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Stone AB, Poeran J, Memtsoudis SG. There remains a role for neuraxial anesthesia for hip fracture surgery in the post-REGAIN era. Reg Anesth Pain Med 2023; 48:430-432. [PMID: 36977527 DOI: 10.1136/rapm-2022-104071] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 03/17/2023] [Indexed: 03/30/2023]
Abstract
Two recent, large-scale, randomized controlled trials comparing neuraxial anesthesia with general anesthesia for patients undergoing surgical fixation of a hip fracture have sparked interest in the comparison of general and neuraxial anesthesia. These studies both reported non-superiority between general and neuraxial anesthesia in this patient cohort, yet they have limitations, like their sample size and use of composite outcomes. We worry that that if there is a perception among surgeons, nurses, patients and anesthesiologists that general and spinal anesthesia are equivalent (which is not what the authors of the studies conclude), it may become difficult to argue for the resources and training to provide neuraxial anesthesia to this patient population. In this daring discourse, we argue that despite the recent trials, there remain benefits of neuraxial anesthesia for patients who have suffered hip fractures and that abandoning offering neuraxial anesthesia to these patients would be an error.
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Affiliation(s)
- Alexander B Stone
- Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Jashvant Poeran
- Orthopaedics/Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Stavros G Memtsoudis
- Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA
- Department of Anesthesiology, Weill Cornell Medicine, New York City, NY, USA
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
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2
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Blood-Transfusion Risk Factors after Intramedullary Nailing for Extracapsular Femoral Neck Fracture in Elderly Patients. J Funct Morphol Kinesiol 2023; 8:jfmk8010027. [PMID: 36810511 PMCID: PMC9945124 DOI: 10.3390/jfmk8010027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 02/11/2023] [Accepted: 02/16/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Extracapsular femoral neck fractures (eFNF) are the third most common type of fracture in traumatology. Intramedullary nailing (IMN) is one of the most frequently used ortho-pedic treatments for eFNF. Blood loss is one of the main complications of this treatment. This study aimed to identify and evaluate the perioperative risk factors that lead to blood transfusion in frail patients with eFNF who undergo IMN. METHODS From July 2020 to December 2020, 170 eFNF-affected patients who were treated with IMN were enrolled and divided into two groups according to blood transfusion: NBT (71 patients who did not need a blood transfusion), and BT (72 patients who needed blood transfusion). Gender, age, BMI, pre-operative hemoglobin levels, in-ternational normalized ratio (INR) level, number of blood units transfused, length of hospital stay, surgery duration, type of anesthesia, pre-operative ASA score, Charlson Comorbidity Index, and mortality rate were assessed. RESULTS Cohorts differed only for pre-operatively Hb and surgery time (p < 0.05). CONCLUSION Patients who have a lower preoperative Hb level and longer surgery time have a high blood-transfusion risk and should be closely followed peri-operatively.
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Goyal A, Pallavi K, Krishnakumar M, Surve RM, Bhadrinarayan V, Chakrabarti D. Reliability of Pre-Induction Inferior Vena Cava Assessment with Ultrasound for the Prediction of Post-Induction Hypotension in Neurosurgical Patients Undergoing Intracranial Surgery. Neurol India 2022; 70:1568-1574. [PMID: 36076660 DOI: 10.4103/0028-3886.355107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Hypotension is one of the most common complications following induction of general anesthesia. Preemptive diagnosis and correcting the hypovolemic status can reduce the incidence of post-induction hypotension. However, an association between preoperative volume status and severity of post-induction hypotension has not been established in neurosurgical patients. We hypothesized that preoperative ultrasonographic assessment of intravascular volume status can be used to predict post-induction hypotension in neurosurgical patients. Our study objective was to establish the relationship between pre-induction maximum inferior vena cava (IVC) diameter, collapsibility index (CI), and post-induction reduction in mean arterial blood pressure in neurosurgical patients. Materials and Methods A prospective observational study was conducted including 100 patients undergoing elective intracranial surgeries. IVC assessment was done before induction of general anesthesia. Receiver operating characteristic (ROC) curve analysis was used to determine the cutoff values of maximum and minimum IVC diameter (IVCDmax and IVCDmin, respectively) and CI for prediction of hypotension. Results Post-induction hypotension was observed in 41% patients. Patients with small IVCDmax and higher CI% developed hypotension. The areas under the ROC curve (AUCs) were 0.64 (0.53-0.75) for IVCDmax and 0.69 (0.59-0.80) for IVCDmin. The optimal cutoff values were1.38 cm for IVCDmax and 0.94 cm for IVCDmin. The AUC for CI was 0.65 (0.54-0.77) and the optimal cutoff value was 37.5%. Conclusion Pre-induction IVC assessment with ultrasound is a reliable method to predict post-induction hypotension resulting from hypovolemia in neurosurgical patients.
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Affiliation(s)
- Amit Goyal
- Department of Neuroanesthesia and Neurocritical Care, Eternal Hospital, Jaipur, Rajasthan, India
| | - Kumari Pallavi
- Department of Neuroanesthesia and Neurocritical Care, Eternal Hospital, Jaipur, Rajasthan, India
| | - Mathangi Krishnakumar
- Department of Neuroanesthesia and Neurocritical Care, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - Rohini M Surve
- Department of Neuroanesthesia and Neurocritical Care, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - V Bhadrinarayan
- Department of Neuroanesthesia and Neurocritical Care, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - Dhritiman Chakrabarti
- Department of Neuroanesthesia and Neurocritical Care, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
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Zhu J, Hu H, Deng X, Cheng X, Li Y, Chen W, Zhang Y. Risk factors analysis and nomogram construction for blood transfusion in elderly patients with femoral neck fractures undergoing hemiarthroplasty. INTERNATIONAL ORTHOPAEDICS 2022; 46:1637-1645. [PMID: 35166874 DOI: 10.1007/s00264-022-05347-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/10/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Elderly patients with femoral neck fractures (FNFs) undergoing hemiarthroplasty usually have poor physical condition. The main aim of this study was to identify risk factors for blood transfusion in these patients and construct a nomogram to intuitively predict the requirement of transfusion. The secondary purpose was to examine the relationship between blood transfusion and complications within 30 days post-operatively. Our hypothesis was that chronic kidney disease (CKD) and hypoalbuminemia may increase the requirement of transfusion. METHODS Data of 414 elderly patients undergoing hemiarthroplasty for FNFs were retrospectively collected. Univariate and multiple regression analysis were performed to identify independent risk factors for blood transfusion, which were used to construct a nomogram subsequently. The discrimination and calibration of the nomogram model were assessed with concordance index (C-index), the area under receiver operating characteristic curve (AUC), and calibration curve. Furthermore, the complications of blood transfusion within 30 days post-operatively were also analyzed. RESULTS Out of 414 patients, 127 (30.7%) received a blood transfusion. Independent risk factors for blood transfusion included CKD, hypoalbuminemia, pre-operative anaemia, general anaesthesia, higher American Society of Anesthesiologists score, more intraoperative blood loss, and longer surgical time. Increased hidden blood loss, deep vein thrombosis, superficial wound infection, and prolonged hospital stays were more common in transfused patients. The C-index of the nomogram model was 0.848 (95% CI = 0.811-0.885), and the AUC value was 0.859. The calibration curve showed a good consistency between the actual transfusion and the predicted probability. DISCUSSION We observed a transfusion rate of 30.7% in elderly FNF patients undergoing hemiarthroplasty. CKD and hypoalbuminemia were firstly identified as independent risk for blood transfusion. In addition, blood transfusion can increase the occurrence of early post-operative complications. CONCLUSION Targeted pre-operative intervention, such as optimizing CKD and correcting hypoalbuminemia is essential and highly regarded.
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Affiliation(s)
- Jian Zhu
- Shanxi Bethune Hospital, Shanxi Academy of Medical Science, No. 99, Longcheng Street, Taiyuan, 030032, Shanxi Province, China.,School of Medicine, Nankai University, Tianjin, 300071, People's Republic of China.,Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, People's Republic of China.,Key Laboratory of Biomechanics of Hebei Province, Orthopaedic Research Institution of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China.,NHC Key Laboratory of Intelligent Orthopeadic Equipment, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Hongzhi Hu
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People's Republic of China
| | - Xiangtian Deng
- School of Medicine, Nankai University, Tianjin, 300071, People's Republic of China.,Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, People's Republic of China.,Key Laboratory of Biomechanics of Hebei Province, Orthopaedic Research Institution of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China.,NHC Key Laboratory of Intelligent Orthopeadic Equipment, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Xiaodong Cheng
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, People's Republic of China.,Key Laboratory of Biomechanics of Hebei Province, Orthopaedic Research Institution of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China.,NHC Key Laboratory of Intelligent Orthopeadic Equipment, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Yonglong Li
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, People's Republic of China.,Key Laboratory of Biomechanics of Hebei Province, Orthopaedic Research Institution of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China.,NHC Key Laboratory of Intelligent Orthopeadic Equipment, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Wei Chen
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, People's Republic of China.,Key Laboratory of Biomechanics of Hebei Province, Orthopaedic Research Institution of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China.,NHC Key Laboratory of Intelligent Orthopeadic Equipment, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Yingze Zhang
- School of Medicine, Nankai University, Tianjin, 300071, People's Republic of China. .,Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, People's Republic of China. .,Key Laboratory of Biomechanics of Hebei Province, Orthopaedic Research Institution of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China. .,NHC Key Laboratory of Intelligent Orthopeadic Equipment, Shijiazhuang, 050051, Hebei, People's Republic of China.
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Doyle CR, Riccó Pereira CH, Wanstrath AW, Lerche P, Aarnes TK, Bednarski RM, Werre SR. Evaluation of perfusion index as a noninvasive tool to determine epidural anesthesia effectiveness in dogs. Vet Anaesth Analg 2021; 48:782-788. [PMID: 34362690 DOI: 10.1016/j.vaa.2021.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 06/07/2021] [Accepted: 06/09/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate perfusion index (PI) as a noninvasive tool to determine effectiveness and onset of epidural anesthesia in dogs. STUDY DESIGN Prospective clinical trial. ANIMALS A total of 21 adult dogs, aged 6.5 ± 3 years and weighing 34.9 ± 6.4 kg, undergoing a tibial plateau leveling osteotomy. METHODS Dogs were premedicated intramuscularly with acepromazine (0.03 mg kg-1) and hydromorphone (0.1 mg kg-1) and anesthetized with intravenous propofol (to effect) and isoflurane in oxygen. A surface transflectance probe was secured to the tail base to monitor PI and a dorsal pedal artery catheter was placed for invasive blood pressure monitoring. A lumbosacral epidural was performed with the dog in sternal recumbency. Dogs were randomly assigned for inclusion of epidural morphine (0.1 mg kg-1) or morphine (0.1 mg kg-1) and lidocaine (4 mg kg-1). PI was recorded following instrumentation of each dog just prior to the epidural (baseline), at 10 minute intervals for 30 minutes, before and after the surgical skin incision and before and after completion of the osteotomy. Physiological variables and end-tidal isoflurane were recorded at the same time points. RESULTS There was no significant difference in PI between the groups at any time point. There was a significant change in end-tidal isoflurane before and after the skin incision in the epidural morphine and epidural morphine-lidocaine groups (p = 0.04, p = 0.05, respectively) and before and after the osteotomy in each group for heart rate (p = 0.001, p = 0.04), diastolic (p = 0.01, p = 0.01) and mean arterial blood pressure (p = 0.03, p = 0.05). CONCLUSIONS AND CLINICAL RELEVANCE PI did not provide an objective means for determining the onset or effectiveness of epidural anesthesia in anesthetized dogs and alternate methods of noninvasive assessment should be investigated.
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Affiliation(s)
- Crystal R Doyle
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH, USA
| | - Carolina H Riccó Pereira
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH, USA.
| | - Audrey W Wanstrath
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH, USA
| | - Phillip Lerche
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH, USA
| | - Turi K Aarnes
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH, USA
| | - Richard M Bednarski
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH, USA
| | - Stephen R Werre
- Department of Population Health Sciences, Virginia-Maryland College of Veterinary Medicine, Blacksburg, VA, USA
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Bian FC, Cheng XK, An YS. Preoperative risk factors for postoperative blood transfusion after hip fracture surgery: establishment of a nomogram. J Orthop Surg Res 2021; 16:406. [PMID: 34162408 PMCID: PMC8220667 DOI: 10.1186/s13018-021-02557-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 06/11/2021] [Indexed: 11/10/2022] Open
Abstract
Background This study aimed to explore the preoperative risk factors related to blood transfusion after hip fracture operations and to establish a nomogram prediction model. The application of this model will likely reduce unnecessary transfusions and avoid wasting blood products. Methods This was a retrospective analysis of all patients undergoing hip fracture surgery from January 2013 to January 2020. Univariate and multivariate logistic regression analyses were used to evaluate the association between preoperative risk factors and blood transfusion after hip fracture operations. Finally, the risk factors obtained from the multivariate regression analysis were used to establish the nomogram model. The validation of the nomogram was assessed by the concordance index (C-index), the receiver operating characteristic (ROC) curve, decision curve analysis (DCA), and calibration curves. Results A total of 820 patients were included in the present study for evaluation. Multivariate logistic regression analysis demonstrated that low preoperative hemoglobin (Hb), general anesthesia (GA), non-use of tranexamic acid (TXA), and older age were independent risk factors for blood transfusion after hip fracture operation. The C-index of this model was 0.86 (95% CI, 0.83–0.89). Internal validation proved the nomogram model’s adequacy and accuracy, and the results showed that the predicted value agreed well with the actual values. Conclusions A nomogram model was developed based on independent risk factors for blood transfusion after hip fracture surgery. Preoperative intervention can effectively reduce the incidence of blood transfusion after hip fracture operations.
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Affiliation(s)
- Fu Cheng Bian
- Chengde Medical University, Chengde, 067000, Hebei, China.,Department of Minimally Invasive Spine Surgery, Chengde Medical University Affiliated Hospital, Chengde, 067000, Hebei, China
| | - Xiao Kang Cheng
- Chengde Medical University, Chengde, 067000, Hebei, China.,Department of Minimally Invasive Spine Surgery, Chengde Medical University Affiliated Hospital, Chengde, 067000, Hebei, China
| | - Yong Sheng An
- Department of Minimally Invasive Spine Surgery, Chengde Medical University Affiliated Hospital, Chengde, 067000, Hebei, China.
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Wang J, Zhao Y, Jiang B, Huang X. Development of a Nomogram to Predict Postoperative Transfusion in the Elderly After Intramedullary Nail Fixation of Femoral Intertrochanteric Fractures. Clin Interv Aging 2021; 16:1-7. [PMID: 33442240 PMCID: PMC7797293 DOI: 10.2147/cia.s253193] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 06/10/2020] [Indexed: 11/30/2022] Open
Abstract
Purpose The aim of our study was to explore the risk factors related to blood transfusion after intramedullary nail fixation of elderly femoral intertrochanteric fracture (FTF) and establish a nomogram prediction model. Patients and Methods We conducted a retrospective study including elderly FTF patients treated by intramedullary nail between January 2017 and December 2019. Perioperative information was obtained retrospectively, uni- and multivariate regression analyses were performed to determine risk factors for blood transfusion. A nomogram model was established to predict the risk of blood transfusion, and consistency coefficient (C-index) and correction curve were used to evaluate the prediction performance and consistency of the model. Results Of 148 patients, 119 were finally enrolled in the study and and 46 patients (38.7%) received a blood transfusion after the operation. Logistic regression analysis the female, lower preoperative Hb, ASA score >2, general anesthesia, and higher intraoperative blood loss were independently associated with the blood transfusion. The accuracy of the contour map for predicting transfusion risk was 0.910. Conclusion These risk factors are shown on the nomogram and verified. Through the assessment of the risk of blood transfusion and the intervention of modifiable risk factors, we may be able to reduce the blood transfusion rate to a certain extent, so as to further guarantee the safety of the elderly patients during the perioperative period.
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Affiliation(s)
- Jiqi Wang
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang, People's Republic of China
| | - Youming Zhao
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang, People's Republic of China
| | - Bingjie Jiang
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang, People's Republic of China
| | - Xiaojing Huang
- Department of Orthopaedics, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang, People's Republic of China
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Dobrońska K, Jureczko L, Kowalczyk R, Dobroński P, Trzebicki J. Open kidney cancer surgery and perioperative cardiac arrhythmias. Cent European J Urol 2020; 73:432-439. [PMID: 33552568 PMCID: PMC7848839 DOI: 10.5173/ceju.2020.1734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 12/04/2020] [Accepted: 10/06/2020] [Indexed: 11/22/2022] Open
Abstract
Introduction Although cardiac arrhythmias during anesthesia are often observed, the literature focuses mainly on cardio-thoracic surgery. We aimed to evaluate the incidence of arrhythmias appearing in the perioperative period in patients undergoing urological surgery and furthermore to define whether combining general with epidural anesthesia prevents them. Material and methods The study included 50 adults, without a prior cardiac or arrhythmia history, undergoing an open kidney cancer surgery, who were randomly allocated to receive either general or combined epidural/general anesthesia. A Holter monitor was applied the evening before the surgery, tracing continuously for a period of 24 hours (7PM–7PM). ClinicalTrials.gov NCT02988219 Results There was no statistical difference in the arrhythmia occurrence between the randomization groups. Among 65.21% the following arrhythmias were observed: 27 – bradycardia, 4 – sinus pause, 6 – ventricular extrasystoles (>1000/24 hours), 3 – supraventricular extrasystoles (>200/24 hours). The patients with arrhythmia were older and often with hypertension (p <0.01). A longer surgery duration predisposed to arrhythmia appearance (122.5 vs. 99 minutes), (p <0.01). The temperature measured at the beginning and at the end of the surgery was significantly lower among the participants with arrhythmia (p = 0.02, p = 0.01). The gender, body mass index (BMI), laboratory tests and the intake of intravenous fluids did not influence the occurrence of arrhythmia. Conclusions Perioperative cardiac arrhythmias (usually sinus arrhythmias) are common during an open kidney surgery and occur regardless of the anesthetic technique and usually do not require any treatment. Age, hypertension, long operation time or low body temperature predispose the patient to perioperative cardiac arrhythmias during surgery.
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Affiliation(s)
- Karolina Dobrońska
- First Department of Anesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - Lidia Jureczko
- First Department of Anesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - Rafał Kowalczyk
- First Department of Anesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Dobroński
- Department of Urology, Medical University of Warsaw, Warsaw, Poland
| | - Janusz Trzebicki
- First Department of Anesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
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Gallegos G, Morgan CJ, Scott G, Benz D, Ness TJ. Effect of Neuraxial Analgesic Procedures on Intraoperative Hemodynamics During Routine Clinical Care of Gynecological and General Surgeries: A Case-Control Query of Electronic Data. J Pain Res 2020; 13:1163-1172. [PMID: 32547179 PMCID: PMC7250300 DOI: 10.2147/jpr.s252760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 05/09/2020] [Indexed: 11/23/2022] Open
Abstract
Background The purpose of this study was to determine whether neuraxial analgesic procedures affect intraoperative hemodynamics and/or postoperative outcomes. Previous studies have examined effects in small samples of patients in highly controlled research environments. This study examined “real-world” data from a large sample of subjects receiving routine clinical cares. Methods A matched case–control analysis of electronic medical records from a large, academic hospital was performed. Patients who underwent neuraxial procedures preoperatively for postoperative analgesia for abdominal surgery (n=1570) were compared with control patients matched according to age, sex, ASA class and type of surgical procedure. Intraoperative hemodynamic measures, fluids and pressor utilization were quantified. Postoperative outcomes were determined based on the changes in laboratory values, the ordering of imaging studies and admission to an intensive care unit during the seven days following surgery as well as 30-day mortality. Results Medical records of 1082 patients who received an epidural catheter placement and 488 patients who received a lumbar intrathecal morphine injection were compared with an equal number of matched control patients. Preoperative placement of an epidural catheter for the management of postoperative pain was demonstrated to be associated with significant reductions in mean arterial pressure intraoperatively and poorer postoperative outcomes (more intensive care unit [ICU] admissions, more myocardial injuries) when compared with controls. A similar analysis of preoperatively administered intrathecal morphine injections was not associated with intraoperative alterations in blood pressure and had improved outcomes (less ICU admissions) in comparison with controls. Conclusion In a “real-world” sample, intrathecal morphine administration proved to be highly beneficial as a neuraxial analgesic procedure as it was not associated with intraoperative hypotension and was associated with improved clinical outcomes, in contrast to opposite findings associated with epidural catheter placement. There should be a careful consideration of elective neuraxial method utilized for postoperative pain control, with the present study raising significant concerns related to the use of epidural analgesia and its potential effect on clinical outcomes.
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Affiliation(s)
- Gabriel Gallegos
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL 35205, USA
| | - Charity J Morgan
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL 35205, USA
| | - Garrett Scott
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL 35205, USA
| | - David Benz
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL 35205, USA
| | - Timothy J Ness
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL 35205, USA
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10
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Wang JQ, Chen LY, Jiang BJ, Zhao YM. Development of a Nomogram for Predicting Blood Transfusion Risk After Hemiarthroplasty for Femoral Neck Fractures in Elderly Patients. Med Sci Monit 2020; 26:e920255. [PMID: 32074099 PMCID: PMC7043352 DOI: 10.12659/msm.920255] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background The aim of this study was to determine the risk factors and develop a nomogram for blood transfusions after hemiarthroplasty (HA) in patients with femoral neck fractures (FNFs). Material/Methods We performed a retrospective study including consecutive elderly FNF patients treated by HA between January 2015 and December 2017. Perioperative information was obtained retrospectively, uni- and multivariate regression analyses were conducted to determine risk factors for blood transfusion, and a nomogram model was constructed to predict the risk of blood transfusion. The predictive performance and consistency of the model were evaluated by the consistency coefficient (C-index) and the calibration curve, respectively. Results Of 178 patients, 151 were finally enrolled in the study and 21 received blood transfusion. Binary logistic regression analysis showed the low preoperative hemoglobin (Hb), longer time to surgery, general anesthesia, longer surgery duration, and higher intraoperative blood loss (IBL) were risk factors for blood transfusion. The accuracy of the contour map for predicting transfusion risk was 0.940. Conclusions We found a correlation between blood transfusion requirement and low preoperative Hb, longer time to surgery, general anesthesia, longer surgery duration, and higher IBL, and we then developed a nomogram. Our nomogram model can be used to evaluate the transfusion risk for FNF patients after HA, and provides better guidance for clinicians to intervene perioperatively, so as to reduce the incidence of blood transfusion.
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Affiliation(s)
- Ji-Qi Wang
- Department of Orthopedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| | - Lu-Ying Chen
- Department of Otolaryngology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| | - Bing-Jie Jiang
- Department of Orthopedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| | - You-Ming Zhao
- Department of Orthopedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
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11
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An R, Pang QY, Liu HL. Association of intra-operative hypotension with acute kidney injury, myocardial injury and mortality in non-cardiac surgery: A meta-analysis. Int J Clin Pract 2019; 73:e13394. [PMID: 31332896 DOI: 10.1111/ijcp.13394] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 07/01/2019] [Accepted: 07/17/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Intra-operative hypotension might induce poor postoperative outcomes in non-cardiac surgery, and the relationship between the level or duration of Intra-operative hypotension (IOH) and postoperative adverse events is still unclear. In this study, we performed a meta-analysis to determine how IOH could affect acute kidney injury (AKI), myocardial injury and mortality in non-cardiac surgery. METHODS We searched PubMed (Medline), Embase, Springer, The Cochrane Library, Ovid and Google Scholar, and retrieved the related clinical trials on intra-operative hypotension and prognosis in non-cardiac surgery. RESULTS Fifteen observational studies were included. The meta-analysis showed that in non-cardiac surgery, intra-operative hypotension (mean arterial pressure [MAP]) <60 mm Hg for more than 1 minute was associated with an increased risk of postoperative acute kidney injury(AKI) [1-5 minutes: odds ratio (OR) = 1.13, 95% CI (1.04, 1.23), I2 = 0, P = .003; 5-10 minutes: OR = 1.18, 95% CI (1.07, 1.31), I2 = 0, P = .001; >10 minutes: OR = 1.35, 95% CI (1.1, 1.67), I2 = 52.6%, P = .004] and myocardial injury [1-5 minutes: OR = 1.16, 95% CI (1.01, 1.33), I2 = 30.6%, P = .04; 5-10 minutes: OR = 1.34, 95% CI (1.01, 1.77), I2 = 70.4%, P = .046; >10 minutes: OR = 1.43, 95% CI (1.18, 1.72), I2 = 39.4%, P < .0001]. Intra-operative hypotension (MAP < 60 mm Hg) for 1-5 minutes was not associated with postoperative 30-day mortality [OR = 1.15, 95% CI (0.95, 1.4), I2 = 0, P = .154], but intra-operative hypotension (MAP < 60 mm Hg) for more than 5 min was associated with an increased risk of postoperative 30-day mortality [OR = 1.11, 95% CI (1.06, 1.17), I2 = 51.9%, P < .0001]. CONCLUSION Intra-operative hypotension was associated with an increased risk of postoperative AKI, myocardial injury and 30-day mortality in non-cardiac surgery. Intra-operative MAP < 60 mm Hg more than 1 minute should be avoided.
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Affiliation(s)
- Ran An
- Department of Anesthesiology, Chongqing University Cancer Hospital/Chongqing Cancer Institute/Chongqing Cancer Center, Chongqing City, 400030, China
| | - Qian-Yun Pang
- Department of Anesthesiology, Chongqing University Cancer Hospital/Chongqing Cancer Institute/Chongqing Cancer Center, Chongqing City, 400030, China
| | - Hong-Liang Liu
- Department of Anesthesiology, Chongqing University Cancer Hospital/Chongqing Cancer Institute/Chongqing Cancer Center, Chongqing City, 400030, China
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12
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Memtsoudis SG, Cozowicz C, Bekeris J, Bekere D, Liu J, Soffin EM, Mariano ER, Johnson RL, Hargett MJ, Lee BH, Wendel P, Brouillette M, Go G, Kim SJ, Baaklini L, Wetmore D, Hong G, Goto R, Jivanelli B, Argyra E, Barrington MJ, Borgeat A, De Andres J, Elkassabany NM, Gautier PE, Gerner P, Gonzalez Della Valle A, Goytizolo E, Kessler P, Kopp SL, Lavand'Homme P, MacLean CH, Mantilla CB, MacIsaac D, McLawhorn A, Neal JM, Parks M, Parvizi J, Pichler L, Poeran J, Poultsides LA, Sites BD, Stundner O, Sun EC, Viscusi ER, Votta-Velis EG, Wu CL, Ya Deau JT, Sharrock NE. Anaesthetic care of patients undergoing primary hip and knee arthroplasty: consensus recommendations from the International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) based on a systematic review and meta-analysis. Br J Anaesth 2019; 123:269-287. [PMID: 31351590 DOI: 10.1016/j.bja.2019.05.042] [Citation(s) in RCA: 164] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/02/2019] [Accepted: 05/20/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Evidence-based international expert consensus regarding anaesthetic practice in hip/knee arthroplasty surgery is needed for improved healthcare outcomes. METHODS The International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) systematic review, including randomised controlled and observational studies comparing neuraxial to general anaesthesia regarding major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, genitourinary, thromboembolic, neurological, infectious, and bleeding complications. Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, from 1946 to May 17, 2018 were queried. Meta-analysis and Grading of Recommendations Assessment, Development and Evaluation approach was utilised to assess evidence quality and to develop recommendations. RESULTS The analysis of 94 studies revealed that neuraxial anaesthesia was associated with lower odds or no difference in virtually all reported complications, except for urinary retention. Excerpt of complications for neuraxial vs general anaesthesia in hip/knee arthroplasty, respectively: mortality odds ratio (OR): 0.67, 95% confidence interval (CI): 0.57-0.80/OR: 0.83, 95% CI: 0.60-1.15; pulmonary OR: 0.65, 95% CI: 0.52-0.80/OR: 0.69, 95% CI: 0.58-0.81; acute renal failure OR: 0.69, 95% CI: 0.59-0.81/OR: 0.73, 95% CI: 0.65-0.82; deep venous thrombosis OR: 0.52, 95% CI: 0.42-0.65/OR: 0.77, 95% CI: 0.64-0.93; infections OR: 0.73, 95% CI: 0.67-0.79/OR: 0.80, 95% CI: 0.76-0.85; and blood transfusion OR: 0.85, 95% CI: 0.82-0.89/OR: 0.84, 95% CI: 0.82-0.87. CONCLUSIONS Recommendation: primary neuraxial anaesthesia is preferred for knee arthroplasty, given several positive postoperative outcome benefits; evidence level: low, weak recommendation. RECOMMENDATION neuraxial anaesthesia is recommended for hip arthroplasty given associated outcome benefits; evidence level: moderate-low, strong recommendation. Based on current evidence, the consensus group recommends neuraxial over general anaesthesia for hip/knee arthroplasty. TRIAL REGISTRY NUMBER PROSPERO CRD42018099935.
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MESH Headings
- Anesthesia, Epidural/adverse effects
- Anesthesia, Epidural/mortality
- Anesthesia, General/adverse effects
- Anesthesia, General/mortality
- Anesthesia, Spinal/adverse effects
- Anesthesia, Spinal/mortality
- Arthroplasty, Replacement, Hip/methods
- Arthroplasty, Replacement, Hip/mortality
- Arthroplasty, Replacement, Knee/methods
- Arthroplasty, Replacement, Knee/mortality
- Evidence-Based Medicine/methods
- Humans
- Postoperative Complications/mortality
- Randomized Controlled Trials as Topic
- Treatment Outcome
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Affiliation(s)
- Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria.
| | - Crispiana Cozowicz
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Janis Bekeris
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Dace Bekere
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Ellen M Soffin
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Edward R Mariano
- Department of Anesthesia, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Rebecca L Johnson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mary J Hargett
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Bradley H Lee
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Pamela Wendel
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Mark Brouillette
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - George Go
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Sang J Kim
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Lila Baaklini
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Douglas Wetmore
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Genewoo Hong
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Rie Goto
- Kim Barrett Memorial Library, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Bridget Jivanelli
- Kim Barrett Memorial Library, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Eriphyli Argyra
- Department of Anaesthesiology, Pain and Palliative Care, National and Kapodistrian University of Athens, Athens, Greece
| | - Michael J Barrington
- Department of Medicine & Radiology, The University of Melbourne, Victoria, Australia
| | - Alain Borgeat
- Department of Anesthesiology and Intensive Care Medicine, Universität Zürich, Zurich, Switzerland
| | - Jose De Andres
- Anesthesia Unit- Surgical Specialties Department, Valencia University Medical School, Spain; Anesthesia, Critical Care, and Pain Management Department, General University Hospital, Valencia, Spain
| | - Nabil M Elkassabany
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Philippe E Gautier
- Department of Anesthesiology, Clinique Ste-Anne St-Remi, Anderlecht, Belgium
| | - Peter Gerner
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Alejandro Gonzalez Della Valle
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Enrique Goytizolo
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Paul Kessler
- Department of Anesthesiology, Intensive Care and Pain Medicine, Orthopedic University Hospital, Frankfurt am Main, Germany
| | - Sandra L Kopp
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Catherine H MacLean
- Value Management Office, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Carlos B Mantilla
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel MacIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Alexander McLawhorn
- Department of Orthopedic Surgery, Hip and Knee Replacement, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Joseph M Neal
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Michael Parks
- Department of Orthopedic Surgery, Hip and Knee Replacement, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, USA
| | | | - Lukas Pichler
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Jashvant Poeran
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, Institute for Healthcare Delivery Science, New York, NY, USA
| | - Lazaros A Poultsides
- Department of Orthopaedic Surgery, New York Langone Orthopaedic Hospital, New York, NY, USA
| | - Brian D Sites
- Department of Anesthesiology, Dartmouth College Geisel School of Medicine, Hanover, NH, USA
| | - Otto Stundner
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Eric C Sun
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA
| | - Eugene R Viscusi
- Department of Anesthesiology, Pain Center, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Effrossyni G Votta-Velis
- Department of Anesthesiology, University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
| | - Christopher L Wu
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Jacques T Ya Deau
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Nigel E Sharrock
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
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13
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Zhong H, Wang Y, Wang Y, Wang B. Comparison of the effect and clinical value in general anesthesia and combined spinal-epidural anesthesia in elderly patients undergoing hip arthroplasty. Exp Ther Med 2019; 17:4421-4426. [PMID: 31086576 PMCID: PMC6489064 DOI: 10.3892/etm.2019.7465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 03/18/2019] [Indexed: 12/19/2022] Open
Abstract
Effect and clinical value in general anesthesia and combined spinal-epidural anesthesia in elderly patients undergoing hip arthroplasty were compared. One hundred and six patients with hip arthroplasty in the Affiliated Nanhua Hospital, University of South China from May 2013 to July 2015 were selected as the research subjects, including 50 patients in the study group who received combined spinal-epidural anesthesia by ondansetron hydrochloride tablets combined with spinal-epidural puncture kit, and 56 patients in the control group who received general anesthesia by fast-induced endotracheal intubation. Retrospective analysis was performed in terms of anesthesia effect, complete block time, anesthesia onset time, hemodynamic parameters at different time points before and after the surgery, and adverse reactions after the surgery. The study group had a statistically shorter onset time and a statistically shorter complete block time than the control group (P<0.05). No significant difference in the heart rate, systolic blood pressure or diastolic blood pressure before the surgery in the two groups was shown (P>0.05); the heart rate, systolic blood pressure, and diastolic blood pressure in the study group 20 min after the start of the operation and 15 min before the end of the operation were significantly higher those in the control group (P<0.05); the adverse reactions such as venous thrombosis, pulmonary infection, and nausea and vomiting in the study group were fewer than those in the control group (P<0.05). For elderly patients with fracture surgery, both the general anesthesia and the combined spinal-epidural anesthesia can maintain a good anesthesia effect, but the combined spinal-epidural anesthesia can shorten the onset time and has less impact on the patient's hemodynamic parameters and less incidence of complications, thus worthy of clinical promotion.
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Affiliation(s)
- Huanhui Zhong
- Department of Anesthesiology, Affiliated Nanhua Hospital, University of South China, Hengyang, Hunan 421002, P.R. China
| | - Yongdong Wang
- Department of Anesthesiology, Affiliated Nanhua Hospital, University of South China, Hengyang, Hunan 421002, P.R. China
| | - Yiqun Wang
- Department of Anesthesiology, Affiliated Nanhua Hospital, University of South China, Hengyang, Hunan 421002, P.R. China
| | - Baiyun Wang
- Department of Anesthesiology, Affiliated Nanhua Hospital, University of South China, Hengyang, Hunan 421002, P.R. China
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14
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Shafy SZ, Hakim M, Villalobos MA, Pearson GD, Veneziano G, Tobias JD. Caudal epidural block instead of general anesthesia in an adult with Duchenne muscular dystrophy. Local Reg Anesth 2018; 11:75-80. [PMID: 30410390 PMCID: PMC6197695 DOI: 10.2147/lra.s180867] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Duchenne muscular dystrophy (DMD), first described in 1834, is an X-linked dystrophinopathy, leading to early onset skeletal muscle weakness. Life expectancy is reduced to early adulthood as a result of involvement of voluntary skeletal muscles with respiratory failure, orthopedic deformities, and associated cardiomyopathy. Given its multisystem involvement, surgical intervention may be required to address the sequelae of the disease process. We present a 36-year-old adult with DMD, who required anesthetic care during surgical debridement of an ischial pressure sore. Given his significant respiratory muscle involvement, ultrasound-guided caudal epidural anesthesia was used instead of general during the surgical procedure. The technique and its applications are discussed, with particular emphasis on the feasibility and safety of using regional anesthetic techniques in patients with DMD.
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Affiliation(s)
- Shabana Z Shafy
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA,
| | - Mohammed Hakim
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA,
| | - Mauricio Arce Villalobos
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA,
| | - Gregory D Pearson
- Department of Plastic Surgery, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Plastic Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Giorgio Veneziano
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA,
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA, .,Department of Anesthesiology & Pain Medicine, The Ohio State University, Columbus, Ohio, USA
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15
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Kratz T, Hinterobermaier J, Timmesfeld N, Kratz C, Wulf H, Steinfeldt T, Zoremba M, Aust H. Pre-operative fluid bolus for improved haemodynamic stability during minor surgery: A prospectively randomized clinical trial. Acta Anaesthesiol Scand 2018; 62:1215-1222. [PMID: 29851024 DOI: 10.1111/aas.13157] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 04/25/2018] [Accepted: 04/25/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Haemodynamic instability during the induction of anaesthesia and surgery is common and may be related to hypovolaemia caused by pre-operative fasting or chronic diuretic therapy. The aim of our prospective, controlled, randomized study was to test the hypothesis that a predefined fluid bolus given prior to general anaesthesia for minor surgery would increase haemodynamic stability during anaesthetic induction. METHODS Two hundred and nineteen fairly healthy adult patients requiring minor surgery were enrolled. All received standard treatment, including a pulse contour analysing device for non-invasive measurement of cardiac index. Infusion therapy was started in all patients at induction. The intervention group (106 patients) was randomized to receive an additional fluid bolus of 8 mL/kg Ringer's acetate solution before the induction of anaesthesia. The primary endpoint was the incidence of haemodynamic instability, defined as a significant reduction of blood pressure or cardiac index during induction of anaesthesia. RESULTS The interventional group had a lesser incidence of haemodynamic instability during induction (41.5% vs 56.6%, P = .025). This group also had higher cardiac index, stroke volume index, systolic and mean blood pressure and a greater left ventricular end-diastolic area. CONCLUSIONS A fluid bolus prior to anaesthesia reduced the incidence of haemodynamic instability during induction of general anaesthesia. The total fluid volume was slightly greater in the intervention group compared to the control group (1370 ± 439 mL vs 1219 ± 483 mL, P = .007). We conclude that a defined fluid bolus can help stabilizing haemodynamics in patients undergoing general anaesthesia.
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Affiliation(s)
- T. Kratz
- Department of Anaesthesia and Intensive Care Medicine; Philipps-University of Marburg; Marburg Germany
- Department of Anaesthesia and Intensive Care Medicine; Clinique Bénigne Joly; Talant France
| | - J. Hinterobermaier
- Department of Anaesthesia and Intensive Care Medicine; Philipps-University of Marburg; Marburg Germany
- Department of Anaesthesia; Krankenhaus St. Joseph-Stift; Dresden Germany
| | - N. Timmesfeld
- Institute of Medical Biometry and Epidemiology; Philipps-University of Marburg; Marburg Germany
| | - C. Kratz
- Department of Anaesthesia and Intensive Care Medicine; Philipps-University of Marburg; Marburg Germany
- Department of Anaesthesia and Intensive Care Medicine; Clinique Bénigne Joly; Talant France
| | - H. Wulf
- Department of Anaesthesia and Intensive Care Medicine; Philipps-University of Marburg; Marburg Germany
| | - T. Steinfeldt
- Department of Anaesthesia and Intensive Care Medicine; Philipps-University of Marburg; Marburg Germany
- Department of Anaesthesiology; Diakonie-Klinikum; Schwäbisch Hall Germany
| | - M. Zoremba
- Department of Anaesthesia and Intensive Care Medicine; Philipps-University of Marburg; Marburg Germany
- Department of Anaesthesia, Intensive Care Medicine and Pain Therapy; Kreisklinikum; Siegen Germany
| | - H. Aust
- Department of Anaesthesia and Intensive Care Medicine; Philipps-University of Marburg; Marburg Germany
- Department of Anaesthesia and Intensive Care Medicine; Ilmtalklinik Pfaffenhofen; Pfaffenhofen Germany
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16
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Dias RSG, Soares JHN, Castro DDSE, Gress MAKDA, Machado ML, Otero PE, Ascoli FO. Cardiovascular and respiratory effects of lumbosacral epidural bupivacaine in isoflurane-anesthetized dogs: The effects of two volumes of 0.25% solution. PLoS One 2018; 13:e0195867. [PMID: 29668768 PMCID: PMC5906007 DOI: 10.1371/journal.pone.0195867] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 03/30/2018] [Indexed: 12/04/2022] Open
Abstract
The purpose of this study was to compare cardiovascular and respiratory effects of two volumes of bupivacaine 0.25% (0.2 mL kg-1-treatment BUP02-and 0.4 mL kg-1 -treatment BUP04) administered epidurally at the lumbosacral intervertebral space in dogs anesthetized with isoflurane. This experimental prospective randomized crossover design trial used six mixed breed adult dogs, four neutered males and two spayed females. Each dog was anesthetized on three different occasions: the first for isoflurane minimum alveolar concentration (MAC) measurement, and the following two assigned treatments (BUP02 or BUP04). On the two treatment days, anesthesia was induced and maintained with isoflurane at 1.3 MAC during the experiments. Cardiovascular and respiratory measurements were recorded before (T0) and 5, 15, 30, 60 and 90 minutes after the epidural administration of bupivacaine. Comparisons between and within groups were performed by a mixed-model ANOVA and Friedman's test when appropriate followed by Bonferroni post-hoc test or Dunnet's test to compare time points within each treatment with T0 (p < 0.05). Mean arterial pressure decreased significantly from 15 to 90 minutes after the administration of BUP02 and from 5 to 60 minutes in BUP04, with lower values in BUP04 than in BUP02 lasting up to 30 minutes after bupivacaine administration. No significant changes in cardiac output and systemic vascular resistance were observed in either treatment. Hypoventilation was only detected in BUP04. Hemoglobin concentration and arterial oxygen content decreased after both treatment of bupivacaine with no significant decrease in oxygen delivery. Two dogs in BUP04 developed Horner's syndrome. The epidural administration of 0.4 mL.kg-1 of bupivacaine to dogs in sternal recumbency anesthetized with isoflurane 1.3 MAC caused more cardiovascular and respiratory depression than 0.2 mL.kg-1.
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Affiliation(s)
- Raquel Sartori Gonçalves Dias
- Graduate Program in Cardiovascular Sciences, College of Medicine, Fluminense Federal University (UFF), Niterói, Rio de Janeiro, Brazil
| | - João Henrique Neves Soares
- Department of Small Animal Clinical Sciences, Virginia–Maryland Regional College of Veterinary Medicine, Virginia Tech, Blacksburg, Virginia, United States of America
| | - Douglas dos Santos e Castro
- Department of Large Animal Clinical Sciences, Anesthesia and Pain Management Service, University of Florida, Gainesville, Florida, United States of America
| | | | - Marcela Lemos Machado
- Graduate Program in Cardiovascular Sciences, College of Medicine, Fluminense Federal University (UFF), Niterói, Rio de Janeiro, Brazil
| | - Pablo E. Otero
- Universidad de Buenos Aires, Facultad de Ciencias Veterinarias, Cátedra de Anestesiología y Algiología, Buenos Aires, Argentina
| | - Fabio Otero Ascoli
- Graduate Program in Cardiovascular Sciences, College of Medicine, Fluminense Federal University (UFF), Niterói, Rio de Janeiro, Brazil
- Department of Physiology and Pharmacology, Biomedical Institute, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil
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17
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Falkensammer J, Hakaim AG, Klocker J, Biebl M, Lau LL, Neuhauser B, Mordecai M, Crawford C, Greengrass R. Paravertebral Blockade with Propofol Sedation versus General Anesthesia for Elective Endovascular Abdominal Aortic Aneurysm Repair. Vascular 2016; 14:17-22. [PMID: 16849018 DOI: 10.2310/6670.2006.00009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The objective of this study was to evaluate the applicability of paravertebral blockade (PVB) for endovascular abdominal aortic aneurysm repair compared with general anesthesia (GA). Data from patients who underwent elective infrarenal endovascular abdominal aortic aneurysm repair between August 2001 and July 2002 using PVB or GA were retrospectively reviewed and compared with respect to risk factors, intraoperative hemodynamic characteristics, operative outcome, and complications. Ten patients underwent elective infrarenal endovascular abdominal aortic aneurysm repair under PVB, whereas 15 patients were operated on under GA. One conversion from PVB to GA was necessary for block failure. The perioperative (< 30 days) cardiovascular morbidity and overall mortality were zero in both groups. The PVB group benefited significantly with respect to the incidence of intraoperative hypotension ( p < .05) and blood pressure lability ( p < .01), as well as postoperative nausea ( p < .01). Our preliminary results indicate that PVB is feasible and can be performed safely in a patient population with significant comorbidities.
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18
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Johnson R, Kopp S, Burkle C, Duncan C, Jacob A, Erwin P, Murad M, Mantilla C. Neuraxial vs general anaesthesia for total hip and total knee arthroplasty: a systematic review of comparative-effectiveness research. Br J Anaesth 2016; 116:163-76. [DOI: 10.1093/bja/aev455] [Citation(s) in RCA: 142] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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19
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Basques BA, Toy JO, Bohl DD, Golinvaux NS, Grauer JN. General compared with spinal anesthesia for total hip arthroplasty. J Bone Joint Surg Am 2015; 97:455-61. [PMID: 25788301 PMCID: PMC4357526 DOI: 10.2106/jbjs.n.00662] [Citation(s) in RCA: 160] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Total hip arthroplasty may be performed under general or spinal anesthesia. The purpose of the current study was to compare perioperative outcomes between anesthetic types for patients undergoing primary elective total hip arthroplasty. METHODS Patients who had undergone primary elective total hip arthroplasty from 2010 to 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Operating room times, length of stay, thirty-day adverse events, and readmission were compared between patients who had received general anesthesia and those who had received spinal anesthesia. Propensity-adjusted multivariate analysis was used to control for selection bias and baseline patient characteristics. RESULTS A total of 20,936 patients who had undergone total hip arthroplasty met inclusion criteria for this study. Of these, 12,752 patients (60.9%) had received general anesthesia and 8184 patients (39.1%) had received spinal anesthesia. On propensity-adjusted multivariate analyses, general anesthesia for total hip arthroplasty was associated with increased operative time (+12 minutes [95% confidence interval, +11 to +13 minutes]; p < 0.001) and postoperative room time (+5 minutes [95% confidence interval, +4 to +6 minutes]; p < 0.001). General anesthesia was also associated with the occurrence of any adverse event (odds ratio, 1.31 [95% confidence interval, 1.23 to 1.41]; p < 0.001), prolonged postoperative ventilator use (odds ratio, 5.81 [95% confidence interval, 1.35 to 25.06]; p = 0.018), unplanned intubation (odds ratio, 2.17 [95% confidence interval, 1.11 to 4.29]; p = 0.024), stroke (odds ratio, 2.51 [95% confidence interval, 1.02 to 6.20]; p = 0.046), cardiac arrest (odds ratio, 5.04 [95% confidence interval, 1.15 to 22.07]; p = 0.032), any minor adverse event (odds ratio, 1.35 [95% confidence interval, 1.25 to 1.45]; p = 0.001), and blood transfusion (odds ratio, 1.34 [95% confidence interval, 1.25 to 1.45]; p < 0.001). General anesthesia was not associated with any difference in preoperative room time, postoperative length of stay, or readmission. CONCLUSIONS General anesthesia was associated with an increased rate of adverse events and mildly increased operating room times.
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Affiliation(s)
- Bryce A. Basques
- Department of Orthopaedics and Rehabilitation, Yale
University School of Medicine, 800 Howard Avenue, New Haven, CT 06510. E-mail address
for J.N. Grauer:
| | - Jason O. Toy
- Department of Orthopaedics and Rehabilitation, Yale
University School of Medicine, 800 Howard Avenue, New Haven, CT 06510. E-mail address
for J.N. Grauer:
| | - Daniel D. Bohl
- Department of Orthopaedics and Rehabilitation, Yale
University School of Medicine, 800 Howard Avenue, New Haven, CT 06510. E-mail address
for J.N. Grauer:
| | - Nicholas S. Golinvaux
- Department of Orthopaedics and Rehabilitation, Yale
University School of Medicine, 800 Howard Avenue, New Haven, CT 06510. E-mail address
for J.N. Grauer:
| | - Jonathan N. Grauer
- Department of Orthopaedics and Rehabilitation, Yale
University School of Medicine, 800 Howard Avenue, New Haven, CT 06510. E-mail address
for J.N. Grauer:
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Sun D, Wu Y, Yang L, Han J, Liu R, Wang L. Effects of continuous intravenous infusion of methoxamine on the intraoperative hemodynamics of elderly patients undergoing total hip arthroplasty. Med Sci Monit 2014; 20:1969-76. [PMID: 25326008 PMCID: PMC4211421 DOI: 10.12659/msm.890760] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 05/27/2014] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Hemodynamic disturbances are common during continuous epidural anesthesia in elderly patients undergoing total hip arthroplasty. This study aimed to investigate the effects of methoxamine on the intraoperative hemodynamics in elderly patients undergoing total hip arthroplasty under epidural anesthesia. MATERIAL AND METHODS This prospective study included 150 elderly patients undergoing elective total hip arthroplasty under epidural anesthesia. Patients were randomly assigned into 5 groups (n=30 per group): a control group receiving saline (Group C), a dopamine group receiving 7 µg/kg/min dopamine (Group D), and methoxamine groups receiving 1, 2, or 3 µg/kg/min methoxamine (Groups M1, M2, and M3, respectively). Hemodynamic parameters were assessed 10 min before anesthesia (T1); 10 min (T2), 20 min, (T3), 30 min (T4), and 60 min (T5) after anesthesia; and at the conclusion of surgery (T6). RESULTS At T2-T6, the mean arterial pressure, central venous pressure, cardiac output, stroke volume, stroke volume ratio, and pulmonary vascular resistance were higher in Groups D, M2, and M3 compared to Group C (p<0.05). Compared to Group D, the heart rate and rate pressure product were significantly lower in Groups M1-M3. Infusion volume, ephedrine dose, and postoperative 24-h urine volume were significantly lower and intraoperative urine volume was significantly greater in Groups D, M2, and M3 compared with Group C. Hypertension occurred more frequently in Group M3 than in any other group. CONCLUSIONS Continuous intravenous infusion of 2 µg/kg/min methoxamine is safe and effective in maintaining hemodynamic stability in elderly patients undergoing total hip arthroplasty.
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Affiliation(s)
- Defeng Sun
- Department of Anesthesiology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Yue Wu
- Department of Anesthesiology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Lin Yang
- Department of Nerve Electroneurophysiology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
- Corresponding Author: Lin Yang, e-mail:
| | - Jun Han
- Department of Anesthesiology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Ruochuan Liu
- Department of Anesthesiology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Lijie Wang
- Department of Anesthesiology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
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Opperer M, Danninger T, Stundner O, Memtsoudis SG. Perioperative outcomes and type of anesthesia in hip surgical patients: An evidence based review. World J Orthop 2014; 5:336-343. [PMID: 25035837 PMCID: PMC4095027 DOI: 10.5312/wjo.v5.i3.336] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Revised: 03/24/2014] [Accepted: 04/29/2014] [Indexed: 02/06/2023] Open
Abstract
Over the last decades the demand for hip surgery, be it elective or in a traumatic setting, has greatly increased and is projected to expand even further. Concurrent with demographic changes the affected population is burdened by an increase in average comorbidity and serious complications. It has been suggested that the choice of anesthesia not only affects the surgery setting but also the perioperative outcome as a whole. Therefore different approaches and anesthetic techniques have been developed to offer individual anesthetic and analgesic care to hip surgery patients. Recent studies on comparative effectiveness utilizing population based data have given us a novel insight on anesthetic practice and outcome, showing favorable results in the usage of regional vs general anesthesia. In this review we aim to give an overview of anesthetic techniques in use for hip surgery and their impact on perioperative outcome. While there still remains a scarcity of data investigating perioperative outcomes and anesthesia, most studies concur on a positive outcome in overall mortality, thromboembolic events, blood loss and transfusion requirements when comparing regional to general anesthesia. Much of the currently available evidence suggests that a comprehensive medical approach with emphasis on regional anesthesia can prove beneficial to patients and the health care system.
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22
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Koç M, Saçan Ö, Gamlı M, Taşpınar V, Postacı A, Fikir E, Dikmen B. Retrospective Evaluation of Anaesthesia Techniques for Hip Replacement Operations. Turk J Anaesthesiol Reanim 2014; 42:133-9. [PMID: 27366407 DOI: 10.5152/tjar.2014.07108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 07/05/2013] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE In this retrospective study, we evaluated the demographic characteristics of patients that underwent hip replacement surgery in our orthopedic clinic. Associated diseases, preoperative laboratory findings, intraoperative findings, and the effect of admission or refusal to the intensive care unit on postoperative mortality and morbidity were recorded. Furthermore, we tried to identify surgical and anaesthetic methods applied, intraoperative hemodynamic changes, length of stay in the post-anaesthesia care unit, and postoperative complications. METHODS Demographic characteristics, co-morbidities, preoperative laboratory findings, intraoperative findings, and admission or refusal to the intensive care unit of patients who underwent hip replacement surgery between January 2008-December 2010 were enrolled. RESULTS Out of 500 patients, 33.4% (n=164) were operated under general anaesthesia, 34% (n=170) under combined spinal-epidural anaesthesia, 22.2% (n=111) under spinal anaesthesia, 6.4% (n=32) under combined lomber plexus block and sciatic nerve block, and 4% (n=20) under epidural anaesthesia. Mean hospital stay was 7 days in the general anaesthesia group and 5 days in the regional anaesthesia group. CONCLUSION American Society of Anesthesiologists (ASA) scores and incidence of co-morbidities were higher in the partial hip replacement group. Admission to the intensive care unit was lower in the total hip replacement group. Hospital stay was shorter in the partial hip replacement group. Mortality rates on the 7(th) and 30(th) days were higher in the partial hip replacement group.
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Affiliation(s)
- Murat Koç
- Clinic of Anaesthesia and Reanimation, Karabük State Hospital, Karabük, Turkey
| | - Özlem Saçan
- Clinic of Anaesthesia and Reanimation, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Mehmet Gamlı
- Clinic of Anaesthesia and Reanimation, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Vildan Taşpınar
- Clinic of Anaesthesia and Reanimation, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Aysun Postacı
- Clinic of Anaesthesia and Reanimation, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Emel Fikir
- Clinic of Anaesthesia and Reanimation, Dumlupınar University Evliya Çelebi Training and Research Hospital, Kütahya, Turkey
| | - Bayazit Dikmen
- Clinic of Anaesthesia and Reanimation, Ankara Numune Training and Research Hospital, Ankara, Turkey
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Lee YC, Park SJ, Kim JS, Cho CH. Effect of tranexamic acid on reducing postoperative blood loss in combined hypotensive epidural anesthesia and general anesthesia for total hip replacement. J Clin Anesth 2013; 25:393-398. [DOI: 10.1016/j.jclinane.2013.02.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 02/12/2013] [Accepted: 02/13/2013] [Indexed: 11/24/2022]
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Donohoe CL, Nguyen M, Cook J, Murray SG, Chen N, Zaki F, Mehigan BJ, McCormick PH, Reynolds JV. Fast-track protocols in colorectal surgery. Surgeon 2011; 9:95-103. [PMID: 21342674 DOI: 10.1016/j.surge.2010.07.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Revised: 07/26/2010] [Accepted: 07/27/2010] [Indexed: 01/22/2023]
Abstract
Fast-track surgery (FTS) is a set of protocols aimed to reduce the physiological burden of surgery thus improving outcomes. FTS aims to use evidence-based practice to reduce complications, improve post-operative quality of life and decrease hospital length of stay. This review seeks to examine the evidence base for protocols employed in colorectal surgery in the areas of pre-operative preparation, anaesthetic management, intraoperative and surgical factors and post-operative care. Despite the evidence that recovery after colorectal surgery can be enhanced by using these approaches, implementation of FTS protocols has been slow. Acceptance of FTS protocols by all members of the multi-disciplinary team and a change in organisational structure to accommodate structured peri-operative care, are imperative to implementation.
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Affiliation(s)
- Claire L Donohoe
- Department of Surgery, Trinity Centre for Health Sciences, Trinity College Dublin/St James' Hospital, Dublin 8, Ireland.
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25
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Phillips DP, Knizner TL, Williams BA. Economics and practice management issues associated with acute pain management. Anesthesiol Clin 2011; 29:213-232. [PMID: 21620339 DOI: 10.1016/j.anclin.2011.04.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The use of regional anesthesia (RA) improves cost benefit (hospital-centered) and cost utility (patient-centered) over general anesthesia with volatile agents (GAVA), based upon research in outpatient populations. To make the cost savings a reality, the authors recommend: (1) avoidance of GAVA or at least volatile agents, (2) adopting published postanesthesia care unit (PACU)-bypass criteria conducive to RA, (3) maximizing PACU-bypass rates, and (4) utilizing a block induction area. Inpatient-based acute pain services are not uniform, which makes cost analyses and comparison between practices unreliable. Additional review and commentary address surgical site infections, cancer recurrence, blood transfusions, and chronic postsurgical pain.
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Affiliation(s)
- Dennis P Phillips
- Department of Anesthesiology, University of Pittsburgh Medical Center, Liliane S. Kaufmann Building, 3471 Fifth Avenue Suite 910, Pittsburgh, PA 15213, USA.
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26
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Taffé P, Sicard N, Pittet V, Pichard S, Burnand B. The occurrence of intra-operative hypotension varies between hospitals: observational analysis of more than 147,000 anaesthesia. Acta Anaesthesiol Scand 2009; 53:995-1005. [PMID: 19572938 DOI: 10.1111/j.1399-6576.2009.02032.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Hypotension, a common intra-operative incident, bears an important potential for morbidity. It is most often manageable and sometimes preventable, which renders its study important. Therefore, we aimed at examining hospital variations in the occurrence of intra-operative hypotension and its predictors. As secondary endpoints, we determined to what extent hypotension relates to the risk of post-operative incidents and death. METHODS We used the Anaesthesia Databank Switzerland, built on routinely and prospectively collected data on all anaesthesias in 21 hospitals. The three outcomes were assessed using multi-level logistic regression models. RESULTS Among 147,573 anaesthesias, hypotension ranged from 0.6% to 5.2% in participating hospitals, and from 0.3% up to 12% in different surgical specialties. Most (73.4%) were minor single events. Age, ASA status, combined general and regional anaesthesia techniques, duration of surgery and hospitalization were significantly associated with hypotension. Although significantly associated, the emergency status of the surgery had a weaker effect. Hospitals' odds ratios for hypotension varied between 0.12 and 2.50 (P < or = 0.001), even after adjusting for patient and anaesthesia factors, and for type of surgery. At least one post-operative incident occurred in 9.7% of the procedures, including 0.03% deaths. Intra-operative hypotension was associated with a higher risk of post-operative incidents and death. CONCLUSION Wide variations remain in the occurrence of hypotension among hospitals after adjustment for risk factors. Although differential reporting from hospitals may exist, variations in anaesthesia techniques and blood pressure maintenance may also have contributed. Intra-operative hypotension is associated with morbidities and sometimes death, and constant vigilance must thus be advocated.
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Affiliation(s)
- P Taffé
- Institute of Social and Preventive Medicine, Hospices-CHUV and University of Lausanne, Lausanne, Switzerland
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27
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Hu S, Zhang ZY, Hua YQ, Li J, Cai ZD. A comparison of regional and general anaesthesia for total replacement of the hip or knee: a meta-analysis. ACTA ACUST UNITED AC 2009; 91:935-42. [PMID: 19567860 DOI: 10.1302/0301-620x.91b7.21538] [Citation(s) in RCA: 156] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We performed a meta-analysis to evaluate the relative efficacy of regional and general anaesthesia in patients undergoing total hip or knee replacement. A comprehensive search for relevant studies was performed in PubMed (1966 to April 2008), EMBASE (1969 to April 2008) and the Cochrane Library. Only randomised studies comparing regional and general anaesthesia for total hip or knee replacement were included. We identified 21 independent, randomised clinical trials. A random-effects model was used to calculate all effect sizes. Pooled results from these trials showed that regional anaesthesia reduces the operating time (odds ratio (OR) -0.19; 95% confidence interval (CI) -0.33 to -0.05), the need for transfusion (OR 0.45; 95% CI 0.22 to 0.94) and the incidence of thromboembolic disease (deep-vein thrombosis OR 0.45, 95% CI 0.24 to 0.84; pulmonary embolism OR 0.46, 95% CI 0.29 to 0.80). Regional anaesthesia therefore seems to improve the outcome of patients undergoing total hip or knee replacement.
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Affiliation(s)
- S Hu
- Department of Orthopaedics, Changhai Hospital, Second Military Medical University, 168, Changhai Road, Shanghai, 200433, People's Republic of China
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28
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Macfarlane AJR, Prasad GA, Chan VWS, Brull R. Does regional anaesthesia improve outcome after total hip arthroplasty? A systematic review. Br J Anaesth 2009; 103:335-45. [PMID: 19628483 DOI: 10.1093/bja/aep208] [Citation(s) in RCA: 126] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Total hip arthroplasty (THA) is amenable to a variety of regional anaesthesia (RA) techniques that may improve patient outcome. We sought to answer whether RA decreased mortality, cardiovascular morbidity, deep venous thrombosis (DVT) and pulmonary embolism (PE), blood loss, duration of surgery, pain, opioid-related adverse effects, cognitive defects, and length of stay. We also questioned whether RA improved rehabilitation. To do so, we performed a systematic review of the contemporary literature to compare general anaesthesia (GA) and RA and also systemic and regional analgesia for THA. To reflect contemporary surgical and anaesthetic practice, only randomized controlled trials (RCTs) from 1990 onward were included. We identified 18 studies involving 1239 patients. Only two of the 18 trials were of Level I quality. There is insufficient evidence from RCTs alone to conclude if anaesthetic technique influenced mortality, cardiovascular morbidity, or the incidence of DVT and PE when using thromboprophylaxis. Blood loss may be reduced in patients receiving RA rather than GA for THA. Our review suggests that there is no difference in duration of surgery in patients who receive GA or RA. Compared with systemic analgesia, regional analgesia can reduce postoperative pain, morphine consumption, and nausea and vomiting. Length of stay is not reduced and rehabilitation does not appear to be facilitated by RA or analgesia for THA.
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Affiliation(s)
- A J R Macfarlane
- Department of Anaesthesia and Pain Management, Toronto Western Hospital, University Health Network, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada
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Mauermann WJ, Shilling AM, Zuo Z. A comparison of neuraxial block versus general anesthesia for elective total hip replacement: a meta-analysis. Anesth Analg 2006; 103:1018-25. [PMID: 17000823 DOI: 10.1213/01.ane.0000237267.75543.59] [Citation(s) in RCA: 165] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND A recent meta-analysis showed that compared with general anesthesia (GA), neuraxial block reduced many serious complications in patients undergoing various types of surgeries. It is not known whether this finding from studying heterogeneous patient groups is applicable to a particular surgical patient population. We performed the present meta-analysis to determine whether anesthesia choice affected the outcome after elective total hip replacement (THR). METHODS Medline (1966 to August 2005), MD Consult (1966 to August 2005), BIOSIS (1969 to August 2005), and EMBASE (1969 to August 2005) databases were searched. Randomized and quasi randomized studies comparing GA and neuraxial (spinal or epidural) block for elective THR were included in this analysis. RESULTS Ten independent trials, involving 330 patients under GA and 348 patients under neuraxial block, were identified and analyzed. Pooled results from five trials showed that neuraxial block significantly decreased the incidence of radiographically diagnosed deep venous thrombosis or pulmonary embolism. The odds ratio (OR) for deep venous thrombosis was 0.27 with 95% confidence interval (CI) 0.17-0.42. The OR for pulmonary embolism was 0.26 with 95% CI 0.12-0.56. Neuraxial block also decreased the operative time by 7.1 min/case (95% CI 2.3-11.9 min) and intraoperative blood loss by 275 mL/case (95% CI 180-371 mL). Data from three trials showed that patients under neuraxial block for THR were less likely to require blood transfusion than were patients under GA (21/177 = 12% vs 62/188 = 33% of patients transfused, P < 0.001 by z-test). The OR for this comparison was 0.26. However, the CIs were wide and compatible with both no effect and a nine-tenths reduction (95% CI 0.06-1.05). CONCLUSIONS Patients undergoing elective THR under neuraxial anesthesia seem to have better outcomes than those under GA.
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Affiliation(s)
- William J Mauermann
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia 22908-0710, USA
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Ezri T, Zahalka I, Zabeeda D, Feldbrin Z, Eidelman A, Zimlichman R, Medalion B, Evron S. Similar incidence of hypotension with combined spinal-epidural or epidural alone for knee arthroplasty. Can J Anaesth 2006; 53:139-45. [PMID: 16434753 DOI: 10.1007/bf03021818] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND We hypothesized that the incidence of hypotension during total knee replacement (TKR) surgery is lower in patients given combined spinal-epidural (CSE) anesthesia vs those receiving epidural anesthesia alone. METHODS In a prospective study, 80 American Society of Anesthesiologists I-II patients (aged 40-80 yr), undergoing elective TKR surgery were randomly assigned to either CSE anesthesia (CSE, n = 40) or epidural anesthesia alone (Epidural, n = 40). Hemodynamic measurements included oscillometric mean arterial blood pressure (MAP), heart rate (HR), and cardiac index (CI) as determined by thoracic bioimpedance; systemic vascular resistance (SVR) was calculated. Our primary endpoint (outcome) was the number of hypotension episodes (defined as MAP < 70 mmHg). RESULTS Using univariate analysis, we found no differences between the groups in regards to MAP, HR, CI, or SVR during the perioperative period. The incidence of hypotension was similar in both groups (two patients in each group), as was the incidence of bradycardia (12 patients in CSE, 7 in Epidural; P = 0.2). There were no differences between groups in other hemodynamic measurements including CI and calculated SVR. Analgesia supplementation with fentanyl was more frequently required in the Epidural group (20 vs 6 patients - P = 0.03). CONCLUSION Combined spinal-epidural anesthesia and epidural anesthesia alone during TKR surgery are associated with the same incidence of hypotension with statistically and clinically similar hemodynamic responses.
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Affiliation(s)
- Tiberiu Ezri
- Department of Anesthesia, the Edith Wolfson Medical Center, Holon 58100, Israel.
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Eroglu A, Uzunlar H, Erciyes N. Comparison of hypotensive epidural anesthesia and hypotensive total intravenous anesthesia on intraoperative blood loss during total hip replacement. J Clin Anesth 2005; 17:420-5. [PMID: 16171661 DOI: 10.1016/j.jclinane.2004.09.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2004] [Accepted: 09/09/2004] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVE To compare hypotensive epidural anesthesia (HEA) and hypotensive total intravenous anesthesia (HTIVA) with propofol and remifentanil on blood loss during primary total hip replacement. DESIGN Prospective, randomized clinical study. SETTING University hospital. PATIENTS Forty ASA physical status I, II, and III patients presenting for primary total hip replacement. INTERVENTIONS Patients received either HEA with bupivacaine (HEA group, n = 20) or HTIVA with propofol and remifentanil (HTIVA group, n = 20) to maintain mean arterial pressure between 50 and 60 mm Hg. MEASUREMENTS Duration of hypotension, blood loss, blood transfusions, hemodynamics, and coagulation studies were recorded in both groups. MAIN RESULTS Intraoperative blood loss, percentage of patients receiving blood substitution, and total packed red blood cells transfused were less in those patients receiving HEA than those receiving HTIVA (P = .001, .04, and .015, respectively). Mean central venous pressure was lower in the HEA group than in the HTIVA group intraoperatively (P = .019). Mean hemoglobin concentrations and coagulation studies were similar between the groups. Neurologic examinations of all patients were intact in the postoperative period. CONCLUSIONS In spite the similar mean arterial pressure levels noted between groups, HEA results in less intraoperative blood loss than HTIVA during primary total hip replacement. This outcome may be associated with non-positive pressure ventilation, distribution of blood flow, and lower mean intraoperative central venous pressure in the HEA group.
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Affiliation(s)
- Ahmet Eroglu
- Faculty of Medicine, Department of Anesthesiology and Reanimation, Karadeniz Technical University, 61080 Trabzon, Turkey.
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Borghi B, Casati A, Iuorio S, Celleno D, Michael M, Serafini PL, Alleva R. Effect of different anesthesia techniques on red blood cell endogenous recovery in hip arthroplasty. J Clin Anesth 2005; 17:96-101. [PMID: 15809124 DOI: 10.1016/j.jclinane.2004.05.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2003] [Accepted: 05/19/2004] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE To compare the magnitude of postoperative red blood cell (RBC) recovery with 3 different anesthetic techniques, general anesthesia (GA), epidural anesthesia (EA) alone, and the combination of these 2 techniques (CA), in patients undergoing total hip arthroplasty. DESIGN Randomized, controlled study. SETTING Seven university or hospital departments of anesthesia. PATIENTS Two hundred ten patients with American Society of Anesthesiologists physical status I to III were randomly selected to receive EA, GA, or CA. INTERVENTION Patients undergoing total hip replacement were randomly assigned to 3 statistically comparable groups based on the type of anesthesia received: GA, EA, and CA groups. MEASUREMENTS AND MAIN RESULTS Intra- and postoperative blood loss was evaluated as either compensated or noncompensated blood loss by using Nadler's formula. The intra- and postoperative bleeding, referred to as compensated blood loss, was similar among groups. The circulating RBC mass, noncompensated blood loss, dropped on the first postoperative day to a similar extent among the groups. The endogenous recovery of the RBC is carried out on the fifth day after surgery in patients who underwent EA, whereas no RBC recovery was observed in those who had received GA alone or GA combined with EA. CONCLUSIONS Patients who had received EA had a faster recovery of the circulating erythrocyte mass than those who had had GA or CA. The presence of nitrous oxide in the anesthetic gas mixture might inhibit erythropoiesis by altering vitamin B(12) functions.
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Affiliation(s)
- Battista Borghi
- Department of Anesthesiology, IRCCS Orthopedic Institute of Rizzoli, Bologna, Italy.
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Abstract
OBJECTIVE To review the potential and proven benefits and complications of epidural anesthesia/analgesia. SUMMARY BACKGROUND DATA Advances in analgesia/anesthesia have improved patient satisfaction and perioperative outcomes. Epidural anesthesia/analgesia is one of these advances that is gaining rapid acceptance due to a perceived reduction in morbidity and overall patient satisfaction. METHODS A MEDLINE search was conducted for all pertinent articles on epidural anesthesia/analgesia. RESULTS Retrospective, prospective, and meta-analysis studies have demonstrated an improvement in surgical outcome through beneficial effects on perioperative pulmonary function, blunting the surgical stress response and improved analgesia. In particular, significant reduction in perioperative cardiac morbidity ( approximately 30%), pulmonary infections ( approximately 40%), pulmonary embolism ( approximately 50%), ileus ( approximately 2 days), acute renal failure ( approximately 30%), and blood loss ( approximately 30%) were noted in our review of the literature. Potential complications related to epidural anesthesia/analgesia range from transient paresthesias (<10%) to potentially devastating epidural hematomas (0.0006%). CONCLUSIONS Epidural anesthesia/analgesia has been demonstrated to improve postoperative outcome and attenuate the physiologic response to surgery.
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Affiliation(s)
- Robert J Moraca
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington 98101, USA
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[Spectral analysis of the ECG R-R interval permits early detection of vagal responses to neurosurgical stimuli]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2003; 22:421-4. [PMID: 12831969 DOI: 10.1016/s0750-7658(03)00094-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess the efficacy of ECG spectral analysis, compared with heart rate (HR) monitoring in the detection of vagal response to surgical stimuli. METHODS Twenty Asa II-III patients (age: 65 +/- 13 years) scheduled for surgery of cerebellopontine angle or implantation of sacral root stimulator were examined. Target controlled infusion of propofol (2-4 microg x ml(-1)) and remifentanil (4 ng x ml(-1)) was guided by the bispectral index (Bis). Arterial pressure via a radial catheter, pulse oximetry and end tidal CO2 were continuously monitored. Spectral analysis was achieved by connecting a computer to the cardiorespiratory monitor. Online power spectrum densities were calculated from the ECG R-R interval by software based on the fast Fourier transform (LabView, National Instruments, USA). Low frequency (LF: 0.04-0.15Hz) and high frequency (HF: 0.15-0.4Hz) were associated with sympathetic and parasympathetic activities respectively. We defined vagal reaction as a decrease in FC or an increase in HF >10% of the prestimuli value. HF and FC were compared according to the detection delay (by a Student t test with p < 0.05 considered significant) and a concordance test with a kappa coefficient (kappa): -1 = total discordance to 1 = total concordance. RESULTS Twelve vagal reactions (observed in 8 patients) were detected within 5.5 +/- 1.3 s (HF) and 12.4 +/- 1.6 (FC); p < 0.001. Concordance between the 2 parameters was 95% (kappa =0.9). CONCLUSION The ECG spectral analysis is a non-invasive technique, which permits the detection of intra-operative vagal reactions earlier than conventional monitoring of HR.
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Casati A, Santorsola R, Aldegheri G, Ravasi F, Fanelli G, Berti M, Fraschini G, Torri G. Intraoperative epidural anesthesia and postoperative analgesia with levobupivacaine for major orthopedic surgery: a double-blind, randomized comparison of racemic bupivacaine and ropivacaine. J Clin Anesth 2003; 15:126-31. [PMID: 12719052 DOI: 10.1016/s0952-8180(02)00513-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
STUDY OBJECTIVE To compare the onset time and duration of epidural anesthesia, and the quality of postoperative analgesia produced by levobupivacaine, racemic bupivacaine, and ropivacaine. DESIGN Prospective, randomized, double-blinded study. SETTING Inpatient anesthesia at a University Hospital. PATIENTS 45 ASA physical status I, II, and III patients, undergoing elective total hip replacement. INTERVENTIONS After standard intravenous midazolam premedication and infusion of 500 mL of Ringer's acetate solution, patients were randomly allocated to receive epidural block with 0.5% levobupivacaine (n = 15), 0.5% bupivacaine (n = 15), or 0.5% ropivacaine (n = 15). Postoperatively, after pinprick sensation recovered at T(t), a patient-controlled epidural infusion was provided with 0.125% levobupivacaine, 0.125% bupivacaine, or 0.2% ropivacaine, respectively (baseline infusion rate 5 mL/hr; incremental bolus 2 mL, lockout time: 20 min). Intravenous ketoprofen was also available for rescue analgesia if required. MEASUREMENTS AND MAIN RESULTS The onset time of sensory block was 31 +/- 16 minutes with levobupivacaine, 25 +/- 19 minutes with bupivacaine, and 30 +/- 24 minutes with ropivacaine (p = 0.98), after a median (range) volume of 15 (10-18) mL in Group Levobupivacaine, 14 (10-18) mL in Group Bupivacaine, and 15 (10-18) mL in Group Ropivacaine (p = 0.85). Six patients in the ropivacaine group (40%) showed an intraoperative Bromage score <2 as compared with only three patients of Group Levobupivacaine (20%) and no patient of Group Bupivacaine (p = 0.02). Recovery of pinprick sensation at T(t) occurred after 214 +/- 61 minutes with levobupivacaine, 213 +/- 53 minutes with bupivacaine, and 233 +/- 34 minutes with ropivacaine (p = 0.26). A similar degree of pain relief was observed in the three groups without differences in local anesthetic consumption and need for rescue analgesia. Motor blockade progressively resolved without differences among the three groups. CONCLUSIONS Levobupivacaine 0.5% produces an epidural block of similar onset, quality, and duration as the one produced by the same volume of 0.5% bupivacaine, with a motor block deeper than that produced by 0.5% ropivacaine. When prolonging the block for the first 12 hours after surgery with a patient-controlled epidural infusion, 0.125% levobupivacaine provides adequate pain relief after major orthopedic surgery, with similar recovery of motor function as compared with 0.125% bupivacaine and 0.2% ropivacaine.
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Affiliation(s)
- Andrea Casati
- Vita-Salute University of Milano-Department of Anesthesiology, IRCCS H San Raffaele, Milan, Italy.
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