The effect of norepinephrine versus epinephrine in irrigation fluid on the incidence of hypotensive/bradycardic events during arthroscopic rotator cuff repair with interscalene block in the sitting position

Intravenous Tranexamic Acid Significantly Improved Visualization and Shortened the Operation Time in Arthroscopic Rotator Cuff Repair: A Systematic Review and Meta-analysis of Level I and II Studies

PURPOSE

To further clarify the role of tranexamic acid (TXA) in arthroscopic rotator cuff repair (ARCR), especially visual field clarity and operation time.

METHODS

We searched the PubMed, Cochrane Library, and Embase databases to find prospective randomized controlled clinical trials (RCTs) examining the use of TXA in ARCR. All included RCTs were evaluated for methodological quality using the Cochrane Collaboration's risk of bias tool. We used Review Manager 5.3 for meta-analysis and calculated the weighted mean difference (WMD) and 95% confidence interval (CI) of the related outcome indicators. The GRADE system was used to evaluate the strength of the clinical evidence provided by the included studies.

RESULTS

Six RCTs (3 Level I, 3 Level II) from four countries or regions were included in this study: 2 studies used intra-articular (IA) TXA, and 4 studies used intravenous TXA. A total of 451 patients underwent ARCR, including 227 patients in the TXA group and 224 patients in the non-TXA group. In 2 RCTs evaluating good visualization, intravenous TXA achieved a better surgical field of view in ARCR compared to the control group (P =.036; P = .045). Meta-analysis showed that compared with non-TXA, intravenous TXA shortened the operation time (WMD = -12.87 min, 95% CI: -18.81 to -6.93). These two RCTs did not reveal a statistically significant difference in the impact of intravenous TXA and non-TXA on mean arterial pressure (MAP) (P = .306; P = .549). Compared with epinephrine (EPN), IA TXA had no significant effects on improving the visual field clarity under arthroscopy, shortening the operation time or reducing the total amount of irrigation fluid (P > .05). Compared with saline irrigation, IA TXA improved the surgical field of vision and shortened the operation time (P < .001). No adverse events were reported for either intravenous TXA or IA TXA.

CONCLUSIONS

Intravenous TXA can shorten the operation time of ARCR, and the conclusions of existing RCTs suggest that intravenous TXA can improve visual field clarity during ARCR, thus supporting the application of intravenous TXA in ARCR. Compared with EPN, IA TXA was not better at improving the visual field clarity under arthroscopy and shortening the operation time, but it was better than saline irrigation.

LEVEL OF EVIDENCE

Level II, systematic review and meta-analysis of Level I and II studies.

Effects of propofol versus sevoflurane on surgical field visibility during arthroscopic rotator cuff repair: a randomized trial

BACKGROUND

During arthroscopic rotator cuff repair (ARCR), clear surgical field visibility (SFV) is the basis of successful surgery, but the choice of anesthesia maintenance drugs may have different effects on SFV. In this study, we aimed to compare the effects of propofol- and sevoflurane-based general anesthesia on SFV in patients undergoing ARCR.

METHODS

Patients (n = 130) undergoing elective ARCR in the lateral decubitus position were randomized into either the propofol group or sevoflurane group (65 per group). The duration of surgery and increased pressure irrigation (IPI), Boezaart score, rocuronium consumption and usage of remifentanil were recorded. The time of both spontaneous respiration recovery and extubation and the incidences of postoperative nausea and vomiting and agitation were also recorded.

RESULTS

The Boezaart score, duration of IPI and ratio of the duration of IPI to the duration of surgery (IPI/S ratio) were similar between the groups (P > 0.05). Rocuronium consumption, number of patients requiring remifentanil infusion and total remifentanil consumption were significantly lower in the sevoflurane group (P < 0.05). The spontaneous respiration recovery time was significantly longer in the propofol group (P < 0.05), but there were no differences in the extubation time between the groups(P > 0.05).

CONCLUSIONS

Compared with propofol, sevoflurane provides equally clear SFV while improving the convenience of anesthesia maintenance in ARCR patients with interscalene plexus (ISB) combined with general anesthesia.

TRIAL REGISTRATION

This single-center, prospective, RCT was retrospective registered at Chinese Clinical Trial Registry with the registration number ChiCTR2300072110 (02/06/2023).

Improving visualization in shoulder arthroscopy

Arthroscopic shoulder procedures are one of the most common procedures used to restore function through minimally invasive techniques. With the demand for shoulder arthroscopic procedures comes the need for safe, effective, and efficient surgery that maximizes patient outcomes while minimizing complications. Many variables contribute to visualization in shoulder arthroscopy including vascular anatomy, blood pressure control, arthroscopic pump systems, turbulence control, epinephrine, and tranexamic acid. Furthermore, patient positioning can have a dramatic effect on visualization with both the beach chair position and lateral decubitus positioning having various strengths and weaknesses depending on the intended procedure being performed. The purpose of this review is to examine the benefits and complications reported in the literature for improving visualization in shoulder arthroscopy.

The effect of tranexamic acid for visualization on pump pressure and visualization during arthroscopic rotator cuff repair: an anonymized, randomized controlled trial

BACKGROUND

Tranexamic acid (TXA) has been used surgically to decrease blood loss. The ability of TXA to improve arthroscopic visualization and allow for reduction in pump pressure is unknown. The purpose of this study was to determine the effect of intravenous (IV) TXA on change in pump pressure and visualization during arthroscopic rotator cuff repair.

METHODS

This was a single-center, prospective, randomized, double-anonymized controlled trial. Patients with full-thickness rotator cuff tears undergoing operative repair were enrolled. Patients were randomized to receive 1 g of IV TXA preoperatively or no TXA (control group). All patients underwent arthroscopy using saline irrigation fluid with 3 mL epinephrine injected into the first 1000-mL saline bag. Total operative time, final pump pressure, number of increases in pump pressure, total amount of irrigation fluid used, blood pressure and anesthesia medical interventions for blood pressure were recorded. Visualization was measured by a visual analog scale (VAS) completed by the surgeon at the end of the case. Postoperative VAS pain scores were obtained 24 hours after surgery. The primary aim of this study was to investigate the effect that IV TXA has on change in pump pressure (ΔP) during shoulder arthroscopy, with a ΔP of 15 mm Hg set as a threshold for clinical significance.

RESULTS

There were 50 patients randomized to the TXA group and 50 patients in the no TXA group. No significant differences were found between the TXA group and the control group regarding any measure of pump pressure, including the final arthroscopic fluid pump pressure (44.5 ± 8.1 mm Hg vs. 42.0 ± 8.08 mm Hg, P = .127), the mean ΔP (20.9 ± 10.5 mm Hg vs. 21.8 ± 8.5 mm Hg, P = .845), or the number of times a change in pump pressure was required (1.7 ± 0.9 vs. 1.7 ± 0.8, P = .915). Overall arthroscopic visualization was not significantly different between the TXA group and the control group (7.2 ± 1.8 vs. 7.4 ± 1.6, P = .464). No significant difference existed between the TXA and control groups regarding postoperative pain scores assessed by VAS pain scale (4.1 ± 2.0 vs. 4.3 ± 1.9, P = .519) at 24 hours after surgery.

CONCLUSION

The use of IV TXA demonstrated no measurable improvement in surgeon ability to maintain a lower pump pressure during arthroscopic rotator cuff repair. Additionally, there was no measurable improvement in arthroscopic visualization or early pain scores.

Fundamentals of Arthroscopy Fluid Management and Strategies to Safely Improve Visualization

Arthroscopy has become increasingly relevant to various subspecialties within the orthopaedic surgery. From a patient safety standpoint and surgical efficiency standpoint, it is critical to know the fundamental concepts of fluid management such as those related to the fluid, pressure, and flow. A satisfactory field of view during arthroscopy can be achieved with the use of gravity-dependent or automated fluid management systems. Fluid management parameters and their physiological impact on the patient should be continuously monitored to avoid morbidity or delayed recovery. Local and systemic complications can occur from careless use of techniques that improve visualization such as tourniquet, epinephrine-diluted irrigation, and controlled hypotensive anesthesia. The purpose of this article is to review the fundamental concepts of fluid management in arthroscopy and the techniques to safely improve arthroscopic visualization.

Scoping review of complications associated with epinephrine use in arthroscopy fluid

Purpose: To identify if addition of epinephrine to irrigation fluid can result in any intra-operative or post-operative complications. It was hypothesized that significant adverse events would be identified with the use of epinephrine in arthroscopic fluid.Methodology: In accordance with PRISMA guidelines (Appendix 2), an electronic database search was conducted, from inception to February 2019 including MEDLINE, EMBASE, Cochrane, CENTRAL, and Scopus (MeSH search). All English-language studies that addressed complications associated with arthroscopic use of epinephrine were included. Defined outcome measures were any reported intra- or post-operative adverse events secondary to epinephrine use. Data collection included: patient demographics, comorbidities, surgical intervention, epinephrine concentration in irrigation fluid, reported complications, and details of the associated clinical prodrome.Results: Three hundred and ninety-three abstracts were screened with 22 studies identified and reviewed in detail. Of these seven case reports and four randomized trials met the inclusion criteria (1999-2017). The case reports encompassed nine patients (seven females and two males) with an average age of 38.8 years (range 19 to 52 y). Five had shoulder arthroscopies, two had knee scopes and two had hip scopes. A pattern of reported complications was noted in all reports in association with epinephrine including hypertension, tachycardia with or without evolving arrhythmia and/or pulmonary edema. One patient died. Of the four randomized trials, three did not report any adverse events in relation to epinephrine with one trial associating epinephrine to the occurrence of hypotensive bradycardic events in the setting of shoulder arthroscopy in the beach-chair position.Conclusion: While a causal association cannot be established, Anesthetists and Orthopedic Surgeons should be aware of the noted pattern of symptoms in patients undergoing epinephrine-assisted arthroscopy.Clinical relevance: While the incidence of epinephrine-related complications is rare, this review raises awareness to the pattern of reported symptoms, as it could help with identification and treatment should this rare complication be encountered.

A Historical Analysis of Randomized Controlled Trials in Rotator Cuff Tears

Background and objectives: Our research aimed to evaluate the quality of reporting of randomized controlled trials (RCTs) linked to rotator cuff (RC) tears. The present study analyzed factors connected to the quality of the RCTs and trends in the quality of reporting through time. Materials and Methods: The online databases used to search all RCTs on the topic of RC surgery completed until March 2020 were PubMed and Ovid (MEDLINE). The quality of reporting was evaluated using the modified Coleman methodology score (MCMS) and the consolidated standards of reporting trials (CONSORT). Results: The online search found 957 articles. Finally, 183 studies were included in the quantitative synthesis. A total of 97 (53%) of 183 studies had a level of evidence I and 86 (47%) of 183 studies had a level of evidence II, according to the Oxford Center of Evidence Based Medicine (EBM). A statistically significant difference in MCMS between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had, on average, the highest Coleman score. The average number of CONSORT checklist items for each article across all analyzed RCTs was 21.67. The 37 studies completed up to 2010 averaged a number of checklist items of 19.97 and the studies completed between 2011 and 2019 averaged a number of checklist items of 22.10. A statistically significant difference in the number of checklist items between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had on average more checklist items. However, low correlation (0.26) between the number of checklist items for each article and the respective Coleman score was found. On the other hand, articles with the CONSORT diagram had a significantly high Coleman score. Conclusions: An improvement in the quantity and quality of RCTs relating to RC surgery over the analyzed period was found.

Adverse heart rate responses during beach-chair position for shoulder surgeries - A systematic review and meta-analysis of their incidence, interpretations and associations

Background and Aims

Evaluations of adverse heart rate (HR)-responses and HR-variations during anaesthesia in beach-chair-position (BCP) for shoulder surgeries have not been done earlier. We analysed the incidence, associations, and interpretations of adverse HR-responses in this clinical setting.

Methods

We performed a meta-analysis of trials that reported HR-related data in anaesthetised subjects undergoing elective shoulder surgeries in BCP. Studies included prospective, randomised, quasi-randomised and non-randomised, controlled clinical trials as well as observational cohorts. Literature search was conducted in MEDLINE, EMBASE, CINHAL and the Cochrane Central Register of Controlled Trials of the 21^st century. In the first analysis, we studied the incidence and associations of bradycardia/hypotension-bradycardia episodes (HBE) with respect to the type of anaesthesia and different pharmacological agents. In the second, we evaluated anaesthetic influences, associations and inter-relationships between monitored parameters with respect to HR-behaviours.

Results

Among the trials designed with bradycardia/HBE as a primary end point, the observed incidence of bradycardia was 9.1% and that of HBE, 14.9% and 22.7% [(for Interscalene block (ISB) ± sedation) subjects and general anaesthesia (GA) + ISB, respectively]. There was evidence of higher observed risk of developing adverse HR-responses for GA subjects over ISB (Risk Difference, P < 0.05). Concomitant use of β-agonists did not increase risk of HBEs (P = 0.29, I ²= 11.4%) or with fentanyl (P = 0.45, I ²= 0%) for ISB subjects (subgroup analysis). Fentanyl significantly influenced the HR-drop over time [meta-regression, estimates (standard error), 14.9 (5.4), 9.8 (4.3) and 17 (2.6); P = 0.007, 0.024 and <0.001; for early, mid and delayed periods, respectively] in GA subjects. With respect to number of subjects experiencing cerebral desaturation events (CDEs), total intravenous anaesthesia (TIVA)- propofol had higher risk over inhalational anaesthesia (P = 0.006, I ² = 86.7%). Meta-correlation analysis showed relationships between the HR and rSO₂(regional cerebral oxygen saturation) or SjvO₂(jugular venous oxygen saturation) values (r = 0.608, 95%CI, 0.439 to 0.735, P < 0.001, I ²= 77.4% and r = 0.397, 95%CI, 0.151 to 0.597, P < 0.001, I ²= 64.3%, respectively).

Conclusions

There is not enough evidence to claim the associations of adverse HR-responses with any specific factor. HR-fall is maximal with fentanyl and its variability is associated with changes in rSO₂. Fall in rSO₂ could be the common link triggering adverse HR-responses in BCP.

Risk factors associated with hypotensive bradycardic events during open shoulder surgery in the beach chair position

BACKGROUND

Shoulder surgery in the beach chair position frequently causes hypotensive bradycardic events (HBEs), which are potentially associated with an increased risk of cerebral hypoperfusion. Here, we aimed to investigate the incidence and characteristics of symptomatic HBEs that require pharmacological interventions, and to identify specific risk factors associated with symptomatic HBEs.

METHODS

We retrospectively examined the records of all patients aged ≥ 18 years who underwent shoulder arthrotomy in the beach chair position between January 2011 and December 2018 at Samsung Medical Center. For patients who experienced HBEs while in the beach chair position, the minimum heart rate and systolic blood pressure were noted, as was the total dose of ephedrine or atropine.

RESULTS

Symptomatic HBEs occurred in 61.0% of all cases (256/420). Two patients with symptomatic HBEs experienced postoperative neurological complications. Multivariable logistic regression analysis showed that preoperative interscalene brachial plexus block (ISB) and advanced age were risk factors associated with symptomatic HBEs (odds ratio [OR]: 3.240, 95% CI: 2.003, 5.242, P < 0.001; OR: 1.060 for each 1-year increase, 95% CI: 1.044, 1.076, P < 0.001, respectively). Receiver operating curve analysis revealed that a threshold of 62 years of age had a moderate degree of accuracy for predicting symptomatic HBEs (area under curve: 0.764, 95% CI: 0.720, 0.804, P < 0.001).

CONCLUSIONS

Considering the increasing risk of neurocognitive complications with aging, proactive hemodynamic management is needed, especially for elderly patients undergoing shoulder surgery in the beach chair position using ISB.

The fragility of findings of randomized controlled trials in shoulder and elbow surgery

BACKGROUND

Considered the gold standard of study designs, randomized controlled trials' (RCTs) results shape clinical practice, effect policy, and influence reimbursement. The fragility index (FI) can be used to quantitate the relative robustness of RCT results, with higher scores indicating more stout results. Unfortunately, most RCTs in surgery have fragile results. The aim of this study was to report on the FI in addition to a qualitative assessment of recent RCTs within the field of shoulder and elbow surgery.

METHODS

A systematic review was performed identifying recently published shoulder/elbow RCTs that included 1:1 allocated parallel study arms, dichotomous primary outcome variables, and statistical significance. The FI was calculated by sequentially modifying outcome groups by exchanging a nonevent in one group to an event until the P value for the outcome comparison, as calculated by the Fisher exact test, was increased above the .05 threshold.

RESULTS

Thirty RCTs were included. The median FI was 4. Sixty percent trials had a FI of 2 or less. Fifty-three percent studies reported that participants were lost to follow-up. In 87.5% of these studies, the losses to follow-up exceeded their respective FIs. Only 53% of studies defined a primary outcome variable and 60% studies performed a prestudy power analysis.

CONCLUSIONS

The median FI reported in the recent shoulder/elbow literature is 4; however, a high proportion of included RCTs display significant methodological concerns. The FI is a useful adjunct to analyze RCT results, but careful analysis of trial methods should be employed in each circumstance before drawing conclusions.

Patient Positioning in Shoulder Arthroscopy: Which is Best?

When performing diagnostic and surgical arthroscopic procedures on the shoulder, the importance of patient positioning cannot be understated. The optimum patient positioning for shoulder arthroscopy should enhance intraoperative joint visualization and surgical accessibility while minimizing potential perioperative risk to the patient. Most shoulder arthroscopy procedures can be reliably performed with the patient either in the lateral decubitus (LD) or beach chair (BC) position. Although patient positioning for shoulder arthroscopy has been subject of controversy, there is no conclusive evidence to suggest superiority of one position versus another. Each position offers advantages and disadvantages and surgeon's experience and training are pivotal on selecting one position versus another. Regardless of the position, a proper positioning of the patient should provide adequate access to the joint while minimizing complications. The purpose of this review is to summarize setup and technical aspects, the advantages and disadvantages, and the possible complications of the LD and BC positions in shoulder arthroscopy.

Comparison of Cytotoxic Effects of Intra-Articular Use of Tranexamic Acid versus Epinephrine on Rat Cartilage

Background

Adequate visualization is known to be essential to perform arthroscopic procedures effectively and efficiently. We hypothesized that tranexamic acid may be considered as an alternative agent to reduce intra-articular bleeding during arthroscopic procedures, after comparing its potential chondrotoxicity with that of epinephrine.

Material/Methods

Seventy-two rats were randomized into 3 groups with 24 rats each. The injections were performed in the right knees, as follows: Group 1: 0.25 mL of tranexamic acid solution, Group 2: 0.25 mL of epinephrine solution, and Group 3: 0.25 mL of 0.9% saline, serving as control. One week after the injections, the animals were euthanized. Samples were evaluated histologically based on the Osteoarthritis Research Society International (OARSI) Histopathology Grading and Staging System and the “live/dead” staining technique to determine chondrocyte viability.

Results

Comparison of epinephrine and tranexamic acid revealed significantly higher OARSI scores in the epinephrine group (epinephrine: 3.42±1.31, TA: 0.92±0.90; P<0.001). The most significant difference between the 2 groups was in the number of joints diagnosed with OARSI grade III. The percentage of viability was significantly higher in the tranexamic acid group when compared with the epinephrine group (tranexamic acid: 79.74±3.343; epinephrine: 63.81±1.914; P<0.05).

Conclusions

Based on the histologic parameters and chondrocyte viability, tranexamic acid is less cytotoxic than epinephrine in rat chondrocytes at the doses typically used in irrigation fluid, and may be a good alternative to epinephrine in arthroscopic surgery.