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Review of Literature and Incorporating Theory

Bailard, N. S., Ortiz, J., & Flores, R. A. (2014). Additives to local anesthetics for peripheral nerve blocks: Evidence, limitations and recommendations. American Journal of Health-System Pharmacy, 71(5), 373-385.

This article establishes the effectiveness of the additives to local anesthetics in the appropriation of peripheral nerve blocks in the postoperative pain management. The article reviews the various added ingredients, noting their therapeutic rationale. The study employs a systematic review of qualitative studies design. Its major strength, therefore, is that it sources data from a wide range of peer-reviewed sources. However, the authors do not describe the population of the study or the methodologies they used to source for the utilized materials. The major finding was that the additives have an effect of hastening the nerve block, prolonging the duration of the nerve blockade and minimizing toxicity of the analgesia postoperatively. Its significance to nursing practice is that the use of peripheral nerve blockades, unlike the use of general analgesia appropriating opioids, bestows more patient benefits as it does not expose patients to unnecessary risks as does IV morphine among others.

Baker, J. F., Byrne, D. P., Hunter, K., & Mulhall, K. J. (2011). Post-operative requirements after hip arthroscopy. Knee Surgery, Sports Traumatology, Arthroscopy, 19(1), 1399-1402.

This article describes the postoperative requirements after a major orthopedic surgery such as hip arthroscopy. According to the authors, not a lot of attention has been paid until recently to the analgesic and anesthetic management for patients who have undergone the procedure. The study employed a qualitative design that was meant to gather information and aid in understanding the phenomenon. The population sample included 85 patients who were about to undergo hip arthroscopy. Their demographic data, analgesic requirements after the operation, and post-operative pain scores were recorded and analyzed. The major finding was that various people have different analgesic requirements even when they have similar demographic data. The mean intra-operative dose was 7.1 mg. However, the lower the dosage, the worse the VAS pain scores that were revealed postoperatively and the more the rescue intravenous opiate requirement postoperatively. An adequate dose of morphine, though, reduces post-operative pain and the need for a rescue analgesia. The significance of this study to nursing practice is that it will establish the right dosage of morphine that does not adversely affect patient outcomes. It also points out the insufficiency of opiate analgesia in the postoperative and pre-operative pain management.

Davidson, M., & Mitchell, J. (2014). Peripheral nerve blockade for anesthesia in a patient with bullous pemphigoid. Journal of Anesthesia & Intensive Care, 42(5), 674-675.

This article evaluated the effectiveness of the use of a peripheral nerve blockade as a postoperative pain management intervention for patients with bullons pemphigoid. The study employed a qualitative case study design where a single case was scrutinized. Its primary weakness is that the data was derived from a single source and thus lacks statistical strength. The result was that a peripheral nerve blockade proved to be an effective post-operative pain intervention, especially in procedures that require immuno-suppression. Its significance to nursing practice is in the fact that it will promote the application of a peripheral nerve blockade beyond the common orthopedic surgeries.

Ekmekci, P., Bengisun, Z. K., Akan, B., Kazbek, B. K., Ozkan, K. S., &Suer, A. H. (2013). The effect of magnesium added to levobupivacaine for femoral nerve block on postoperative analgesia in patients undergoing ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy, 21(5), 1119-112.

This study investigated the effect of adding a magnesium component to aid in peripheral nerve blockade, specifically the femoral nerve block. The study utilized a randomized controlled double blind design. One group had magnesium added to levobupivacaine while the control group did not have this element. The upside is that it is random and the participants are not biased as they do not know what is being measured. Results showed that adding magnesium improved the effectiveness of the nerve block and reduced analgesic requirements and opioid consumption after the operations. The implication to nursing process is that though more effective than the use of morphine in the postoperative management, a peripheral nerve blockade’s effectiveness can be optimized through additives so as to  prolong sensory and motor block.

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Fredrickson, M. J., &Danesh-Clough, T. K. (2015). Spinal anesthesia with adjunctive intrathecal morphine versus continuous lumbar plexus blockade: A randomized comparison for analgesia after hip replacement. Anesthesia & Intensive Care, 43(4), 449-453.

This article seeks to compare the effectiveness of intrathecal morphine and a continuous lumbar plexus blockade in postoperative pain management after the hip replacement surgery. The study used a randomized control trial where 50 participants were used to test the two interventions. Results showed no significant difference between the two groups in so far as worst pain is concerned. However, those who used adjunctive intrathecal morphine had a higher supplemental opioid consumption. The significance of the study is that a peripheral nerve blockade will increase to some extent as its effectiveness in reducing rescue opiate increases.

Hasanbegovic, I., Kapur, E., Cosovic, E., Kulenovic, A., & Mornjakovic, Z. (2012). Blockade of peripheral nerves and prevention of unintentional consequences. Homo Sporticus, 14(1), 17-22.

This article explores the unintentional consequences of peripheral nerve blocks, especially those that may arise from injection  pressures. The study made use of a case experimental design. Its sizable weakness is that it used very few samples, namely 24, which does not satisfy the statistical rigor. The research established that injection application for a nerve blockade in different tissues results in different injection pressures. Its importance is in the fact that the injection pressure needs to be taken into consideration so as to prevent the neurological damage, which by itself is one of the major risks of a peripheral nerve blockage as a postoperative pain management strategy.

Kirksey, M. A., Haskins, S. C., Cheng, J., & Liu, S. S. (2015). Local anesthetic peripheral nerve adjuvants for prolongation of analgesia: A systematic qualitative review. PLoS ONE, 10(9), 1-23.

This article investigates the use of peripheral nerve adjuvants to prolong postoperative analgesia. The study employed a systematic review of randomized controlled trials and meta-analyses. It reviewed articles published in Medline/PubMed, Cochrane and EMBASE databases. Its dominant strength is that it gathered reliable, level I evidence through the use of  the systematic review. The results determined that different adjuvants such as buprenorphine, epinephrine, tramadol and magnesium have different prolongation capacities. The reason it is critical in nursing practice is that the relevant adjuvants can now be used to prolong the effectiveness of peripheral nerve blocks, thus reducing the need for rescuing opiods such as morphine, which might have dire side effects.

Dahl, V., Spreng, U. J., Waage, M, & Raeder, J. C. (2012). Short stay and less pain after ambulatory anterior cruciate ligament (ACL) repair: COX-2 inhibitor versus glucocorticoid versus both combined. Acta Anaesthesiologica Scandinavica, 56(1), 95-101.

This article investigates which between COX-2 inhibitor and glucocorticoid is best suited for postoperative management of pain when added to paracetamol or any other local analgesia. The study used a randomized controlled trial in which 89 patients scheduled to undergo ACL were sampled. They were divided into three groups, with one group having COX-2 inhibitor added to analgesia; the next had glucocorticoid added and the third – a combination of both. The outcome was that the one that had a combination of both lower VAS scores and lower need for the rescue morphine. The significance of this study is in the aspect that nurses should employ a multimodal pain regime and not necessarily depend on the general analgesia. Other techniques such as a peripheral nerve blockade, though less popular, can be more effective in postoperative pain management if the right additives are used.

Lin, P. C. (2012). An evaluation of the effectiveness of relaxation therapy for patients receiving joint replacement surgery. Journal of Clinical Nursing 21(5-6), 601-608.

This article investigated the effectiveness of the relaxation therapy as a postoperative pain management strategy for patients undergoing the joint replacement surgery. The study employed a randomized control trial. Its most notable strength stems from the fact that it collects level II evidence, which enhances credibility.  Those who appropriated relaxation therapy alongside the peripheral nerve blockade had lower VAS scores than those who did not. Its contribution to the nursing practice is that it emphasizes not only the use of peripheral nerve blocks but also complementary strategies such as the relaxation therapy for postoperative pain management.

Magnussen, R. A., & Spindler, K. P. (2013). Anterior cruciate ligament reconstruction: Two-incision technique. Operative Techniques in Sports Medicine, 21(1), 34-39.

This article explores the benefits of applying the two-incision technique in ACL reconstruction. It briefly describes ACL pain management and recovery. Its design is subject of the expert’s opinion. The study found out that for the ACL construction the two-incision technique is the best as it postoperatively produces lower VAS scores. Its importance to nursing and patient benefits is that such technique not only ensures a quick recovery but also reduces the need in analgesia by diminishing the postoperative pain. If combined with peripheral nerve blocks it can optimize patient safety and outcomes.

O’Donnell, B. D., & Szucs, S. (2014). Peripheral nerve block and local anesthetic dose, how much is enough? Anesthesia, 69(7), 665-668.

This article investigates the apt dosage in local anesthetic and peripheral nerve block. The article employs a qualitative systematic review. However, the authors do not explicitly state how they sourced for the literature they consulted or the databases they searched. The results established that the peripheral nerve block dosage should be pegged to the principle of a maximum allowable dose. The significance of the study is represented by the fact that systemic toxicity, which is a dose-dependent phenomenon, can be reduced through lowering the dose of a local anesthetic during a peripheral nerve block to manage postoperative pain.

Paech, M. J. (2015). Analgesia after major lower limb joint surgery- Now a matter of only peripheral interest? Anesthesia & Intensive Care, 43(4), 441-444.

This article explores the benefits and downsides of the regional and general anesthesia and analgesia in managing pain after a major lower limb joint surgery. The study utilized a method of systematic review of qualitative studies. The results confirmed that the peripheral neuraxial analgesia was a better pain relief, earlier functional recovery and an improved patient satisfaction than general analgesia interventions such as appropriation of morphine. They have lower risks of incidents and local infections. The implication for nursing practice is that in the case of ACL reconstruction, peripheral nerve blocks, more specifically femoral nerve blocks are the most apt postoperative pain management interventions.

Sahin, L., Sahin, M., Gul, R., & Mandollu, E. (2012). Continued sciatic blockade for Phantom Limb Pain. European Journal of General Medicine, 9(2), 135-137.

This article explores the use of continued sciatic blockade for managing phantom limb pain postoperatively after a traumatic amputation. The study employed a descriptive study design. The results established that over 80% of patients who have undergone amputation experience severe pain (phantom limb pain) for an upwards of 4 weeks. Continued sciatic blockade is effective for prolonged analgesic pain management. The implication to the nursing practice is that peripheral nerve blocks should be appropriated instead of morphine in instances where there is severe pain that subsists for long periods.

Sakura, S., Hara, K., Ota, J., & Tadenuma, S. (2010). Ultrasound-guided peripheral nerve blocks for anterior cruciate ligament reconstruction: Effect on obturator nerve block during and after surgery. Journal of Anesthesia, 24(3), 411-417.

This article explores the effectiveness of the obturator nerve blocks in postoperative pain management. The study employed a non-randomized control trial design. Level II data, which has enhanced credibility, was also collected. The study found out that the obturator nerve blockade was more effective in managing postoperative pain than femoral and PLP nerve blocks. However, it was only active during the first 24 hours. The implication is that it helps determine whether the possible obturator nerve blockade should be appropriated instead of femoral nerve blocks in managing postoperative pain for patients who have undergone ACL reconstruction in the short run instead of morphine and other opiate analgesics.

Turjanica, M. A. (2007). Postoperative continuous nerve blockade in the lower extremity: Total joint arthroplasty population. MEDSURG Nursing, 16(3), 151-154.

This article examines the effectiveness of a peripheral nerve blockade in managing postoperative pain after a total joint operation. The study made use of a systematic review of qualitative studies. The downside is that the study does not identify how it sourced for the materials used. The study found out that a peripheral nerve blockade, as compared to opiate analgesics such as intravenous morphine, improved the patients’ satisfaction and significantly prolonged analgesia, while at the same time reducing the length of hospital stay. The significance of the study is that it presents the benefits of peripheral nerve blocks both in the long and short run, enabling nurses to make better pain management decisions.

Incorporating Theory

This study promotes the use of peripheral nerve blockade as opposed to intravenous morphine in postoperative pain management for patients who have undergone anterior cruciate ligament reconstruction. The main reason, as shall be established later on, is that peripheral nerve blocks are more effective in blocking severe pain and can be utilized for prolonged periods of time without the dire side effects (Baker et al., 2011). One of the theories that support this intervention is the specific receptor theory. It supports the use of localized analgesic interventions such as peripheral nerve blockade, rather than general analgesia. The theory posits that the degree of receptor occupancy is directly correlated with the effectiveness of the elicited response (Sakura, Hara, Ota, & Tadenuma, 2010). The main components of the theory are the receptors, the cerebral system, and the binding and activation phenomenon, as well as the drugs concentration. The magnitude of the elicited response will be determined by the concentration of drugs used.

The rationale behind using this theory is hinged on the fact that blocking the nerve receptors will impair the transmission of pain signals to the brain. The drugs used for peripheral nerve blocks should alter and inhibit the voltage-gated sodium channels, limiting neuronal membrane transmission of pain signals. This theory will be incorporated in the study through employing the rationale of localized analgesic interventions in designing postoperative pain strategies. The study will, thus, vouch for peripheral nerve blocks and its variants, including femoral nerve blocks and obturator blocks. The localized analgesic interventions can then be applied even beyond managing pain in patients who have undergone ACL reconstruction to all applicable orthopedic surgeries.

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