Effects Of Ultrasound-guided Femoral Nerve Block Combined With Patient Controlled Intravenous Analgesia On Sleep Quality After Total Hip Arthroplasty In Frail Elderly Patients

Background & Objective: Sleep disturbance is a common problem after total hip arthroplasty(THA),the incidence of postoperative sleep disturbance up to 50% of patients.Patients undergoing surgery,especially major surgery,usually immediately appear obvious postoperative sleep disturbance including severe sleep deprivation,sleep fragmentation along with the decline or loss of slow-wave sleep(SWS)and rapid eye movement sleep(REM sleep).Frailty is a state that is vulnerable to external stress,which increases the risk of adverse outcomes,including death rates,nursing home admissions and falls.A risk factor for sleep disturbance is frailty,factors such as stress response and postoperative pain can induce frail old people’s postoperative sleep disturbance.Sleep disturbances,in turn,lead to fatigue gait instability decreased activity,which is one of the important factors affecting the frail.So the two interact with each other after surgery,together form a vicious circle.Postoperative sleep disturbance usually caused by pain at night,and sleep quality is an important determinant of postoperative pain sensitivity and functional recovery,and both are associated with postoperative sleep quality,directly affect the patients’ satisfaction.In recent years,the femoral nerve block(FNB)commonly used in postoperative analgesia after THA.Compared with patient controlled intravenous analgesia(PCIA),FNB has better pain control effect and less opioid analgesic drug side effects.The purpose of this study was to explore the effects of ultrasonic-guided femoral nerve block combined with intravenous analgesia on sleep quality after total hip arthroplasty in frail patients,with secondary objectives including postoperative analgesic effects and analgesia-related complications.Methods: Seventy-five cases of patients,aged 65 to 90,weighing 50 to 85 kg,American Society of Anesthesiologists grade I-III,from June 2020 to October 2020 undergoing total hip replacement in Northern Jiangsu People’s Hospital,defined frail by the Fried’s Frailty Phenotype were involved in this study.We use random number table method to distribute all patients into two groups: single PCIA group(group A,N=37)and ultrasound-guided femoral nerve block combined with PCIA group(group B,N=38).After the surgery group B received ultrasound-guided femoral nerve block in PACU,injecting 0.375%ropivacaine 20 ml,two groups both use PCIA.Using Pittsburgh Sleep Quality Index(PSQI)scores and Epworth Sleepiness Score(ESS)along with self-rated sleep quality,time to fall asleep,sleep duration and sleep efficiency to measure sleep quality before and after surgery.The 24 h and 48 h resting and active VAS scores were recorded,the number of compressing analgesic pump,the amount of analgesia rescue drug,analgesia-related complications were also collected,C-reactive protein level before and 3 days after surgery,the total and postoperative hospitalization time as well as the time of starting ground movement and functional recovery exercise were also recorded.Results: There is no significant differences between two groups in baseline preoperative the PSQI and ESS score.At three weeks after surgery,B group got lower score in six dimension of PSQI including self-rated sleep quality,time to fall asleep,sleep duration,sleep efficiency,sleep disturbance,daytime dysfunction as well as PSQI total score than group A.At each postoperative time,self-reported sleep quality score in group B was lower than those in group A.At postoperative 1 day,3 days and 3 weeks,group B’s nightly sleep duration is longer.At 1 day and 3 weeks after surgery,group B showed higher sleep efficiency than group A(P<0.05).The ESS score of group B at 1,3 and 3 weeks after surgery also performed better than group A(P<0.05).In group B,the resting as well as active VAS score at 24 and 48 h after surgery were significantly reduced,the effective compression times and the analgesia rescue drugs as well as the amount of flurbiprofen were significantly reduced within 48 h after surgery(P<0.05).The postoperative analgesia satisfaction was higher,and the incidence of postoperative analgesia insufficiency was significantly decreased(P<0.05).The hospitalization days after operation of group B showed shorter than group A’s,and group B started the ground movement and functional recovery exercise earlier(P<0.05).No difference was shown significantly in C-reactive protein level between the two groups both before and after surgery(P> 0.05).Conclusion: Ultrasound-guided femoral nerve block combined with intravenous analgesia can improve sleep quality within 3 weeks after total hip arthroplasty,and the analgesia effect is better than that of PCIA alone,which is more conducive to postoperative recovery of patients.