasty: Evidence from the Marketscan Database. Anesth Analg 2017.