Lower Limb Orthopedic Surgery Research Articles

The Effect of Epidural Magnesium Sulfate as An Adjuvant to Fentanyl for Postoperative Analgesia after Lower Limb Orthopedic Surgery

Background Magnesium, a physiological antagonist of calcium and N-methyl-D-aspartate receptors (NMDA), has a role in the prevention of pain in patients undergoing surgeries. Patients and Methods A prospective randomized double-blinded controlled study was conducted on 60 patients undergoing lower extremities arthroscopic surgery. Spinal anesthesia was given an epidural catheter inserted prior to surgery for postoperative pain management. Postoperatively, patients were randomly allocated into three equal groups. Group I (S group; n 20 patients) patients received epidural saline at a rate of 1ml/h for 24 hours. Group II (MI; n 20 patients) patients received 50mg magnesium sulfate followed by continuous epidural infusion of 100mg at a rate of 4mg/h. Group III (M II; n 20 patients) patients received 50mg magnesium sulfate followed by 500mg at a rate of 20 mg/h. All patients will be provided an infusion of fentanyl 3 mic/ml at a rate of 10 ml/h) via an epidural catheter. The visual analog score, vital signs, time of the first request for rescue analgesia, motor block, need for supplemental analgesic and adverse effects were recorded in the postoperative period. Results VAS scores were significantly lower in both MI and MII groups as compared with the control group at the 1st hour and the 2nd hour of the postoperative course. Conclusion The addition of epidural magnesium sulfate for postoperative analgesia provided a pronounced significant reduction in postoperative rescue analgesia with no significant difference between the two magnesium doses and minimal side effects. Keywords: Lower extremities, orthopedic surgeries, magnesium sulfate, and epidural.

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The role of preoperative oral pregabalin on acute post?operative pain after orthopedic lower limb surgery

Introduction: Postoperative pain after orthopedic surgery has remained a challenging problem, which prolongs hospital stay and early rehabilitation. Pregabalin comes under class of gabapentinoids that have been used in postoperative pain in arthroplasty and spine surgeries but studies regarding its role as preemptive analgesia in orthopedic limb surgeries are very few. Aim: To study the efficacy and safety of pregabalin as preemptive medication for acute postoperative pain management in patients undergoing orthopedic lower limb fracture surgeries. Materials and Methods: A randomized double blinded prospective study was undertaken. Sixty patients were enrolled with age between 18–70 years and were divided into 2 groups. Group A ­ received 150mg of oral pregabalin capsule, Group B – received matched colour empty capsules. Standard spinal anaesthesia was given. Breakthrough analgesia was given with Inj. Diclofenac 1.5 mg/kg i/m. Assessment of pain was done with visual analog scale (VAS). Results: There was marked reduction in postoperative VAS score in group A and the amount of breakthrough analgesia needed in the 24-hour postoperative period was also much lower in the Group A as compared to the Group B. Conclusion: 150mg of oral pregabalin as preemptive medication offers satisfactory postoperative analgesia in orthopaedic lower limb fracture surgeries with very few undesirable side effects. Keywords: Postoperative pain, Pregabalin, Gabapentinoids, Preemptive analgesia, Diclofenac, Visual analog scale.

Comparison between intrathecal nalbuphine and butorphanol as adjuvants to isobaric ropivacaine in elective lower limb orthopedic surgeries: A prospective, randomized, double blind study

Background: Intrathecal ropivacaine is now routinely used for lower limb surgery. Adjuvants e.g. fentanyl, dexmedetomidine or morphine etc. are commonly used to prolong the intraoperative anesthesia or postoperative analgesia. The available literature lacks information on use of butorphanol and nalbuphine as adjuvants with 0.75% isobaric ropivacaine. We aimed to compare nalbuphine and butorphanol as adjuvant with isobaric ropivacaine in lower limb orthopedic surgeries.
 Methodology: After institutional ethical committee approval and informed written consent, a total of 108 patients of ages between 18 to 65 y, of either sex, American Society of Anesthesiologists (ASA) grade ӏ & ӏӏ, scheduled for elective lower limb orthopedic surgeries, were enrolled and randomly allocated into two groups: Group RN; to receive isobaric ropivacaine (0.75%, 7.5 mg/ml) 2.5 ml plus nalbuphine 500 µg (0.5 ml), and Group RB; to receive isobaric ropivacaine 2.5 ml plus butorphanol 100 µg (0.5 ml) intrathecally. Primary outcome measure was the duration of sensory‑motor blockade from the time of intrathecal drug administration. Statistical analysis was performed by using t-test and chi-square test as applicable. A p < 0.05 was considered as significant.
 Results: Duration of sensory (p < 0.001) and motor blockade (p = 0.02) was significantly prolonged in nalbuphine group than butorphanol group. Onset of blockade was earlier in nalbuphine group. Duration of motor block and sensory analgesia was prolonged in group RN (p < 0.001). Perioperative hemodynamic parameters and the observed side effects including bradycardia, hypotension, nausea and vomiting, sedation and shivering were comparable between the two groups (p = 0.77).
 Conclusion: Intrathecal nalbuphine produces prolonged motor blockade as well as postoperative analgesia than intrathecal butorphanol when used as adjuvants to isobaric 0.75% ropivacaine.
 Citation: Nirmal A, Singh Y, Mathur SK, Patel S. Comparison between intrathecal nalbuphine and butorphanol as adjuvants to isobaric ropivacaine in elective lower limb orthopedic surgeries: A prospective, randomized, double blind study. Anaesth pain & intensive care 2019;23(4)__
 Received: 22 August 2019; Reviewed: 8, 9 October 2019; 6, 7 November 2019; Revised: 18 November 2019; Reviewed: 19 November 2019; Accepted: 20 November 2019

Bacterial Profile, Multi-Drug Resistance and Seasonality Following Lower Limb Orthopaedic Surgery in Tropical and Subtropical Australian Hospitals: An Epidemiological Cohort Study.

We aimed to describe the epidemiology, multi-drug resistance and seasonal distribution of bacteria cultured within 12 months following lower limb orthopaedic surgery in tropical and subtropical Australian hospitals between 2010 and 2017. We collected data from four tropical and two subtropical hospitals. Categorical variables were examined using the Pearson Chi-squared test or Fisher’s Exact test, and continuous variables with the Student t-test or Mann–Whitney U test. A Poisson regression model was used to examine the relationship between season, weather and the incidence of Staphylococcus and nonfermentative species. We found that at tropical sites, nonfermenters (Pseudomonas aeruginosa and Acinetobacter baumannii) were more common (28.7% vs. 21.6%, p = 0.018), and patients were more likely to culture multi-drug-resistant (MDR) nonfermenters (11.4% vs. 1.3%, p = 0.009) and MDR Staphylococcus aureus (35.9% vs. 24.6%, p = 0.006). At tropical sites, patients were more likely to be younger (65.9 years vs. 72.0, p = < 0.001), male (57.7% vs. 47.8%, p = 0.005), having knee surgery (45.3% vs. 34.5%, p = 0.002) and undergoing primary procedures (85.0% vs. 73.0%, p = < 0.001). Species were similar between seasons in both tropical and subtropical hospitals. Overall, we found that following lower limb orthopaedic surgery in tropical compared with subtropical Australia, patients were more likely to culture nonfermenters and some MDR species.

Comparison of nalbuphine versus fentanyl as an adjuvant to 0.75% isobaric ropivacaine in subarachnoid block for orthopedic surgery of lower limbs: A randomized, double-blind study

Background: Ropivacaine is an effective and safe alternative local anesthetic for subarachnoid block with a lesser duration of motor blockade and less neuro-cardiotoxicity. While fentanyl is commonly used as an adjuvant, nalbuphine recently got popular by its μ-attenuation and k-accentuation effects. We compared the efficacy of intrathecal fentanyl versus nalbuphine as an adjuvant to ropivacaine in subarachnoid block. Materials and Methods: In this prospective, randomized, double-blind study, seventy adult patients who were posted for elective lower limb orthopedic surgeries were randomly allocated to two groups. Group F received 22.5 mg of 0.75% isobaric ropivacaine with 25 μg fentanyl, and Group N received 22.5 mg of 0.75% isobaric ropivacaine with 1 mg nalbuphine intrathecally. Hemodynamics, onset, block duration, peak sensory level, two-segment regression time, and adverse effects such as nausea, vomiting, pruritus, sedation, hypotension, and bradycardia were studied. P < 0.05 was considered statistically significant. Results: Both groups achieved the target sensory level of T10. Time for onset of sensory and motor blockade, time to achieve peak sensory level, and motor block duration were statistically comparable in both groups. The duration of the sensory block was 254.45 ± 20.69 min in Group F and 297.4 ± 19.0 min in Group N (P < 0.001). The duration of analgesia was 275.6 ± 18.76 min in Group F and 318.2 ± 14.14 min in Group N (P < 0.001). Conclusions: Nalbuphine prolongs the duration of the sensory block along with the duration of postoperative analgesia in comparison to fentanyl as an intrathecal adjuvant to 0.75% isobaric ropivacaine for subarachnoid block.

Incidence and severity of pruritus in pregnant women undergoing lower-segment cesarean section under spinal anesthesia with fentanyl and bupivacaine

Background: Regional anesthesia and analgesia are being widely used nowadays, especially for lower-segment cesarean section (LSCS). However, according to some studies, as well as our observation, there is a high incidence of pruritus among patients undergoing LSCS under regional technique as compared to nonpregnant female patients. To enhance the quality of analgesia and increase the duration of spinal anesthesia, fentanyl is often added as an adjuvant drug. Till date, only few studies have reported the incidence of pruritus among this group after spinal anesthesia with added fentanyl, but none compared it to nonpregnant patients. Aim and Objective: The primary aim of this study was to estimate the magnitude of pruritus after intrathecal fentanyl in parturient patients. The secondary objective was to establish other pathophysiological mechanisms such as patient's body habitus and sex of the baby, which might influence the incidence and severity in this population as compared to nonpregnant patients. Materials and Methods: One hundred and sixty American Society of Anesthesiologists I and II female patients aged between 18 and 45 years were divided into two equal groups. Pregnant women group underwent LSCS, while nonpregnant patients had lower limb orthopedic surgery. Spinal anesthesia was administered using 20 mcg of fentanyl with 2.5 ml of 0.5% bupivacaine. Frequency and severity of pruritus were recorded in the patients of either group. Statistical analysis of the data was done using Chi-square test and logistic regression using SPSS version 22. A P 0.05). Conclusions: Pregnancy is not only a risk factor for pruritus after intrathecal fentanyl but is also responsible for increasing the severity of pruritus.

A COMPARATIVE STUDY OF EPIDURAL BUTORPHANOL AND TRAMADOL FORPOSTOPERATIVE ANALGESIA IN ORTHOPEDIC LOWER LIMB SURGERIES

Post operative pain management is a challenge in anaesthesia practice. Many opioids are available for epidural use with various side effects. The main objectives of the study is to asses and compare the postoperative analgesia and quality of analgesia with epidural butorphanol or tramadol in patients undergoing orthopaedic lower limb surgeries. 100 patients of either sex, belonging to 20-60 yrs of age, ASA grade I and II admitted for orthopedic lower limb surgeries were included in the study. In the post-operative period when the patients visual analogue score >4 received either 1 mg of butorphanol (group B) or 50 mg of tramadol (group T) diluted to 10 ml with normal saline. We monitored and compared the Onset ,Duration , Quality of analgesia, consciousness, Cardio-respiratory and Side effects. the mean time of onset of analgesia in group-T was 13.28±2.04 min and in group-B was 11.20±1.02 min, which is statistically significant(p<0.01). The duration of action of analgesia in group-T was 369.8±25.6 min and in group-B was 215.2±26.0 min which is Statistically significant as ‘p’ value is <0.01. Quality of Analgesia (VRS) was better with butorphanol group. The Quality of Analgesia (VRS) in group-T was 3.22±0.54 (SD) min and in group-B was 3.62±0.49 (SD) min (p<0.01) which is statistically significant. Sedation Score was significantly higher with butorphanol group at first hour(P<0.01). Tramadol group had significantly higher incidence of nausea and vomiting(P,0.01). In conclusion epidural butorphanol is better then epidural tramadol for post-operative analgesia. Epidural butorphanol produces faster onset of analgesia , but the duration of analgesia is lesser when compared to tramadol . Side effects like nausea and vomiting are less in butorphanal group but sedation score was higher. Patient satisfaction was better in butorphanol group

Characteristics of Block and Post-Operative Analgesia of Low Dose Intrathecal Fentanyl and Midazolam Combined With Hyperbaric 0.5% Bupivacaine in Patients Undergoing Lower Limb Orthopaedic Surgeries

Aim: To investigate characteristics of block and post-operative analgesia of low dose intrathecal Fentanyl and Midazolam combined with hyperbaric 0.5% bupivacaine in patients undergoing lower limb orthopaedic surgeries. Material and method: Selected consented 60 patients scheduled for orthopaedic surgeries under subarachnoid blockade were randomized into two comparable equal groups of 30 patients each i.e. Group A(Sub arachnoid block with addition of 25 μg (0.5 ml available preservative free) fentanyl to 3ml of 0.5% Bupivacaine hydrochloride (hyperbaric) and Group B: (Sub arachnoid block with addition of 1 mg (0.2 ml preservative free) midazolam (+ 0.3 ml normal saline) to 3ml of 0.5% Bupivacaine hydrochloride (hyperbaric).The motor block of the lower extremities was evaluated bilaterally by modified Bromage scale (0-3). Duration of sensory analgesia was taken from onset of spinal anesthesia to time of administration of first rescue analgesic, reflected on visual analogue scale (VAS). Results: The mean time required to achieve Complete Sensory blockade was 142.77±8.73 sec in patients of Group A and 138.57±7.65 sec in patients of Group B.Sedation score was recorded every 30 min for 90 mins (using Ramsay sedation score) considering the time of study drug given as zero in both groups.The mean sedation score at 30 mins in patients of Group A was 2.10±0.31 and in patients of Group B it was 2.27±0.45. Conclusion: It can be concluded that intrathecal midazolam can be used as an adjuvant to local anesthetics if fentanyl is not available or contraindicated.

Ultrasound Guided Paramedian versus Landmark Guided Midline Technique for Spinal Anaesthesia- A Randomised Clinical Trial

Introduction: Spinal anaesthesia has been traditionally performed using landmark guided technique. Ultrasound helps in identifying the insertion point, depth, as well as angle of the needle advancement by visualisation of the neuraxial structures, thus, increasing the probability of successful dural puncture. Aim: To compare the success rates of dural puncture at first attempt between Preprocedural Ultrasound (PUS) guided paramedian and landmark guided midline approach in spinal anaesthesia. Materials and Methods: This was a randomised clinical study, conducted at a Tertiary Care Hospital during May 2017-December 2018. Patients (n=110) undergoing lower limb orthopaedic surgery were randomly allocated into group US (PUS guided with paramedian approach) and group LM (landmark guided with midline approach), with 55 patients each. Number of attempts and passes, procedure time, any complication, periprocedural pain and patient satisfaction were noted. The correlation between quality of ultrasound view and success rate was also analysed using Fisher’s-exact test. Results: The success rate of dural puncture at first attempt was 89.09% in US group versus 76.36% in LM group, p&gt;0.05. Total number of needle insertion attempts (1.31±0.63 in group LM, 1.11±0.31 in group US, p&gt;0.05) were comparable. Total procedure time was higher (11.96±1.55 minutes) in US group as compared to LM group (3.26±0.68 minutes), p&lt;0.001. Periprocedural pain score was significantly lower in US group with p&lt;0.01. The patient satisfaction score was comparable in the two groups, p&gt;0.05. Correlation between the quality of parasagittal oblique view and success rate of dural puncture was good, p&lt;0.01. Conclusion: PUS guided paramedian approach does not significantly increase the success rate at first attempt as compared to midline landmark guided approach.

Comparative study of postoperative analgesia provided by butorphanol and fentanyl as an adjunct to spinal levo-bupivacaine for lower limb orthopaedic surgeries

Comparative study of postoperative analgesia provided by butorphanol and fentanyl as an adjunct to spinal levo-bupivacaine for lower limb orthopaedic surgeries

Use of Peripheral Nerve Blocks in Perioperative Management of Cases with Hypertrophic Cardiomyopathy Undergoing Lower Limb Orthopedic Surgeries.

Hypertrophic obstructive cardiomyopathy is a type of hypertrophic cardiomyopathy (HCM) that involves the left ventricular outflow tract obstruction. Most important parameters are preload, afterload, and ventricular contractility that are prone to fluctuations in HOCM patients in the perioperative period due to the surgical procedure, anesthetic agents and changes in intravascular volume. These lead to increased chances of arrhythmias and myocardial ischemia and can pose significant morbidity and mortality in HCM patients perioperatively. Here, we report three challenging cases of HCM with comorbidities who underwent successful operative management of lower limb fractures using regional nerve blocks. Although general anaesthesia is usually preferred in cases of HCM, this was not the preferred choice in these cases due to the asthmatic status, extremes of age, and also associated comorbidities such as chronic kidney disease Stage IV on maintenance hemodialysis. We selected Ultrasonography and peripheral nerve stimulator (PNS) guided regional nerve blocks including lumbar plexus and parasacral approach of sciatic nerve block in the first two patients and fascia iliaca compartment block with parasacral sciatic nerve block in the third case to successfully manage the patients perioperatively. Postoperative pain management was satisfactory. All the patients were discharged in a hemodynamically stable condition with advice for follow-up.

Direct Oral Anticoagulants in the Prevention of Venous Thromboembolism Following Surgery for Hip Fracture in Older Adults: A Population-Based Cohort Study.

Introduction:Direct oral anticoagulants (DOACs) decrease the risk of venous thromboembolism (VTE) without increasing the risk of hemorrhage in elective lower limb orthopedic surgery. However, the role of DOACs in preventing VTE following hip fracture surgery in the older adults remains unclear. This study aims to evaluate the efficacy and safety of DOACs in older adults undergoing surgery for hip fracture.Materials and methods:Single-center, retrospective, population-based cohort study of patients receiving either a DOAC or low-molecular-weight heparin (LMWH) for VTE prophylaxis following hip fracture surgery. Data obtained included patient demographics, comorbidities, fracture classification, time to surgery, procedure performed, and length of stay. Main outcomes assessed were incidence of VTE, incidence of major hemorrhage, and death within 30 days of surgery.Results:A total of 321 patients were included. Incidence of VTE was 0% in the DOAC group and 3.4% in the LMWH group (risk ratio [RR]:0.26, 95% confidence interval [CI]: 0.02-4.34, P = .35). Hemorrhage occurred in 7.4% and 3.0% of patients in the DOAC and LMWH groups, respectively (RR: 2.47, 95% CI: 0.77-7.91, P = .13). Mortality from VTE was 0% in the DOAC group and 0.7% in the LMWH group (RR: 0.97, 95% CI: 0.05-20.02, P = .99). Mortality from hemorrhage was 1.9% in the DOAC group and 0.7% in the LMWH group (RR: 2.47, 95% CI: 0.23-26.78, P = .46).Discussion:The use of DOACs for VTE prophylaxis following surgery in older adults with hip fracture was associated with a similar rate of VTE compared to LMWH. However, there was a worrying trend toward an increased risk of hemorrhage.Conclusion:In the present study of a carefully selected cohort of patients, the effect of DOACs in reducing the risk of VTE following surgery for hip fracture in the older adults was comparable to LMWH. However, a trend toward increased risk of hemorrhage was noted. Larger prospective studies will be required to identify patients who will benefit the most from treatment.

A randomized controlled trial on epidural volume extension in combined spinal epidural anesthesia for lower limb surgeries using intrathecal ropivacaine in older adults

Background: Epidural volume extension (EVE) is a technique wherein normal saline is injected into epidural space, soon after the neuraxial block. We studied the effectiveness of EVE using intrathecal ropivacaine and normal saline in the elderly. Patients and Methods: This was randomized, control, double-blinded, double arm, parallel study of 75 patients of American Society of Anesthesiologists I and II, age ≥60 years, undergoing lower limb orthopedic surgery. Patients were allocated into two groups (E and NE), both receiving 3 ml of 0.75% injection ropivacaine intrathecally. Group E also received EVE. The primary outcome was the maximum level of sensory block. Secondary outcomes were the characteristics of blocks, hemodynamic changes, adverse effects, and analgesic requirements until 24 h. The statistical analysis of quantitative data was done by the Student's t-test and that of qualitative data using the Chi-square test. Results: The sensory level of block achieved in Group E T4(T2–T5) was higher as compared to Group NE, T6(T3-T8). Time to two-segment sensory regression was earlier in Group NE (mean = 66.5 min; 95% confidence interval [CI], 63.31–69.69) than in Group E (mean = 91.5 min; 95% CI, 87.70–95.31) (P < 0.001; df = 58). The duration of analgesia in Group E (mean = 316.5 min; 95% CI, 309.09–323.91) was more than in Group NE (mean = 230.67 min; 95% CI, 226.49–234.850) (P < 0.001). There was no statistically significant difference in the 24 h analgesic consumption (P = 0.64), hemodynamic stability, or adverse effects. Conclusion: EVE results in a higher level of the sensory block and a longer duration of postoperative analgesia than that without EVE with no hemodynamic instability in the older population.

Does an acute pain service improve the perception of postoperative pain management in patients undergoing lower limb surgery? A prospective controlled non-randomized study

Background and Aim:An acute pain service (APS) has been running in our institute since April 2013 and is managed by the Department of Anesthesia and Intensive Care. However, it is not clear to what extent the patients feel benefited from the APS. The aim of the study was to compare the perception of postoperative pain management in patients receiving care under APS with those receiving routine postoperative pain relief following lower limb surgery.Material and Methods:This was a prospective, hospital-based, controlled non-randomized study. American Society of Anesthesiologists (ASA) grades I–III patients with age 18–75 years undergoing lower limb orthopedic surgery were prospectively recruited into APS (index group) or routine postoperative care (control group) (n = 55 each). Postoperatively, American Pain Society Patient Outcome Questionnaire-Revised (APS-POQ-R) and Short Form (SF-12) were used to evaluate the outcome of postoperative pain management at 24 h and health-related quality of life after 4 weeks respectively.Results:Both groups were comparable in terms of demographic data. Patients in the index group had statistically significant better perception of care than the control group. Index group scored significantly higher than control group on median patient satisfaction score (9; interquartile range [IQR] [7–10] vs. 5 [3–6]; P < 0.001). In index group, there was significant reduction of worst pain in first 24 h along with decreased frequency of severe pain.Conclusion:Implementation of acute pain service plays an important role in improving the quality of postoperative pain relief, perception of care, and patient satisfaction.

Comparison of the efficacy of epidural nalbuphine versus dexmedetomidine on the characteristics of spinal anaesthesia in patients undergoing lower limb orthopaedic surgeries: A prospective randomised, double-blind, placebo-controlled study

Background: Using adjuvants to local anaesthetic agents either intrathecally or epidurally is a common practice for achieving longer duration of a denser neuraxial block to provide adequate intraoperative conditions, for the length of the procedure. Methods: We compared the efficacy of epidural dexmedetomidine or nalbuphine on the characteristics of spinal anaesthesia in patients undergoing lower limb orthopaedic surgeries. Ninety patients were randomly allocated to three groups (n = 30 each). Group D received dexmedetomidine 1.5 μg/kg diluted to 5 mL; Group N received nalbuphine 0.2 mg/kg diluted to 5 mL and Group S received 5 mL of normal saline epidurally 10 min before receiving subarachnoid block (SAB) with 0.5% heavy bupivacaine. Results: The three groups were comparable demographically and haemodynamically. Significantly shorter time for the onset of sensory and motor block (sec), longer duration of sensory and motor blockade (min), higher sedation scores intraoperatively and postoperatively were observed in GroupD compared to other two groups. VAS scores were lower in Group D for a significantly longer period postoperatively, at 60 min, 120 min and 180 min than in other two groups (P Conclusions: Both dexmedetomidine and nalbuphine were found to be useful and safe epidural adjuvants when given prior to SAB. Dexmedetomidine was found to be a better choice of epidural adjuvant when compared to nalbuphine in terms of earlier onset and longer duration of both sensory and motor block, longer post-operative analgesia and useful intraoperative sedation.

Comparative Study of Intrathecal Hyperbaric 0.5% Bupivacaine and Hyperbaric 0.5% Bupivacaine with Low Dose Dexmedetomidine in Lower Limb Orthopaedic Surgeries

Comparative Study of Intrathecal Hyperbaric 0.5% Bupivacaine and Hyperbaric 0.5% Bupivacaine with Low Dose Dexmedetomidine in Lower Limb Orthopaedic Surgeries

The Effect of Negative Pressure Therapy on Closed Wound After the Orthopedic Surgery of Lower Limb: A Meta-Analysis

Background. Negative-pressure wound therapy is applied increasingly to manage closed wounds. However, no consensus has been reached with regard to surgical site infection and wound complication. Aim. To evaluate the effect of negative pressure therapy on closed wounds after orthopedic surgeries. Methods. PubMed, EMBASE, Cochrane Library, and MEDLINE databases were searched from 1966 to January 2019; the references in the identified studies were also searched. Results. Ten studies on arthroplasty and 3 studies on fractures were included. Significantly few infections appeared in the negative pressure group (odds ratio [OR] = 0.28, 95% confidence interval [CI] = 0.18-0.46, P < .001; I2 = 0%, P = .80). There was no significant difference for other complications (OR = 0.54, 95% CI = 0.21-1.39, P = .20; I2 = 81%, P < .001). Few patients needed reoperation in the negative pressure group (OR = 0.28, 95% CI = 0.14-0.53, P < .001; I2 = 0%, P = .82). Conclusion. Negative pressure therapy can decrease surgical site infection and reoperation of closed incisions.

Fractalidade e comportamento caótico da variabilidade da frequência cardíaca como preditores de hipotensão após raquianestesia: protocolo de ensaio clínico randomizado

Introdução: Todas as drogas e técnicas que induzem o estado anestésico atuam de alguma forma no SNA. A administração de anestésicos locais no espaço subaracnóideo produz bloqueio motor, sensitivo e simpático, com latências e níveis de bloqueio variáveis e independentes. O bloqueio motor é o primeiro a ser instalado, seguido pelo simpático e sensitivo. O bloqueio simpático afeta de 2 a 6 dermátomos acima do bloqueio sensitivo. A recuperação da raquianestesia é avaliada através de uma escala definida em 1979 por Bromage e baseia-se exclusivamente no retorno da função motora e não leva em conta a recuperação da atividade da SNA. A persistência do bloqueio simpático pode implicar em maior incidência de retenção urinária, bradicardia e hipotensão. Objetivo: Caracterizar a variabilidade da frequência cardíaca durante anestesia subaracnóidea por meio de métodos lineares no domínio da frequência e métodos não lineares no domínio caos e definir a duração do bloqueio autonômico em raquianestesia através desses parâmetros, bem como identificar índices de variabilidade da frequência cardíaca (VFC) que podem ser usados como preditores de hipotensão perioperatória. Método: Um ensaio clínico randomizado, duplo-cego será realizado em um hospital de grande porte localizado na região sul do Ceará, no Brasil, e no HUJB em Cajazeiras, na Paraíba. Sessenta pacientes do ambulatório de anestesia serão incluídos. Os pacientes serão divididos em dois grupos: um grupo receberá Bupivacaína com clonidina e o outro grupo receberá apenas bupivacaína na dose de 15 mg. A amostra será composta por 60 pacientes ASA I a III, a serem submetidos a cirurgia ortopédica de membros inferiores e abdome inferior sob raquianestesia. A Variabilidade da Frequência Cardíaca será avaliada em três momentos: repouso, antes da anestesia; 20 min após a instalação do bloqueio, e no momento da recuperação da função motora, de acordo com os critérios de Bromage. Será avaliada a incidência de hipotensão perioperatória nos dois grupos. Métodos lineares serão utilizados no domínio da freqüência e não-lineares no domínio do caos: plot de Poincaré, entropia aproximada, Análise de Flutuação Destendenciada (DFA) e Dimensão de Correlação. Os dados serão recolhidos através de um cardiofrequencímetro Polar V800® e devidamente submetidos para análise e filtragem pelo software Kubios 3.0®. Discussão: Na literatura encontramos dados avaliando a instalação do bloqueio simpático através da VFC utilizando métodos lineares, no entanto, faltam estudos utilizando métodos baseados no domínio do caos. Alguns estudos abordam o valor da VFC como um preditor de hipotensão após a anestesia subaracnóidea, principalmente usando métodos lineares no domínio da frequência. Entende-se ser importante analisar esses fatores utilizando métodos já validados no domínio do caos, complexidade e fractalidade, mais compatíveis com a complexidade do comportamento dos sistemas biológicos, na caracterização da função autonômica durante a anestesia subaracnóidea. Registro: O ensaio clínico foi registrado no Registro Brasileiro de Ensaios Clínicos (ReBEC) sob o número RBR-4Q53D6.

Application of ultrasound-guided nerve block combined with patient-controlled intravenous analgesia after orthopedic surgery in elderly patients analgesia for enhanced recovery after surgery

Objective To observe the effect of ultrasound-guided nerve block combined with patient-controlled intravenous analgesia(PCIA) as a postoperative analgesic method for elderly patients with lower limb orthopedic surgery. Methods Seventy-two elderly patients undergoing lower limb orthopedic surgery are randomly divided into three groups, each consisting of 24cases: patient-controlled intravenous analgesia(PCIA) group (group Ⅰ), ultrasound-guided single injection of nerve block analgesia + PCIA group (group Ⅱ), ultrasound-guided continuous injection of nerve block analgesia + PCIA group (group Ⅲ). The VAS scores of pain and the doses of sufentanil are compared at the 6th, 12th, 24th, 36th, and 48th hours after surgery, and the postoperative adverse reactions and overall satisfaction were observed. Results At the 6th, 12th, 24th, and 36th hours after operation, the differences in the doses of sufentanil and VAS scores between the groups are statistically significant (P<0.01), with the highest in group Ⅰ and the lowest in group Ⅱ. Differences in the incidence of adverse reactions between the groups are statistically significant (χ2=9.333, P<0.01), with the highest in group Ⅰ (45.83%) and the lowest in group Ⅲ (8.33%). Differences in the overall satisfaction between the groups are statistically significant (χ2=6.799, P<0.05), with the highest in group Ⅱ (66.67%) and the lowest in group Ⅰ (29.16%). Conclusion Being both effective and safe, ultrasound-guided nerve block combined with PCIA is an ideal postoperative analgesic method for elderly patients with lower limb orthopedic surgery. Key words: Ultrasound; Nerve block; Analgesia; Enhanced recovery after surgery