Lower Limb Orthopedic Surgery Research Articles

Efficacy of 5 µg and 10 µg Dexmedetomidine as Adjuvants to 3 mL 0.5% Hyperbaric Bupivacaine in Pelvic and Lower Limb Orthopaedic Surgeries: A Randomised Clinical Study

Introduction: Low-dose bupivacaine used in spinal anaesthesia results in speedy recovery. For lower limb orthopaedic surgeries, to provide sufficient anaesthesia and prolong postoperative analgesia in a less cumbersome way, author can add potent adjuvants like dexmedetomidine (an alpha-2 adrenergic receptor agonist) in effective and safer doses intrathecally. Aim: To compare the effects of intrathecal 5 µg dexmedetomidine versus 10 µg dexmedetomidine as adjuvants to 3 mL of 0.5% hyperbaric bupivacaine in pelvic and lower limb orthopaedic surgeries. Materials and Methods: This randomised clinical and singleblind study study was conducted at the Operation Theatre (OT) complex of Dheeraj Hospital, SBKS, and MIRC, Sumandeep Vidyapeeth, Vadodara, Gujarat, India in the Department of Anaesthesia over a period of 18 months, from September 2022 to March 2024 and total of 82 patients scheduled for lower limb and pelvic orthopaedic surgery who were to receive spinal anaesthesia were divided into Group D1 and D2. Group D1 (n=41) received 3 mL of bupivacaine (0.5% heavy) with 5 µg dexmedetomidine, totaling 3.1 mL, while group D2 (n=41) received 3 mL of bupivacaine (0.5% heavy) with 10 µg dexmedetomidine, also totaling 3.1 mL intrathecally. The onset and duration of sensory and motor blockade, as well as the duration of analgesia, were noted, along with the monitoring of haemodynamic parameters and any side effects. All observed data were analysed using statistical tests such as the unpaired t-test and Chi-square test. A p-value <0.05 was considered statistically significant. Results: Demographic data were comparable in both groups and were non significant (p-value >0.05). The onset of sensory block was earlier in group D2 (2.01±0.12 min) than in group D1 (2.87±0.36 min) (p-value <0.05). The onset of motor block was also earlier in group D2 (2.63±0.26 min) compared to group D1 (3.36±0.43 min). The duration of sensory block was longer in group D2 (457.46±32.85 min) than in group D1 (318.02±32.27 min). The duration of motor block was also longer in group D2 (396.17±36.13 min) than in group D1 (257.37±25.02 min) (p-value <0.05). The duration of analgesia and the time until the need for the first rescue analgesia was significantly longer in group D2 (364.29±43.64 min) compared to group D1 (219.51±23.39 min). Conclusion: Intrathecal bupivacaine with dexmedetomidine at a dose of 10 µg results in an earlier onset and longer duration of sensory and motor block compared to a dose of 5 µg. The duration of postoperative analgesia was longer, and the time until the need for the first rescue analgesia was extended with the 10 µg dosage. No significant side effects were observed in either group.

Effect of Different Doses of Intrathecal Nalbuphine as Adjuvant to Hyperbaric Bupivacaine on Characteristics of Subarachnoid Block in Pelvic and Lower Limb Orthopaedic Surgeries: A Randomised Clinical Study

Introduction: Hyperbaric bupivacaine 0.5% is most commonly used amide local anaesthetic drug in spinal anaesthesia. Various additives have been used as an adjuvant to hyperbaric bupivacaine 0.5% to modify its anaesthetic properties. Nalbuphine, a mix opioid with high efficacy kappa receptors agonism has also been used as an adjuvant to hyperbaric bupivacaine 0.5% at different doses. Aim: To compare and discover the effective dose of nalbuphine as adjuvant in subarachnoid block with hyperbaric bupivacaine in pelvic and lower limb orthopaedic surgeries in terms of onset and duration of sensory and motor block along with postoperative analgesia duration. Materials and Methods: This randomised clinical study was conducted in the Department of Anaesthesia, Shrimati Bhikhiben Kanjibhai Shah Medical Institute and Research Centre (SBKS MIRC), Piparia, Vadodara, Gujarat, India over a period of 18 months from February 2023 to August 2024 on 80 patients belonging to 20-60 years of age, American Soceity of Anaesthesiology (ASA) Grade I or II, of either gender undergoing elective pelvic and orthopaedic surgeries. Patients were randomly divided into two groups having 40 patients each. Group A received hyperbaric bupivacaine 12.5 mg+0.4 mg nalbuphine (total 3 mL) and Group B received hyperbaric bupivacaine 12.5 mg + 0.8 mg nalbuphine (total 3 mL). Sensory and motor block characteristics like their onset time, time to achieve highest sensory level, time to achieve bromage 3, time of two segment regression, duration of sensory and motor block, duration of postoperative analgesia and time for requirement of first rescue analgesia dose were observed and assessed. Haemodynamic parameters along with intraoperative and postoperative sideeffects were also observed. Results: Both the study groups had similar demographics and haemodynamic parameters. Time of two segment regression of sensory block was significantly longer in Group B (135.25±11.49 min) than A (120.95±16.98 min) with statistically significant prolonged duration of sensory block in Group B (228.25±21.91 min) than A (206.75±15.21 min) (p<0.0001). Postoperative analgesia was also prolonged in Group B (294.75±19.15 min) than A (226.19±14.78 min) without significant increase the incidence of side-effects (p≥0.05). Conclusion: Study concluded that 0.8 mg nalbuphine as an adjuvant to 0.5% hyperbaric bupivacaine in subarachnoid block is more effective dose as it provides prolonged duration of sensory block and postoperative analgesia with good haemodynamic stability and minimal side-effects.

Intrathecal Clonidine versus Dexmedetomidine as Adjuvants to Hyperbaric Ropivacaine in Lower Limb Orthopaedic Surgeries: A Randomised Clinical Study

Introduction: Subarachnoid block is the most chosen mode for orthopaedic surgeries in lower limb. Adjuvants such as opioids and α2 agonists are often added intrathecally to improve or prolong the anaesthetic and analgesic effects. Ropivacaine, a novel local anaesthetic agent, is widely accepted as it has better safety profile as compared to bupivacaine and lignocaine. Aim: To compare clonidine and dexmedetomidine as adjuvants to hyperbaric ropivacaine given intrathecally in lower limb orthopaedic surgeries, focusing on haemodynamic changes, sedation, duration of analgesia, and sensory and motor blockades. Materials and Methods: This randomised clinical study was conducted in a teritary care facility at the Operation Theatre (OT) complex in the Department of Anaesthesiology at Dhiraj Hospital, Smt. Bhikhiben Kanjibhai Shah Medical Institute and Research Centre (SBKS and MIRC), Piparia, Waghodia, Vadodara, Gujarat, India. The study duration was 18 months, with a total sample size of 60 patients, comprising of 30 patients in each group. Group RC30 (Ropivacaine+Clonidine) was given 3.5 mL of 0.75% hyperbaric ropivacaine with 30 μg of clonidine, while Group RD5 (Ropivacaine + Dexmedetomidine) was given 3.5 mL of 0.75% hyperbaric ropivacaine along with 5 μg of dexmedetomidine, intrathecally. Results were assessed by comparing the onset and duration of sensory and motor blockade. The absolute and effective analgesia durations were also compared and side-effects and complications along with haemodynamic changes were analysed. Data was analysed using Statistical Package of Social Sciences (SPSS) Software version 26.0. Mean and Standard Deviation (SD) were derived for continuous variables and t-test or Analysis of Variance (ANOVA) was used to evaluate relationship between them, proportions for categorical variables and the Chi-square test was used for categorical variables. Results: The mean for age in Group RD5 was 39.43±10.6 years and Group RC30 was 41.43±13.65 years. The time to S2 regression was longer in Group RD5 (136.10±8.10 min) compared to Group RC30 (102.67±7.69 min) (p<0.0001). Longer duration of sensory and motor blockade was seen in Group RD5 (312.53±23.22 min, 381.40±30.01 min) as compared to Group RC30 (279.90±29.64 min, 321.63±38.82 min) (p<0.0001, respectively). Group RD5 also required fewer analgesic interventions in the first 24 hours. Absolute and effective analgesia was found longer in Group RD5 as compared to Group RC30 (p=0.0006, p=0.0022, respectively). Conclusion: Dexmedetomidine offers superior postoperative analgesia compared to clonidine but is associated with a higher incidence of bradycardia and hypotension, both of which are manageable with standard interventions.

Comparing the Effect of Intrathecal Injection of Pethidine with that of Bupivacaine on Hemodynamics in Hip Surgery: A Double Blinded Clinical Trial

Background: The use of regional anesthesia for lower limb orthopedic surgery is preferable to general anesthesia. In some studies comparing regional anesthesia and general anesthesia, the one-month mortality of patients undergoing regional surgery was significantly lower. Given the relative advantages observed about intrathecal injection of pethidine, including fewer side effects, and longer postoperative analgesia, in combination with effective sensory, motor, and sympathetic blocks, we sought to compare the influence of intrathecal injection of pethidine and bupivacaine on the hemodynamics of patients. Methods: In this double blind randomized parallel trial, patients undergoing surgery with femoral and hip fractures, were divided into two groups. In the first group bupivacaine and in the second group pethidine were used for spinal anesthesia. Hemodynamic changes were examined and recorded during surgery. The results were analyzed by SPSS18 software Results: 67 patients undergoing surgery with femoral and hip fractures, were divided into two groups of 30 and 37 individuals. The mean heart rate in patients with a high risk of surgery was higher in the group receiving pethidine compared to the group of bupivacaine, with a Cohen's effect size of 0.294. This effect size is evaluated as average, while the rate of mean arterial pressure with Cohen's effect size of 0.511 was evaluated as large. Conclusion: Pethidine can be a good alternative to bupivacaine, especially in patients at high risk of surgery, given its hemodynamic stability.

Effect of Music Therapy on Anxiety, Stress and Sedative Requirements in Patients Undergoing Lower Limb Orthopedic Surgery Under Spinal Anesthesia: A Randomized Controlled Study.

Background Music therapy is a safe, non-pharmacological way to help reduce anxiety, especially before surgery. It helps to calm the nervous system, promotes relaxation, and offers comfort by blocking outside noise and distracting from pain. This can be helpful in managing preoperative anxiety and symptoms like hypertension and tachycardia. While the benefits of music therapy for stress and sedation are well known, its specific effects on patients receiving spinal anesthesia haven't been studied yet. Understanding this could improve care for these patients. Overall, music therapy could be a valuable tool in the surgical process. Objectives Primary objective: The study aimed to compare sedative requirements between two patient groups. Secondary objectives: To compare anxiety levels between two patient groupsusing the State-Trait Anxiety Inventory. It also assessed hemodynamic changes and measured stress levels by analyzing serum cortisol and immunoglobulin A levels in both groups. Materials and methods Ninety-two American Society of Anesthesiologists physical status class I and II patients, aged 18-65 years, with a body mass index of 18-25 kg/m2 undergoing lower limb orthopedic surgery under spinal anesthesia were selected for the study. After spinal anesthesia, the group M (n=46)patients received the music of their choice from headphones connected to mobile phones and patients in group NM (n=46)were attached headphones without any music therapy. After the attachment of headphones, propofol was administered in both the groups for sedation in a bolus dose of 1-2mg/kg iv followed by an infusion dose of 5-50 μg/kg/min. The propofol infusion was titrated based on Bispectral Index (BIS) values kept between 70 and 80 for moderate sedation. Preoperatively, blood samples were collected to measure baseline serum cortisol and IgA levels. Intraoperatively, hemodynamic parameters were measured, and anxiety level was assessed using the State-Trait Anxiety Inventory (STAI) Scale 30 minutes prior to the administration of spinal anesthesia. Postoperatively, anxiety was re-evaluated, and additional blood samples for the assessment of cortisol and IgA were taken at 30 minutes and 12 hours after the administration of spinal anesthesia. Results The mean serum cortisol was lower in Group M as compared to Group NM (15.1±1.2 vs. 17.1±1; p = 0.0001). Mean serum IgA was significantly lower in Group M as compared to Group NM (269.3±54.5 vs. 294.2±49.9; p = 0.024) during the intraoperative period. The mean STAI Score was lower in Group Mcompared to Group NM (34.87±4.53 vs. 34.61±5.06; p = 0.008). The mean propofol requirement (mg) was lower in Group M as compared to Group NM (147.8±11.3 vs. 193±16; p = 0.0001). The hemodynamic parameters were comparable between the groups (p>0.05). Conclusion Patients in the music therapy group experienced lower anxiety, stress, and serum cortisol levels during surgery, with reduced serum IgA levels and decreased propofol requirement for sedation. Overall, music therapy was effective in reducing anxiety, stress, and sedative requirements during surgery under regional anesthesia.

A comparative study of epidural nalbuphine versus tramadol as an adjuvant to bupivacaine for post operative analgesia in lower limb orthopaedic surgeries

A comparative study of epidural nalbuphine versus tramadol as an adjuvant to bupivacaine for post operative analgesia in lower limb orthopaedic surgeries

A Comparative Study of Intrathecal Hyperbaric Bupivacaine With Fentanyl Versus Intrathecal Hyperbaric Bupivacaine With Dexmedetomidine Administered Sequentially for Lower Limb Orthopaedic Surgeries: A Prospective Randomised Double-Blind Study.

The subarachnoid block is the predominant and relatively safe approach duringlower limb orthopaedic operations. When used as an additive to intrathecal local anaesthetic, both fentanyl and dexmedetomidine can extend the duration of sensory and motor blockade and improve postoperative analgesia. The objective of this study is to assess and compare the efficacy of sequential administration of fentanyl and dexmedetomidine alongside 0.5% hyperbaric bupivacaine intrathecally in lower limb orthopaedic surgeries, focussing on block characteristics, postoperative analgesia as measured by visual analogue scale (VAS) scores, haemodynamic changes, and adverse effects. Sixty patients were randomised into two groups of 30 each. Group A received 15 mg of 0.5% hyperbaric bupivacaine followed by 25 µg of fentanyl, whereas group B received 15 mg of 0.5% hyperbaric bupivacaine followed by 5 µg of dexmedetomidine, administered sequentially for spinal anaesthesia. Patients in group B exhibited a markedly prolonged sensory and motor block durationcompared to group A. The duration required to achieve maximum sensory blockage (T6) was reduced significantly in group B (2.40 ± 0.50 minutes) compared to group A (5.03 ± 0.81 minutes). The average duration of sensory regression to S1 was 207.33 ± 20.18 minutesin group B and 146.57 ± 19.01 minutesin group A (p < 0.001).Patients in group B exhibited a markedly prolonged sensory and motor block durationcompared to group A. The duration to attain total motor blockage (Modified Bromage 3) was markedly reduced in group B (4.23 ± 0.68 minutes) relative to group A (7.03 ± 0.81 minutes). Theoverall analgesicrequired over a 24-hour period and the average VAS ratings were both lower in group B compared to group A. Additionally, patient satisfaction was higher ingroup B (207.33 ± 20.18 minutes) than in group A (146.57 ± 19.01 minutes) (p < 0.001). The study concludes that the sequential administration of dexmedetomidine as an adjuvant with the local anaesthetic agent during the subarachnoid block enhances the onset of sensory and motor block, prolongs analgesia, diminishes overall analgesic requirements,increases patient satisfaction, and maintains stable haemodynamics compared to fentanyl. Bradycardia is common with dexmedetomidine.

ANALGESIC EFFICACY OF TWO DIFFERENT DOSES OF NALBUPHINE 0.8 MG AND 1.6 MG AS AN ADJUVANT TO ROPIVACAINE 0.75% FOR ELECTIVE LOWER LIMB SURGERIES: RANDOMIZED DOUBLE-BLIND INTERVENTIONAL STUDY

Background And Aim: Intrathecal Nalbuphine as an adjuvant with Ropivacaine providing profound analgesia with lesser side effects. We aimed to compare the analgesic efficacy of two different doses of intrathecal Nalbuphine (0.8mg versus 1.6mg) as an adjuvant to 0.75% isobaric Ropivacaine for elective lower limb Orthopaedic surgeries. Material And Method: It was a Prospective Randomized Double-blind Interventional study in a total of 90 patients posted for elective lower limb surgeries under spinal anaesthesia, age 18-60 years, either gender, ASA I and II, weight 40-70 kg, height ≥ 145cm allocated in 3 groups, all of whom received 2.5ml total drug volume, Group A- Ropivacaine 2ml +0.5ml normal saline, Group B- Ropivacaine 2ml + 0.8mg Nalbuphinein 0.5ml normal saline, Group C- Ropivacaine 2ml+ 1.6mg Nalbuphine in 0.5 ml normal saline. We recorded the onset of sensory and motor block, total duration of analgesia, sedation, VAS (Visual Analogue Scale) and side effects. Results: Onset of motor and the sensory block was earlier in Nalbuphine groups as compared to Ropivacaine alone. Analgesia was prolonged in 1.6mg Nalbuphine&gt;0.8 mg Nalbuphine&gt;Ropivacaine alone. VAS Score for rescue analgesia (&gt;3) was achieved at 240 min in group B &amp;C, and 210 min in groups A. Haemodynamic variables and sedation were comparable in all three groups and statistically non-significant. Hypotension, nausea and vomiting were higher in group C. Conclusion: Nalbuphine dose 0.8mg and 1.6mg doses are equivalently effective as an intrathecal adjuvant in providing prolonged analgesia with isobaric Ropivacaine, but 0.8 mg is the optimal dose with lesser side effects.

Estimated glomerular filtration rate versus creatinine clearance to determine anticoagulant dosage after lower-limb orthopedic surgery.

Anticoagulation is recommended for thromboprophylaxis after lower-limb orthopedic surgery. The suggested dosage is based on creatinine clearance (CCr) in the labels. However, most facilities only provide estimated glomerular filtration rate (eGFR) as laboratory data. Because the eGFR equation adjusts for a body surface area (BSA) of 1.73 m2, it may overestimate renal function in patients with a small BSA. This retrospective study aimed to determine whether different renal function estimation formulas affect the incidences of venous thromboembolism (VTE) and bleeding when determining anticoagulant dosages. This study included patients who underwent lower-limb orthopedic surgery and received anticoagulants (edoxaban, enoxaparin, and fondaparinux) between 2017 and 2020 at Yaizu City Hospital. Anticoagulant dosing was evaluated using CCr, eGFR, and de-indexed eGFR (without correction for BSA), and the incidences of VTE and bleeding were compared among these formulas. The median values for BSA, CCr, eGFR, and de-indexed eGFR were 1.40 m2, 56.0mL/min, 73.0mL/min/1.73m2, and 60.9mL/min, respectively. There was no significant difference in the VTE incidence among these formulas. However, when dose reduction or contraindication threshold was determined by eGFR vs. CCr, the bleeding incidence was significantly higher in the group that was overdosed by CCr (6.0% vs. 25.7%, p < 0.05). Similarly, using de-indexed eGFR vs. CCr, the bleeding incidence was significantly higher in the group that was overdosed by CCr (7.5% vs. 28.6%, p < 0.05). In orthopedic surgery, anticoagulant dosages should be based on CCr for patients with a small BSA to avoid bleeding risks.

Impact of International Classification of Functioning, Disability and Health personal factors on outcomes following lower limb orthopaedic surgery in children with cerebral palsy: a systematic review

Purpose To investigate impact of International Classification of Functioning, Disability and Health (ICF) personal factors on pain, function, or quality of life following lower limb orthopaedic surgery in children with cerebral palsy (CP). Materials and methods Systematic review of prospective studies of lower limb orthopaedic surgery in children with CP reporting relationships between ICF personal factors, and pain, function, or quality of life. Results Eight prospective studies reporting various orthopaedic procedures (median follow-up 2.1 years) were eligible, but not sufficiently homogenous for meta-analysis. Functional outcomes most reported (n = 6), then pain (n = 3) and quality of life (n = 1). Personal factors were age (n = 3), sex (n = 4), child education (n = 1), and co-morbidities (n = 1). Older children had lower function (p < 0.01), and children in “special education” greater improvement in function compared to those in “regular” education (p = 0.001) post-single-event multi-level surgery (SEMLS). Age and sex not associated with function, pain, or quality of life post-single-joint procedures (p > 0.05), except females with higher pain intensity (p = 0.019) and lower function (p = 0.018) post-Schanz procedure. No association between sex and function post-SEMLS (p > 0.05). Conclusions Further prospective cohort studies are needed to understand the influence of personal factors identified in this review and investigate the effect of other personal factors on pain, quality of life, and function.

Comparison of intrathecal dexmedetomidine and intrathecal fentanyl as an adjuvant to bupivacaine during spinal anaesthesia for lower limb orthopaedic surgery

Comparison of intrathecal dexmedetomidine and intrathecal fentanyl as an adjuvant to bupivacaine during spinal anaesthesia for lower limb orthopaedic surgery

Magnesium Sulphate Versus Fentanyl as Adjuncts to Epidural Anaesthesia for Lower Limb Orthopaedic Surgeries: A Comparative Study

Abstract Introduction: Pain relief for lower limb orthopaedic surgeries is achievable with epidural anaesthesia. This study compared the analgesic effects of epidural anaesthesia with magnesium sulphate or fentanyl adjuvant in patients scheduled for elective lower limb orthopaedic surgeries. Patients and Methods: A double-blind randomisation study was carried out on 96 patients categorised into three groups; M, F, and C. All participants received 18 mL of 0.5% bupivacaine plus 1.5 mL of 75 mg magnesium sulphate in Group M or 50 mg of fentanyl in Group F or normal saline in Group C via the lumbar epidural route. Variables including the onset time of sensory and motor blockade, duration of anaesthesia, and time for postoperative Numerical Rating Scale (NRS) score of 3 were summarised using mean, median, standard deviation, and percentages as appropriate. A P value of &lt;0.05 was considered statistically significant. Results: Mean onset time for the sensory blockade at T8 was 23.7 ± 5.3, 20.5 ± 3.4, and 17.9 ± 5.6 min for groups C, F, and M, respectively (P = 0.001). The onset time for the motor blockade (Bromage score 3) was 29.8 ± 4.0, 26.6 ± 3.5, and 24.5 ± 5.3 min in groups C, F, and M, respectively (P = 0.001). The duration of epidural anaesthesia was 121.6 ± 31.5, 145.9 ± 29.6, and 167.0 ± 27.0 min in groups C, F, and M, respectively (P = 0.001). The time to attain an NRS pain score of 3 was 133.2 ± 27.7, 151.8 ± 32.4, and 172.0 ± 30.9 min in groups C, F, and M, respectively (P = 0.001). Conclusion: Magnesium sulphate is better as an epidural adjuvant compared to fentanyl in patients undergoing lower limb orthopaedic surgeries.

Feasibility, Safety, and Efficacy of Segmental Spinal Anesthesia with Predominantly Isobaric Levobupivacaine: A Tertiary Care Hospital Study

Objective: To assess feasibility, safety, and efficacy of segmental spinal anesthesia with isobaric levobupivacaine in patients undergoing various abdominal and lower limb surgeries. Methods: This was a prospective cohort study conducted at the department of anesthesiology and critical care of Kota heart institute and group of hospitals in India. The study involved 100 patients undergoing various abdominal and lower limb surgeries under segmental spinal anesthesia (SSA). Isobaric levobupivacaine 0.5% with fentanyl 20-25 μg or dexmedetomidine 5-10 as adjuvant or hypobaric levobupivacaine 0.167% was injected in intervertebral space depending on the surgery. Hemodynamic parameters, postoperative pain level, and adverse effects were analyzed with a p-value less than 0.05 was considered statistically significant.Results: An overall male predominance was observed with a 1:0.515 male-to-female ratio. The most affected age group was 41-50 years (37%), with a mean age of 44.51 ± 11.72 years. ASA classification indicated 34% of patients in ASA I, 40% in ASA II, 24% ASA III and 2% in ASA IV . The primary surgery was laparoscopic cholecystectomy (26%) in normal risk group and orthopedic in high-risk group(20%). Postoperative pain assessment showed mean VAS scores ranging from 1.92 to 3.42 at different time intervals. Common adverse effects were hemodynamic instability (13%), shoulder tip pain (33%), PONV (3%), headache (6%), pruritis (2%) and urinary retention (1%). The hemodynamic instability showed less incidence in ASA III/IV category.Conclusion: Segmental spinal anesthesia can be used successfully for abdominal and lower limb orthopedic surgeries in patients of ASA I to ASA IV.

A Comparative Study of Infusion of Ephedrine and Phenylephrine on Hemodynamic Stability After Spinal Anesthesia in Elderly Patients Undergoing Lower Limb Orthopedic Surgeries.

Background Hypotension during spinal anesthesia occurs due to sympathetic nervous system blockade, resulting in decreased systemic vascular resistance and reduced cardiac output. Due to reduced sympathetic tone, peripheral arterial vasodilatation and blood pooling in lower limbs due to venodilatation occur, reducing preload to the heart and stroke volume. The elderly patients have reduced cardiovascular compensatory mechanisms, increasing the frequency and severity of hypotension due to sympathetic blockade after spinal anesthesia significantly. Vasopressors correct hypotension during the intraoperative period to maintain organ perfusion. Fluids can be administered, and if given excessively, can cause fluid overload and urinary retention. This study aimed to compare the effectiveness of vasopressors, phenylephrine, and ephedrine in maintaining hemodynamic stability intraoperatively through prophylactic infusion after spinal anesthesia in elderly patients for lower limb orthopedic surgeries. Methodology A total of 174 elderly patients aged 60 years and above with American Society of Anesthesiologists (ASA) Classification I and II, undergoing lower limb orthopedic surgeries, enrolled in a randomized comparative study, were allocated into three groups: Group P (phenylephrine, n=58) received 250 mcg phenylephrine in 30 ml normal saline using infusion syringe pump, Group E (ephedrine, n=58) received 30 mg ephedrine in 30 ml normal saline using infusion syringe pump, and Group C (control group, n=58) received mephentermine I/V (6 mg bolus) when the fall in blood pressure was below 30% of baseline without any placebo infusion. Hemodynamic parameters (systolic and diastolic blood pressure, mean arterial pressure (MAP), heart rate) at 15, 10, and 5-minute intervals before spinal anesthesia, and at 3, 6, 9, 12, 15, 20, 25, and 30-minute intervals after spinal anesthesia. The need for rescue doses to treat hypotension after spinal anesthesia was recorded. Result At all time intervals following spinal anesthesia, Group E reported heart rate and systolic blood pressure better than Groups P and C, significantly. At 3, 6, 9, 12, 15, and 25-minute intervals following spinal anesthesia, the diastolic blood pressure in Group E was enhanced significantlythan Groups P and C. The MAP in Group E was substantially higher than in other groups at 3, 6, 15, and 20-minute intervals following spinal anesthesia, which was statistically significant. Compared to Groups P and C, Group E required lesser rescue doses to treat intraoperative fall in hypotension 30% below baseline and lesser events of bradycardia. Conclusion Following spinal anesthesia, the preload to the heart is to be maintained with intravenous (crystalloid or colloidal) solutions to maintain cardiac output adequately. Intraoperative use of phenylephrine and ephedrine as a low-dose prophylactic infusion can be used, as it increases both systemic vascular resistance and preload without cardiac stimulation along with intravenous solutions to maintain hemodynamic parameters such as systolic and diastolic blood pressure, MAP, heart rate effectively but preferably ephedrine in elderly patients.

Ultrasound-Guided Lumbar Plexus-Sciatic Nerve Blocks Versus Epidurals for Orthopaedic Surgeries: A Study to Compare the Competency of Novice Anaesthesiology Residents in a High-Volume Level 1 Trauma Centre.

The relative merits of peripheral nerve blocks (PNB) over central neuraxial anaesthesia and the advantages of the above two techniques over general anaesthesia for surgical interventions of the lower limb are well established. The competency of anaesthetic trainees in a high-volume level 1 trauma centre in administering dual ultrasound and nerve stimulator-guided lumbar plexus-sciatic nerve block(DUNLuPS) vs. epidural anaesthesia (EA) was compared by reporting the adequacy of anaesthesia with the two techniques, time taken for the performance of block, time of onset of sensoryblock (TOSB), and time of onset of motor block (TOMB). This prospective, randomized, study enrolled 92 patients aged 18-80 years with lower limb fractures admitted in trauma triage and scheduled for surgery. Thepatients were randomly allocated equally into the EA group and the DUNLuPS group. A total of 20 anaesthesia trainees in the third year of residencywith clinical experience of more than 15 independent lumbar plexus-sciatic nerve blocks were included in the study.A volume of 20 ml of 0.5% ropivacaine was administered in the lumbar plexus (Shamrock technique) but the volume used for sciatic nerve (subgluteal approach) was varied so that the cumulative dose did not exceed 3 mg/kg. For each block, the onset of nerve blockade was assessed every five minutes, and the assessments continued for an additional 30 minutes after the nerve blocks were finished. Clinical characteristics and adequacy of anaesthesia were comparable, i.e., 95.65% and93.47% success in the EA (n = 46) and DUNLuPS (n = 46) groups, respectively. Performance time was significantly more in the DUNLuPS group but followed by significantly less TOSB and TOMB. The time for the first analgesic request was 351.63 ± 148.70 minutes in the DUNLuPS group and 147.60 ± 52.65 minutes in the EAgroup (p < 0.0001). Both EA and DUNLuPS provide effective and comparable intra-operative anaesthesia for orthopaedic lower limb surgeries (OLLS) when administered by residents with more than two years of experience (third year of residency)in ultrasound-guided regional nerve blocks in a high-volume level 1 trauma centre. Statistically significant differences in the block performance characteristicshad no clinical advantage as it was compensated by the faster onset time in the DUNLuPS group. Post-operative pain management was better in the DUNLuPS group, sothe practice and conduct of anaesthesia for trauma patients should focus on the establishment of "block rooms" and timely training of residents in the former so that the advantages can be extended to the patient population.

Peripheral nerve stimulation for lower-limb postoperative recovery: A systematic review and meta-analysis of randomized controlled trials.

Patients undergoing lower-limb orthopedic surgery may experience multiple postoperative complications. Although peripheral nerve stimulation (PNS) is a promising non-pharmacological approach that has been used in lower-limb postoperative recovery, the clinical efficacy of PNS remains inconclusive. This study systematically searched three databases (PubMed, Embase, and Cochrane Library) for randomized controlled trials (RCTs) that examined the treatment effects of PNSs in patients who underwent lower-limb orthopedic surgery up to September 29, 2023. Two investigators independently identified studies, extracted data, and conducted meta-analyses with Review Manager 5.4. The outcomes were pain relief (measured by reductions in pain intensity and analgesic consumption) and functional improvements (range of motion [ROM] and length of hospitalization [LOH]). A total of 633 patients including 321 in the experimental groupsand 312 in the control groups from eight RCTs were included. PNS showed no significant effect on pain intensity, while analgesic consumption was marginally significantly reduced in the experimental group. Furthermore, no significant differences were observed regarding functional improvements in ROM or LOH after the intervention. Although PNS had no significant effect on pain relief or functional improvements, the intervention exhibited a marginally significant reduction in analgesic consumption. Future trials should be conducted with larger sample sizes, longer follow-up periods, and more varied stimulation parameters.

Comparing the effects of three local anaesthetic agents on cardiac conduction system - A randomised study.

This study aimed to compare the effects of three local anaesthetic (LA) agents, namely bupivacaine, levobupivacaine, and ropivacaine, on the cardiac conduction system as assessed by corrected QT (QTc) and P wave dispersion (PWD) intervals in lower limb orthopaedic surgeries and to find the most suitable LA agent that can be used for a long duration. The study included 75 patients with American Society of Anesthesiologists physical status I and II of either gender in the age group of 18-65 years undergoing elective lower limb orthopaedic surgeries under epidural anaesthesia. These were allocated to groups B (bupivacaine), L (levobupivacaine), and R (ropivacaine). We observed blood pressure, heart rate, respiratory rate, PWD, and QTc intervals from baseline value through Holter monitoring, pain assessment by visual analogue scale, and demand and total volume of LA consumed by patient-controlled analgesia devices. The repeated measures of ANOVA were carried out to find the effect of time and time-to-group interaction among the groups across the periods. On intergroup comparison of QTc and PWD, no significant difference among groups was observed, but on intragroup analysis, a statistically significant increase in QTc and PWD from baseline was observed for each of groups B, L, and R at all time intervals. However, the mean increase in QTc and PWD recorded for Group B was higher than in groups L and R. Bupivacaine has the maximal tendency to prolong QTc and PWD. All three agents showed comparable haemodynamic effects and time to onset of sensory and motor blockade.

Effect of hydroxyethyl starch (Voluven ® 6% 130/0.4) on blood glucose levels during orthopaedic lower limb surgery under spinal anaesthesia – a prospective, randomised controlled trial

Effect of hydroxyethyl starch (Voluven ^® 6% 130/0.4) on blood glucose levels during orthopaedic lower limb surgery under spinal anaesthesia – a prospective, randomised controlled trial

A Comparative Study of Combined Spinal Epidural Anesthesia Versus Spinal Anesthesia in Major Lower Limb Orthopedic Surgeries.

Background Neuraxial blockade includes epidural and spinal anesthesia (SA) that have gained wide acceptance for major lower limb orthopedic surgery. Both techniques are competent in rendering surgical anesthesia and pain relief, with specific advantages and disadvantages. SA has the merits of rapid onset and adequate anesthesia with a small volume of the drug but has significant hypotension and unpredictable duration. Epidural anesthesia allows for finer control over analgesia and the duration of anesthesia but requires more substantial volumes of drugs and is slower in onset. Combined spinal-epidural anesthesia (CSEA) combines the rapid commencement of action of SA with flexibility in epidural anesthesia, thus optimizing the management of the intraoperative and postoperative phases. This study aims to evaluate hemodynamic changes, compare the severity and duration of sensory and motor block, and track any problems related to CSEA and SA in major lower limb orthopedic procedures. Additionally, this study contrasts the hemodynamic, motor, and sensory changes in the two groups. Methodology A total of 30 individuals were randomized to one of two groups in this prospective comparative trial, which included 60 patients receiving major lower limb orthopedic surgery and meeting the American Society of Anesthesiologists physical status I-II criteria. Group A received CSEA, and Group B received SA. The degree and duration of sensory and motor blockade, hemodynamic changes, and complications were all recorded. A p-value of less than 0.05 was used to evaluate statistical significance using Student's t-test and chi-square test. Results The onset of sensory block in our study was earlier in Group B compared to Group A. In both groups, hemodynamic stability was maintained throughout the study. We recorded the onset/duration of sensory and motor block and hemodynamic changes and took mean values to find any significant difference. Postoperative complications and rescue analgesic requirements were monitored and managed and were a part of our study. Conclusions This study compared CSEA and SA regarding the severity and duration of sensory and motor block, hemodynamic stability, and associated complications in major lower limb orthopedic surgeries. The results shed light on the advantages and shortcomings of each anesthesia technique and, therefore, will help choose the correct method of anesthesia in a given surgery.

Comparison of intravenous dexmedetomidine versus ketamine-dexmedetomidine combination on spinal block characteristics in patients undergoing lower limb orthopaedic surgery - A randomised clinical trial.

One major limitation of the spinal block remains the inability to extend the duration of the block intraoperatively unless planned before with spinal or epidural catheters and/or intrathecal additives. This study was designed to compare the effects of intravenous dexmedetomidine versus low-dose ketamine-dexmedetomidine combination infusion on spinal anaesthesia in lower limb orthopaedic surgeries. This randomised study was conducted in 60 patients scheduled for unilateral lower limb surgeries under spinal anaesthesia. Patients were randomised into Group D (n = 30) (0.5 µg/kg of intravenous (IV) dexmedetomidine bolus followed by maintenance infusion at 0.5 µg/kg/h) and Group LKD (n = 30) (IV bolus of 0.5 µg/kg of dexmedetomidine and 0.2 mg/kg of ketamine, followed by maintenance infusions of dexmedetomidine and ketamine at 0.5 µg/kg/h and 0.2 mg/kg/h, respectively). Ramsay Sedation Scale score of 3-4 was maintained. The t-test or the Wilcoxon-Mann-Whitney U test was used to compare the parameters between groups. The mean sacral segment 1 (S1) regression time was 390.3 [standard deviation (SD):84.38] [95% confidence interval (CI): 360.13, 420.53] versus 393.23 (SD: 93.01) (95% CI: 363.04, 423.43) min in Group D versus Group LKD respectively ((P = 0.701). The number of episodes of hypotension was significantly higher in Group D (19 patients) compared to Group LKD (nine patients) (P = 0.001). Pre- and postoperative stress markers (24 h) and the incidence of postoperative nausea and shivering were comparable between the two groups (P > 0.05). Tramadol requirement in the postoperative period was significantly less in Group LKD compared to Group D (P = 0.003). The duration of S1 regression was similar between group dexmedetomidine (Group D) and group low-dose ketamine and dexmedetomidine (Group LKD).