Acquired Idiopathic Stiffness After Contemporary Total Knee Arthroplasty: Incidence,Risk Factors,and Results Over 25 Years

BackgroundAcquired idiopathic stiffness (AIS) remains a common failure mode of contemporary total knee arthroplasties (TKAs). The present study investigated the incidence of AIS and manipulation under anesthesia (MUA) at a single institution over time, determined outcomes of MUAs, and identified risk factors associated with AIS and MUA.MethodsWe identified 9771 patients (12,735 knees) who underwent primary TKAs with cemented, modular metal-backed, posterior-stabilized implants from 2000 to 2016 using our institutional total joint registry. Mean age was 68 years, 57% were female, and mean body mass index was 33 kg/m². Demographic, surgical, and comorbidity data were investigated via univariate Cox proportional hazard models and fit to an adjusted multivariate model to access risk for AIS and MUA. Mean follow-up was 7 years.ResultsDuring the study period, 456 knees (3.6%) developed AIS and 336 knees (2.6%) underwent MUA. Range of motion (ROM) increased a mean of 34° after the MUA; however, ROM for patients treated with MUA was inferior to patients without AIS at final follow-up (102° vs 116°, P < .0001). Significant risk factors included younger age (HR 2.3, P < .001), increased tourniquet time (HR 1.01, P < .001), general anesthesia (HR 1.3, P = .007), and diabetes (HR 1.5, P = .001).ConclusionAcquired idiopathic stiffness has continued to have an important adverse impact on the outcomes of a subset of patients undergoing primary TKAs. When utilized, MUA improved mean ROM by 34°, but patients treated with MUA still had decreased ROM compared to patients without AIS. Importantly, we identified several significant risk factors associated with AIS and subsequent MUA.Level of EvidenceLevel III, retrospective comparative study.     

Impact of Dexamethasone on Length of Stay and Early Pain Control in Direct Anterior Approach Total Hip Arthroplasty With Neuraxial Anesthesia

BackgroundDexamethasone has been shown to reduce postoperative pain and opioid consumption for total joint arthroplasty patients; however, its impact on patients who received neuraxial anesthesia (NA) is not well described. We examined the impact of perioperative dexamethasone on outcomes for patients undergoing direct anterior approach total hip arthroplasty (THA) under NA.MethodsA retrospective review was conducted for 376 THA patients from a single institution. Univariate analysis was used to compare postoperative outcomes for 164 THA patients receiving dexamethasone compared to 212 who did not receive dexamethasone.ResultsNo differences in age, gender, body mass index, or American Society of Anesthesiologists (ASA) Score were observed between the groups. Patients receiving perioperative dexamethasone reported statistically significantly lower postanesthesia care unit (PACU) pain numeric rating scale (Dexamethasone 1.6 vs No dexamethasone 2.3, P = .014) and received lower PACU morphine milligram equivalents (MME) (Dexamethasone 8.57 vs No dexamethasone 11.44, P < .001). Patients receiving dexamethasone had significantly shorter LOS (Dexamethasone 29.40 vs No dexamethasone 35.26 hrs., P < .001).ConclusionPerioperative dexamethasone is associated with decreased postoperative pain and narcotic consumption, and shorter length of stay for patients undergoing primary direct anterior approach THA with NA.     

Liposomal Bupivacaine vs Ropivacaine for Adductor Canal Blocks in Total Knee Arthroplasty: A Prospective Randomized Trial

BackgroundThe purpose of this study is to determine the benefit of the analgesic liposomal bupivacaine compared to ropivacaine, by assessing pain and joint stiffness, and total oral opioid consumption by milligram morphine equivalent (MME) after total knee arthroplasty.MethodsPatients were randomized to receive either the study drug (liposomal bupivacaine admixed with bupivacaine) or the control drug (ropivacaine) in an adductor canal block. Only the anesthesiologist performing the block was aware of which arm of the study the patient was randomized to. MME, pain, Knee injury and Osteoarthritis Outcome Score Joint Replacement, and overall benefit of analgesia scores were recorded 24, 48, and 72 hours post-surgery either face-to-face or via telephone depending on patient discharge status.ResultsOne hundred patients were enrolled into the study and analyzed: 54 in the control group and 46 in the experimental group. Primary outcomes measured were pain as a numerical rating scale, MME, and length of stay in hours. Secondary outcomes were joint pain and stiffness recorded as Knee injury and Osteoarthritis Outcome Score Joint Replacement outcome and overall benefit of analgesia score. No statistically significant between-group differences were observed for any measured outcome.ConclusionWe did not find any supporting evidence that liposomal bupivacaine yields increased pain relief following total knee arthroplasty compared to the control drug, ropivacaine.     

Vía clínica de recuperación intensificada en cirugía cardiaca. Documento de consenso de la Sociedad Española de Anestesiología,Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) y la Asociación Española de Perfusionistas (AEP)

The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.     

Bloqueo del plano del músculo erector de la columna para analgesia de dolor lumbar crónico: serie de casos

BackgroundChronic low back pain (CLBP) is a frequent condition, poorly managed with conventional treatments. The ultrasound-guided erector spinae plane block has increasingly been used in the management of acute and chronic pain. We aimed to determine this technique's analgesic efficacy in patients with moderate to severe CLBP.MethodsTen consecutively selected patients: adults, regularly followed in our Pain Clinic with moderate/severe long-term CLBP refractory to pharmacological treatment, VAS > 4. Prospective data collection: before the intervention –demographical data, past medical history, current pain therapies, VAS pain level, Brief Pain Inventory– Short Form and Neuropathic Pain Questionnaire; 30 minutes after – VAS and satisfaction level; 24 and 72 hours, 7 days and 1 month after - complications and pain level.ResultsMajority of females (90%), mean age of 70.3 years-old. All had primary musculoskeletal CLBP. 90% experienced severe pain (VAS > = 7) in the last 24 hours. Half presented neuropathic characteristics. Patients were very satisfied with the technique (mean: 8.75) with immediate pain relief (VAS mean: 2.3). 24 and 72 hours, 7 days and 1 month after the treatment VAS means were 3.2, 3.1, 3.8 and 6.2. We report a 20.8 days duration mean. No short or long-term complications.Discussion and conclusionsUltrasound-guided erector spinae plane block has preliminary advantages in CLBP: easily performed with low complications risk, immediate discharge home with absence of motor block, 100% efficacy at short and medium-terms. Even though pain's relief was shorter than a month, it is a useful tool allowing patients’ well-being, physical rehabilitation and exercise during this period.     

Effect of QT interval prolongation on cardiac arrest following liver transplantation and derivation of a risk index

Liver transplantation (LT) has a 4-fold higher risk of periprocedural cardiac arrest and ventricular arrhythmias (CA/VAs) compared with other noncardiac surgeries. Prolongation of the corrected QT interval (QTc) is common in patients with liver cirrhosis. Whether it is associated with an increased risk of CA/VAs following LT is unclear. Rates of 30-day CA/VAs post-LT were assessed in consecutive adults undergoing LT between 2010 and 2017. Pretransplant QTc was measured by a cardiologist blinded to clinical outcomes. Among 408 patients included, CA/VAs occurred in 26 patients (6.4%). QTc was significantly longer in CA/VA patients (475 ± 34 vs 450 ± 34 ms, P < .001). Optimal QTc cut-off for prediction of CA/VAs was ≥480 ms. After adjustment, QTc ≥480 ms remained the strongest predictor for the occurrence of CA/VAs (odds ratio [OR] 5.2, 95% confidence interval [CI] 2.2-12.6). A point-based cardiac arrest risk index (CARI) was derived with the bootstrap method for yielding optimism-corrected coefficients (2 points: QTc ≥480, 1 point: Model for End-Stage Liver Disease [MELD] ≥30, 1 point: age ≥65, and 1 point: male). CARI score ≥3 demonstrated moderate discrimination (c-statistic 0.79, optimism-corrected c-statistic 0.77) with appropriate calibration. QTc ≥480 ms was associated with a 5-fold increase in the risk of CA/VAs. The CARI score may identify patients at higher risk of these events. Whether heightened perioperative cardiac surveillance, avoidance of QT prolonging medications, or beta blockers could mitigate the risk of CA/VAs in this population merits further study.     

When laparoscopy for fertility preservation prior to gonadotoxic treatment of an anterior mediastinal mass is a dilemma: A case report

IntroductionThe management of anterior mediastinal masses is a challenge for anesthesiologists. Recommendations for their management in the context of diagnostic or curative surgery are well described. The added risk of laparoscopic surgery for fertility preservation has however never been discussed in the literature.Presentation of caseWe present the case of a 32-year-old female patient with a large malignant anterior mediastinal mass. She was referred for anesthesia evaluation before laparoscopic ovarian tissue harvesting as part of fertility preservation prior to gonadotoxic treatment. The patient presented dyspnea at rest. Chest computed tomography revealed a tracheal deviation and a partial obstruction of the left mainstem bronchus. Transthoracic echocardiography showed a pericardial effusion. Proceeding to high risk anesthesia for a non-curative surgery in a patient with a highly symptomatic mass was considered unacceptable and the procedure was postponed. The patient received a single cycle of neoadjuvant chemotherapy. Clinical and radiological improvement were shown after this single dose and laparoscopic surgery was performed under general anesthesia without complications.ConclusionIn the context of an anterior mediastinal mass and fertility preservation a thorough benefit-risk analysis must be undertaken before non-curative laparoscopic surgery. In case of severe symptoms, surgery should be postponed until the patient’s condition improves after the minimum necessary chemotherapy treatment. So far it is impossible to say whether the risk exceeds the expected benefit in this difficult situation. Further studies need to be conducted in this area.     

不同浓度、剂量布比卡因用于剖宫产脊麻的效果比较

目的研究比较不同浓度、剂量,等比重布比卡因对产妇的麻醉效果及新生儿的影响,为临床麻醉提供参考依据。方法选择ASAⅠ~Ⅱ级初次足月妊娠拟择期剖宫产手术孕妇80例,随机分为A、B二组,每组各40例。均在左侧卧位下行腰-硬联合穿刺,L2-3进针,见脑脊液外流后,针斜面向下注入等比重布比卡因:A组:8mg(0·5%,1·6ml;配法:0·75%布比卡因2ml+脑脊液1ml);B组:9·6mg(0·6%,1·6ml;配法:0·75%布比卡因2ml+脑脊液0·5ml),20s注药完毕。记录麻醉前(基础值)和脊麻注药后1、3、5、7、10、15min各时间点的平均动脉压(MAP)、心率(HR)、脉搏血氧饱合度(SpO2)。测定并记录麻醉起效时间、平面固定时间、最高麻醉平面点(胸,T)、麻醉完全消退时间、下肢阻滞的最大程度、麻醉并发症等。结果A组感觉阻滞起效时间长于B组(69·27±21·48vs52·43±27·61s,P<0·05);两组最高阻滞平面(T4·50±1·44vsT4·10±0·57)及最高阻滞平面的固定时间(7·69±1·36vs7·35±1·22min)相似(P>0·05)。A组麻醉完全消退时间快于B组(218·40±18·57vs256·22±16·72min,P<0·05);Bromage评分A组明显小于B组(2·03±0·68vs2·93±0·21,P<0·05);麻醉后B组低血压发生率明显高于A组(P<0·05)。两组病人的麻醉效果均优,肌松满意。所有新生儿的Apgar评分均在7分以上,无组间差异。结论两组病人均产生了良好的脊麻效果,权衡利弊剖宫产脊麻时应用8mg(0·5%,1·6ml)布比卡因更为安全合理。