The threshold elicited motor response via an in situ femoral nerve catheter predicts analgesia following total knee replacement

BACKGROUND: Continuous femoral nerve blocks are a part of the multimodal perioperative anesthetic regimen following total knee replacement. Elicitation of a quadriceps muscle contraction (QC) at placement is desirable. We prospectively evaluated the relationship between elicited motor response and threshold current with block success in situ femoral nerve catheters after total knee replacement. METHODS: After Institutional Review Board approval and written informed consent, 100 adults aged ≥18 years, undergoing total knee replacement were studied. The threshold current for an elicited motor response (QC or sartorius muscle contraction [SC]) was recorded during needle insertion, after femoral nerve catheter advancement, and prior to local anesthetic administration on the first postoperative day. Patients were assessed for pinprick sensory anesthesia of the femoral nerve distribution by an observer unaware of the current threshold or evoked motor response at 5-minute intervals for 30 minutes. A successful block was considered a lack of pinprick sensation within 30 minutes. RESULTS: Ninety patients completed the study. A QC was obtained at needle insertion in 89 and maintained following catheter advancement in 77 subjects. Prior to drug administration a QC was obtained in 66 patients, 13 demonstrated an SC, and 11 had no motor response. QC prior to drug administration had a sensitivity of 0.85 (95% confidence intervals [CI]: 0.75 to 0.92) and a specificity of 0.55 (95% CI: 0.37 to 0.72) for complete femoral nerve block. The specificity of a QC prior to drug administration was greater than at catheter placement (P = 0.006). Compared to the threshold current at catheter placement, 27 patients had a decrease, 60 had an increase, and 3 exhibited no change in the threshold current prior to drug administration (P < 0.01). The median interquartile range (IQR) threshold current in patients that achieved a complete block was 0.56 (0.29 to 0.80) mA compared with 1.1 mA (0.41 to 2.75) mA for incomplete blocks (P < 0.01). The area under the receiver operator characteristics curve for current threshold prior to local anesthetic administration (0.74) was greater than at catheter placement (0.45) (P < 0.001). The intersection of sensitivity and specificity for the minimal threshold current prior to local anesthetic injection was 0.84 mA. CONCLUSION: The elicited motor response and current threshold from a stimulating femoral catheter measured prior to local anesthetic injection is an important determinant of the success of femoral nerve block following bolus administration.