Duration of Analgesia after Popliteal Fossa Nerve Blockade: Effects of Dexamethasone and Buprenorphine

June 30, 2011

Institutional Review Board, Hospital for Special Surgery

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Principal Investigator

Jacques T. Ya Deau, MD, PhD

Co-Investigators

Kethy M. Jules-Elysee, MD
Richard L. Kahn, MD
David H. Kim, MD
Vincent R. LaSala, MD
David S. Levine, MD
Spencer S.Liu, MD
Leonardo Paroli, MD, PhD
Jiabin Liu, MD
Matthew Roberts, MD
Barbara Wukovits, RN, BSN
Carey Ford, CCRC
Valeria Buschiazzo
Amanda Goon, BA

Summary

Analgesia after ambulatory foot and ankle surgery remains problematic.  At HSS, these patients routinely receive neuraxial anesthesia, a sciatic nerve block in the popliteal fossa, and oral analgesics (often acetaminophen with oxycodone: “Percocet”). Prolongation of the peripheral nerve blockade should reduce pain, reduce opioid intake, reduce opioid-related side effects, and improve patient-oriented outcomes such as satisfaction. Increasing the concentration of bupivacaine did not increase the duration of analgesia (YaDeau et al, The HSS Journal 2007;3: 173-176).  Duration of analgesia can be extended to 18 hours with the use of clonidine. (Ya Deau et al, Anesthesia and Analgesia 2008;106:1916-1920).
Dexamethasone and buprenorphine are sometimes, but not routinely, used at HSS to prolong the duration of analgesia from peripheral nerve blockade. This is a randomized controlled study to see if these medications provide the benefit of prolonging the analgesia provided by the nerve block.
We will enroll between 100-125 patients, over the period of 1-2 years.  Participants are followed for 2-3 days.

Inclusion/Exclusion Criteria

Inclusion Criteria:

·        Patients of Dr Levine or Dr Roberts.

·        Scheduled for discharge from HSS after foot or ankle surgery.

·        A single-injection popliteal fossa nerve block is judged appropriate.

·        Surgery confined to foot and ankle (no iliac crest bone graft planned - iliac aspirate is not an exclusion criterion).

·        Patients aged 18-75 years.
         
Exclusion Criteria

·        Surgery that will cause pain at sites outside the distal lower extremity (e.g. iliac crest bone graft).

·        Bilateral surgery

·        Chronic pain (defined as regular use of opioid analgesics for > 3 months).

·        Chronic use of steroids (defined as regular use of steroids for > 3 months).
Contraindication to performance of the popliteal fossa nerve block with 30 cc 0.25% bupivacaine with clonidine (e.g. alleged bupivacaine sensitivity, low body weight, clonidine allergy, etc.).

·        Contraindications to dexamethasone or buprenorphine (e.g. allergy, Insulin Dependent Diabetes Mellitus, etc.)

·        Inability of the patient to describe postoperative pain (e.g. psychiatric disorder, dementia).

·        Non-English speaking patients (the questionnaire is in English, and translations would have to be separately validated)

Contact Information

Jacques T. Ya Deau, MD, PhD
yadeauj@hss.edu
212.606.1206