Objectively measured activity is not associated with average pain intensity 1 week after surgery: A cross-sectional study.

BACKGROUND: Measures of physical activity and pain-related patient-reported outcomes are important components of patient recovery after surgery. However, little is known about their association in the early post-operative period. This study aims to increase this knowledge. Our primary objective was to determine the association between average pain intensity and activity (in steps) 1 week after surgery. Secondary objectives were the association of activity with other patient-reported outcomes, age, sex, comorbidities and body mass index. METHODS: Data were obtained from the PROMPT sub-project of IMI-PainCare. Patients after breast and endometriosis-related surgery, sternotomy and total knee arthroplasty completed pain-related outcomes questionnaires and wore an ActiGraph activity-tracking device. We correlated steps with average pain intensity on post-operative days 6 and 7. Secondary analyses were done using correlations and t-tests. RESULTS: In 284 cases, there was no statistically significant correlation between steps and average pain intensity. In addition, none of the 28 secondary analyses showed a statistically significant result. CONCLUSIONS: Pain-related patient-reported outcome measures and physical activity are separate entities. Both should be measured after surgery to assess patient recovery and to identify treatment deficiencies. SIGNIFICANCE STATEMENT: Measuring recovery is a multi-dimensional challenge. After surgery, clinicians need to be aware that neither pain intensity nor activity levels tell the whole story. Each can hint to problems and treatment requirements.

Bypassing the post-anaesthesia care unit after elective hip and knee arthroplasty: a prospective cohort safety study.

Following knee and hip arthroplasty, transfer to a recovery area immediately following surgery and before going to ward might be unnecessary in low-risk patients. Avoiding the recovery area in this way could allow for more targeted use of resources for higher risk patients, which may improve operating theatre flow and productivity. A prospective single-centre cohort study on the safety of criteria for bypassing the post-anaesthesia care unit in elective hip and knee arthroplasty was designed. Criteria were: ASA physical status < 3; peri-operative bleeding < 500 ml; low postoperative discharge-score (modified Aldrete-score); and an uncomplicated surgical and neuraxial anaesthesia procedure. The primary outcome was the number of patients in need of secondary readmission to the post-anaesthesia care unit. Events within the first 24 postoperative hours were recorded, along with readmission and complication rates. A total of 696 patients were included, with 287 (41%) undergoing total hip arthroplasty, 274 (39%) undergoing total knee arthroplasty and 135 (19%) undergoing unicompartmental knee-arthroplasty. Of these, 207 (44%) bypassed the post-anaesthesia care unit. Patients all received multimodal analgesia without peripheral nerve blockade. Only one patient in the ward group required secondary readmission to the post-anaesthesia care unit. Within 24 h, 151 events were reported, with 41 (27%) in the ward group and 110 (73%) in the post-anaesthesia care unit group. Two events in each group occurred within 2 hours of surgery. No complications were attributed to bypassing the post-anaesthesia care unit. The use of simple pragmatic criteria for bypassing the post-anaesthesia care unit for patients undergoing knee and hip arthroplasty with spinal anaesthesia is possible and associated with significant reduction of post-anaesthesia care unit admission and without apparent safety issues. Confirmation is needed from other studies and external validity should be interpreted cautiously in centres with different peri-operative regimens, organisational and staffing structures.

Bioimpedance spectroscopy fluid analysis in acute high-risk abdominal surgery, a prospective clinician-blinded observational feasibility study.

Objective assessment of fluid status in critical surgical care may help optimize perioperative fluid administration and prevent postoperative fluid retention. We evaluated the feasibility of hydration status and fluid distribution assessment by Bioimpedance spectroscopy Analysis (BIA) in patients undergoing acute high-risk abdominal (AHA) surgery. This observational study included 73 patients undergoing AHA surgery. During the observational period (0-120 h), we registered BIA calculated absolute fluid overload (AFO) and relative fluid overload (RFO), defined as AFO/extracellular water ratio, as well as cumulative fluid balance and weight. Based on RFO values, hydration status was classified into three categories: dehydrated (RFO < - 10%), normohydrated (- 10% ≤ RFO ≤ + 15%), overhydrated RFO > 15%. We performed a total of 365 BIA measurements. Preoperative overhydration was found in 16% of patients, increasing to 66% by postoperative day five. The changes in BIA measured AFO correlated with the cumulative fluid balance (r2 = 0.44, p < .001), and change in weight (r2 = 0.55, p < .0001). Perioperative overhydration measured with BIA was associated with worse outcome compared to patients with normo- or dehydration. We have demonstrated the feasibility of obtaining perioperative bedside BIA measurements in patients undergoing AHA surgery. BIA measurements correlated with fluid balance, weight changes, and postoperative clinical complications. BIA-assessed fluid status might add helpful information to guide fluid management in patients undergoing AHA surgery.

Functional recovery after discharge in enhanced recovery video-assisted thoracoscopic lobectomy: a pilot prospective cohort study.

Little is known about functional recovery following patient discharge in an established enhanced recovery programme after video-assisted thoracoscopic lobectomy. We conducted a single-centre pilot prospective observational cohort study. We hypothesised that patients achieved early functional recovery after discharge. A total of 32 patients aged ≥ 18 years were enrolled. A digital device was used for objective activity measurements, and patient-reported outcomes were collected as subjective measurements. Primary outcomes were the difference in physical activity; sleep duration; pain; fatigue; and average quality of life scores between pre-operative baseline and 7 days following discharge. The secondary outcome was the reason for reduced daily activity during the first 7 days after discharge. Median (IQR [range]) length of stay was 3 (2-5 [1-13]) days. Up to post-discharge day 7, total, lower intensity and moderate-to-vigorous activities were lower than pre-operative activity (p < 0.001; p = 0.005 and p = 0.027, respectively). Numerical rating scale (0-10) pain scores increased postoperatively at rest (mean difference 1.2, p < 0.001) and during walking (mean difference 1.4, p < 0.001). Fatigue assessed by the Christensen Fatigue Scale (1-10) was also increased postoperatively (mean difference 1.7, p = 0.001). There was a reduction in quality of life scores, while sedentary activity and sleep duration were unchanged postoperatively. Dominant reasons for not recovering daily activity included fatigue in 43% and pain in 33% of patients. Despite compliance with an enhanced recovery programme with a median length of hospital stay of 3 days after video-assisted thoracoscopic lobectomy, functional recovery was not achieved within 7 days after hospital discharge. Reduction in postoperative pain and fatigue are important factors to enhance functional recovery.

Preoperative high-dose glucocorticoids for early recovery after liver resection: randomized double-blinded trial.

BACKGROUND: Glucocorticoids modulate the surgical stress response. Previous studies showed that high-dose preoperative glucocorticoids reduce levels of postoperative inflammatory markers and specific biomarkers of liver damage compared with placebo, and suggested a reduced complication rate and shorter hospital stay after liver surgery. However, there are no studies with a clinical primary outcome or of early recovery outcomes. The aim of this study was to investigate whether a single high dose of preoperative glucocorticoid reduces complications in the immediate postoperative phase after liver surgery. METHODS: This was a single-centre, double-blinded, parallel-group RCT investigating preoperative methylprednisolone 10 mg/kg (high dose) versus dexamethasone 8 mg (standard-dose postoperative nausea prophylaxis) in patients scheduled for open liver resection. The primary outcome was number of patients with a complication in the postanaesthesia care unit; secondary outcomes included duration of hospital stay, pain and nausea during admission, and 30-day morbidity. RESULTS: A total of 174 patients (88 in high-dose group, 86 in standard-dose group) were randomized and analysed (mean(s.d.) age 65(12) years, 67.2 per cent men); 31.6 per cent had no serious co-morbidities and 25.3 per cent underwent major liver resection. Complications occurred in the postanaesthesia care unit in 51 patients (58 per cent) in the high-dose group and 58 (67 per cent) in the standard-dose group (risk ratio 0.86, 95 per cent c.i. 0.68 to 1.08; P = 0.213). Median duration of hospital stay was 4 days in both groups (P = 0.160). Thirty-day morbidity and mortality rates were similar in the two groups. CONCLUSION: A high dose of preoperative glucocorticoids did not reduce acute postoperative complications after open liver resection compared with a standard dose. Registration number: NCT03403517 (http://www.clinicaltrials.gov); EudraCT 2017-002652-81 (https://eudract.ema.europa.eu/).

Hypoxemia following hospital discharge after fast-track hip and knee arthroplasty - A prospective observational study subanalysis.

BACKGROUND: Post-operative hypoxemia is prevalent in hospitalized patients and may adversely affect recovery. However, little data exist on the post-discharge phase or details on duration, severity and potential risk factors. Thus, we investigated the incidence and risk factors for severe desaturation during the first post-operative week after THA/TKA by continuous nocturnal oxygen saturation monitoring. METHODS: The study was a secondary analysis of a prospective cohort study of 112 patients undergoing fast-track THA/TKA. Patients with known sleep apnoea were excluded. Oxygen saturation and heart rate were recorded by a wireless wrist-worn pulse oximeter 2 nights before and 7 nights after surgery. Data on demographics, opioid consumption and cognitive function were collected from medical charts, patient diaries and clinical testing respectively. The primary outcome was occurrence of severe desaturation defined as periods with saturation <85% lasting ≥10 minutes. Secondary outcomes included description of various saturation levels and relevant risk factors. RESULTS: Severe oxygen desaturation occurred in 35% of the patients during the first post-operative week. Duration and severity of hypoxemic episodes increased after the first post-operative day. Pre-operative episodes of hypoxemia significantly increased the risk of post-operative hypoxemic events (OR 2.4-4.4, CI 0.4-46), while pre- and post-operative opioid use, age, gender, ASA classification, type of surgery or anaesthesia were significantly related to the development of post-operative hypoxemia. CONCLUSIONS: One third of the patients suffered from increased and prolonged episodes of severe nocturnal hypoxemia during the first week after THA/TKA discharge. Increased risk for severe hypoxemic episodes was related to pre-operative hypoxemia.

Challenges in optimising recovery after emergency laparotomy.

Standardised peri-operative care pathways for patients undergoing emergency laparotomy or laparoscopy for non-traumatic pathologies have been shown to be inadequate and associated with high morbidity and mortality. Recent research has highlighted this problem and showed that simple pathways with 'rescue' interventions have been associated with reduced mortality when implemented successfully. These rescue pathways have focused on early diagnosis and surgery, specialist surgeon and anaesthetist involvement, goal-directed therapy and intensive or intermediary postoperative care for high-risk patients. In elective surgery, enhanced recovery has resulted in reduced length of stay and morbidity by the application of procedure-specific, evidence-based interventions inside rigorously implemented patient pathways based on multidisciplinary co-operation. The focus has been on attenuation of peri-operative stress and pain management to facilitate early recovery. Patients undergoing emergency laparotomy are a heterogeneous group consisting mostly of patients with intestinal perforations and/or obstruction with varying levels of comorbidity and frailty. However, present knowledge of the different pathophysiology and peri-operative trajectory of complications in these patient groups is limited. In order to move beyond rescue pathways and to establish enhanced recovery for emergency laparotomy, it is essential that research on both the peri-operative pathophysiology of the different main patient groups - intestinal obstruction and perforation - and the potentially differentiated impact of interventions is carried out. Procedure- and pathology-specific knowledge is lacking on key elements of peri-operative care, such as: multimodal analgesia; haemodynamic optimisation and fluid management; attenuation of surgical stress; nutritional optimisation; facilitation of mobilisation; and the optimal use and organisation of specialised wards and improved interdisciplinary collaboration. As such, the future challenges in improving peri-operative patient care in emergency laparotomy are moving from simple rescue pathways to establish research that can form a basis for morbidity- and procedure-specific enhanced recovery protocols as seen in elective surgery.

Why still in hospital after laparoscopic colorectal surgery within an enhanced recovery programme?

AIM: Enhanced recovery after surgery programmes in elective colorectal surgery have been developed and implemented widely, but a subgroup of patients may still require longer hospital stays than expected. The aim of this study was to identify and describe factors compromising early postoperative recovery by asking 'why is the patient still in hospital today?' after laparoscopic colorectal cancer surgery within an enhanced recovery after surgery programme. METHOD: Patients undergoing elective laparoscopic colorectal cancer resection were evaluated postoperatively with predefined potential reasons for still being in hospital. The primary outcome was 'reason for still being in hospital' on postoperative day 0-4 and secondarily length of stay with a focus on differences between patients with and without a stoma. RESULTS: Ninety-six patients having colorectal cancer surgery were included. The median length of stay for the whole group was 3 days (range 1-14). The four dominant causes for patients without a stoma to be in hospital were lack of gastrointestinal function, lack of early mobilization, lack of normal micturition and nausea. Patients with a stoma stayed in hospital due to stoma training, lack of gastrointestinal function, lack of free micturition and a miscellaneous 'others' group. CONCLUSION: Delayed gastrointestinal function, insufficient mobilization, poor urinary function and stoma care training have been characterized as dominant compromising factors for postoperative recovery. Together with a focus on frailty, future studies should focus on improving early mobilization, prevention and treatment of postoperative urinary retention and improved stoma care training, in order to minimize delay in postoperative recovery and discharge.

Development of evidence-based recommendations for procedure-specific pain management: PROSPECT methodology.

Effective peri-operative pain management is a prerequisite for optimal recovery after surgery. Despite published evidence-based guidelines from several professional groups, postoperative pain management remains inadequate. The procedure-specific pain management (PROSPECT) collaboration consists of anaesthetists and surgeons with broad international representation that provide healthcare professionals with practical and evidence-based recommendations formulated in a way that facilitates clinical decision-making across all stages of the peri-operative period on a procedure-specific basis. The aim of this manuscript is to provide a detailed description of the current PROSPECT methodology with the intention of providing the rigour and transparency in which procedure-specific pain management recommendations are developed. The high methodological standards of the recommendations should improve the quality of clinical practice.

Hypoxaemia during recovery after surgery for colorectal cancer: a prospective observational study.

Episodic and ongoing hypoxaemia are well-described after surgery, but, to date, no studies have investigated the occurrence of episodic hypoxaemia following minimally-invasive colorectal surgery performed in an enhanced recovery setting. We aimed to describe the occurrence of postoperative hypoxaemia after minimally-invasive surgery in an enhanced recovery setting, and the association with morphine use, incision site, fluid intake and troponin increase. We performed a prospective observational study of 85 patients undergoing minimally-invasive surgery for colorectal cancer between 25 August 2016 and 17 August 2017. We applied a pulse oximeter with a measurement rate of 1 Hz immediately after surgery either until discharge or until two days after surgery, and recorded the oxygen saturation. We measured troponin I during the first four days after surgery, or until discharge. The median (IQR [range]) length of stay was 3 (2-4 [1-38]) days. Thirty-six percent of patients spent more than 1 h below an oxygen saturation of 90% (4.2% of the day), and with a median (IQR [range]) proportion of 1.3 (0.2-11.1 [0.0-21.4])% of the day spent with an oxygen saturation below 88%. We found no associations between time spent below an oxygen saturation of 88% and morphine use (p = 0.215), fluid intake (p = 0.446), complications (p = 0.808) or extraction site (p = 0.623). Postoperative increases in troponin I were associated both with time spent below an oxygen saturation of 88% (p = 0.026) and hypopnoea episodes (p = 0.003). Even with minimally-invasive surgery and enhanced recovery after surgery, episodic hypoxaemia and hypopnoea episodes are common, but are not associated with morphine use, fluid intake or incision site. Further studies should investigate the relationship between hypoxaemia and troponin increase.

Simultaneous vs staged bilateral total knee arthroplasty: a propensity-matched case-control study from nine fast-track centres.

INTRODUCTION: Limited data exist on patient safety after simultaneous vs staged bilateral total knee arthroplasty (TKA) in matched groups. Hence, the aim of this study was to compare length of stay (LOS), in-hospital complications, 30-day readmissions and mortality after simultaneous and staged bilateral TKA in matched patients. PATIENTS AND METHODS: A retrospective case-control study of prospectively collected data in nine centres from February 2010 to November 2015. Propensity scores (PS) were used to match simultaneous and staged (1-6 months between stages) bilateral TKA patients with prospectively collected patient characteristics from the Lundbeck Foundation Centre for Fast-track THA and TKA Database. 30-day follow-up was acquired from the Danish Patient Registry and patient records. RESULTS: A total of 344 (47.1%) simultaneous and 386 (52.9%) staged bilateral TKA procedures were performed. PS matching was possible in 232 simultaneous and 232 staged bilateral TKA patients. LOS was median 4 days (IQR 3-5) after simultaneous and cumulated 4 days (IQR 4-6) after staged procedures. The in-hospital complication rate was 15.5% after simultaneous vs 7.3% (p = 0.004) after staged procedures. Two cases (0.9%) of venous thromboembolic events were found in each group. Eight patients (3.4%) were re-operated after simultaneous vs one patient (0.4%) after staged bilateral TKA (p = 0.037). The 30-day readmission rate was 8.6% after simultaneous vs 5.6% after staged procedures (p = 0.281). No patients died in either group. CONCLUSIONS: We found no significant differences in 30-day readmission rates and mortality between simultaneous and staged bilateral TKA, but the in-hospital complication rate and re-operation rate was higher after the simultaneous procedure calling for further matched investigations in larger cohorts.

An international consensus statement on the management of postoperative anaemia after major surgical procedures.

Despite numerous guidelines on the management of anaemia in surgical patients, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in the postoperative period. A number of experienced researchers and clinicians took part in a two-day expert workshop and developed the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best-practice and evidence-based statements to advise on patient care with respect to anaemia and iron deficiency in the postoperative period. These statements include: a diagnostic approach to iron deficiency and anaemia in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow-up that is easy to implement. Available data allow the fulfilment of the requirements of Pillar 1 of Patient Blood Management. We urge national and international research funding bodies to take note of these recommendations, particularly in terms of funding large-scale prospective, randomised clinical trials that can most effectively address the important clinical questions and this clearly unmet medical need.

Analgesic consumption trajectories in 8975 patients 1 year after fast-track total hip or knee arthroplasty.

BACKGROUND: Persistent or increased long-term opioid consumption has previously been described following total hip- (THA) and knee arthroplasty (TKA). However, detailed information on postoperative analgesic consumption trajectories and risk factors associated with continued need of analgesics in fast-track THA and TKA is sparse. METHODS: This is a descriptive multicentre study in primary unilateral fast-track THA or TKA with prospective data on patient characteristics and information on reimbursement entitled dispensed prescriptions of paracetamol, non-steroidal anti-inflammatory drugs, opioids, anticonvulsants and antidepressants 1 month preoperatively and 1 year postoperatively. Patients were stratified according to preoperative opioid use. Postoperative analgesic consumption trajectories were stratified as increased, decreased or no use compared to the preoperative period. RESULTS: Of 8975 patients (4849 THA/4126 TKA), 33.9% had relevant reimbursed prescriptions 9-12 months postoperatively. Of 2136 (23.8%) patients with preoperative opioid use, 3.4% had unchanged opioid consumption at 9-12 months postoperatively. However, increased opioid consumption after 9-12 months occurred in 17.6 (TKA) and 10.2% (THA) compared to 9.9 and 6.3% in opioid-naive TKA and THA patients, respectively. Increased NSAID and paracetamol use was seen in 11.5 and 12.4% of all patients. Preoperative analgesic use (any), TKA, psychiatric disorder, tobacco abuse, cardiac disease and use of walking aids were associated with increased opioid consumption. CONCLUSION: Continued and increased opioid and other analgesic use occur in a clinically significant proportion of fast-track TKA and THA patients 9-12 months postoperatively, suggesting treatment failure and need for early intervention. Preoperative risk assessment may allow identification of patients in risk of increased postoperative opioid consumption. SIGNIFICANCE: We found a considerable fraction of patients with continued or increased opioid consumption 9-12 months after fast-track THA and TKA. Increase in opioid consumption was more frequent in preoperative opioid users than opioid-naive patients, but a pattern of increased analgesic consumption was present across all analgesics. Our data demonstrate a need for increased focus on long-term analgesic strategies and postoperative follow-up after THA and TKA, especially in preoperative opioid users.

Systematic review and consensus definitions for the Standardised Endpoints in Perioperative Medicine (StEP) initiative: patient comfort.

BACKGROUND: Maximising patient comfort during and after surgery is a primary concern of anaesthetists and other perioperative clinicians, but objective measures of what constitutes patient comfort in the perioperative period remain poorly defined. The Standardised Endpoints in Perioperative Medicine initiative was established to derive a set of standardised endpoints for use in perioperative clinical trials. METHODS: We undertook a systematic review to identify measures of patient comfort used in the anaesthetic, surgical, and other perioperative literature. A multi-round Delphi consensus process that included up to 89 clinician researchers was then used to refine a recommended list of outcome measures. RESULTS: We identified 122 studies in a literature search, which were the basis for a preliminary list of 24 outcome measures and their definitions. The response rates for Delphi Rounds 1, 2, and 3 were 100% (n=22), 90% (n=79), and 100% (n=13), respectively. A final list of six defined endpoints was identified: pain intensity (at rest and during movement) at 24 h postoperatively, nausea and vomiting (0-6 h, 6-24 h, and overall), one of two quality-of-recovery (QoR) scales (QoR score or QoR-15), time to gastrointestinal recovery, time to mobilisation, and sleep quality. CONCLUSIONS: As standardised outcomes will support benchmarking and pooling (meta-analysis) of trials, one or more of these recommended endpoints should be considered for inclusion in clinical trials assessing patient comfort and pain after surgery.

Incidence and related factors for intraoperative failed spinal anaesthesia for lower limb arthroplasty.

BACKGROUND: Spinal anaesthesia is the preferred choice for total hip- and knee arthroplasty (THA/TKA), due to the claimed superior outcome profile, relative simple technique and without the need for advanced airway support. However, choosing and informing about spinal anaesthesia should also include the risk for intraoperative failed spinal anaesthesia with associated pain, discomfort and suboptimal settings for airway management. Small-scale studies suggest incidences from 1 to 17%; however, no multi-institutional large data exists on failed spinal incidence and related factors during THA/TKA, hindering evidence-based information and potential anaesthesia stratification. METHODS: In a sub-analysis, data from a prospective study on spinal anaesthesia for THA/TKA were examined for incidence of intraoperative conversion to general anaesthesia. Potential perioperative factors (age, gender, American Society of Anaesthesiologist (ASA) score, height, weight, BMI, procedure, bupivacaine dosage and duration of time from spinal administration until end of surgery) were analysed with logistic regression for relation to failed spinal anaesthesia. RESULTS: In all, 1451 patients were included for analysis, whereof 57 (3.9%) had failed spinal anaesthesia. Spinal failure patients were significantly younger (61 vs. 67 years, P = 0.003), and operation time longer in the failed spinal group vs no-failure, respectively (133 vs. 89 min, P < 0.001). No significant differences were found with regard to bupivacaine volume, gender, ASA-score, height, weight, BMI or THA vs. TKA. CONCLUSION: Failed spinal anaesthesia for THA and TKA is a relatively frequent occurrence and identification of risk patients is not feasible. These results should be considered when choosing anaesthesia and included in the information to patients.

Effect of pre-operative methylprednisolone on orthostatic hypotension during early mobilization after total hip arthroplasty.

BACKGROUND: Orthostatic hypotension (OH) and intolerance (OI) are common after total hip arthroplasty (THA) and may delay early mobilization. The pathology of OH and OI includes a dysregulated post-operative vasopressor response, by a hitherto unknown mechanism. We hypothesized that OI could be related to the inflammatory stress response which is inhibited by steroid administration. Consequently, this study evaluated the effect of a pre-operative high-dose methylprednisolone on OH and OI early after THA. METHODS: Randomized, double-blind, placebo-controlled study in 59 patients undergoing elective unilateral THA with spinal anesthesia and a standardized multimodal analgesic regime. Patients were allocated (1 : 1) to pre-operative intravenous (IV) methylprednisolone (MP) 125 mg or isotonic saline (C). OH, OI and cardiovascular responses to sitting and standing were evaluated using a standardized mobilization protocol pre-operatively, 6, and 24 h after surgery. Systolic and diastolic arterial pressure and heart rate were measured non-invasively (Nexfin® ). The systemic inflammation was monitored by the C-reactive protein (CRP) response. RESULTS: At 6 h post-operatively, 11 (38%) versus 11 (37%) patients had OH in group MP and group C, respectively (RR 1.02 (0.60 to 1.75; P = 1.00)), whereas OI was present in 9 (31%) versus 13 (43%) patients (RR 0.76 (0.42 to 1.36; P = 0.42)), respectively. At 24 h post-operatively, the prevalence of OH and OI did not differ between groups, though CRP levels were significantly reduced in group MP (P < 0.001). CONCLUSION: Pre-operative administration of 125 mg methylprednisolone IV did not reduce OH or OI compared with placebo despite a reduced inflammatory response.

Preoperative methylprednisolone increases plasma Pentraxin 3 early after total knee arthroplasty: a randomized, double-blind, placebo-controlled trial.

Preoperative glucocorticoid administration reduces the systemic inflammatory response. Pentraxin 3 (PTX3) is a novel inflammatory marker belonging to the humoral arm of innate immunity exerting a potentially protective host response. This study evaluated PTX3 and other complement marker changes after preoperative methylprednisolone (MP) early after total knee arthroplasty (TKA). Seventy patients were randomized (1 : 1) to preoperative intravenous (i.v.) MP 125 mg (group MP) or isotonic saline i.v. (group C). The outcomes included change in plasma PTX3, mannose-binding lectin (MBL), ficolins (ficolin-1, -2 and -3), complement components (C4 and C3), terminal complement complex (TCC) and C-reactive protein (CRP) concentrations. Blood samples were analysed at baseline and 2, 6, 24 and 48 h after surgery with complete sampling from 63 patients for analyses. MP resulted in an increase in circulating PTX3 compared to saline from baseline to 24 h postoperatively (P < 0·001), while MP reduced the systemic inflammatory response (CRP) 24 and 48 h postoperatively (P < 0·001). However, the small postoperative changes in MBL, ficolin-1, -2 and -3, C4, C3 and TCC concentrations did not differ between groups (P > 0·05). In conclusion, preoperative MP 125 mg increased circulating PTX3 and reduced the general inflammatory response (CRP) early after TKA, but did not affect other complement markers.

Preoperative ultraviolet B inflammation in skin: Modelling individual differences in acute postoperative pain and neuro-immune interactions.

BACKGROUND: Neuroimmune interactions play a vital role in many of the most common pain conditions, such as arthritis. There have been many attempts to derive clinically predictive information from an individual's inflammatory response in order to gauge subsequent pain perception. OBJECTIVES: Here, we wanted to test whether this effort could be enhanced and complemented by the use of a model system which takes into account the function of not just circulating, but also tissue-resident immune cells: ultraviolet B (UVB) irradiation of the skin. METHODS: We conducted psychophysical and transcriptional analysis of hyperalgesia arising as a result of UVB-induced inflammation in patients before total knee arthroplasty (TKA, n = 23). Levels of acute postoperative pain were assessed and correlated with preoperative data. RESULTS: Cytokine and chemokine responses after UVB irradiation were found to be inversely correlated with the level of pain experienced after surgery (Spearman's ρ = -0.498). CONCLUSION: It may be possible to use this simple model to study and predict the nature of neuro-immune responses at more remote, clinically relevant sites. SIGNIFICANCE: A simple model of UVB inflammation in the skin might predict the degree of a patient's neuro-immune response and the extent of their postoperative pain after total knee arthroplasty.

Safety aspects of preoperative high-dose glucocorticoid in primary total knee replacement.

Background: Preoperative single high-dose glucocorticoid may have early outcome benefits in total hip arthroplasty (THA) and knee arthroplasty (TKA), but long-term safety aspects have not been evaluated. Methods: From October 2013, the departments reporting to the prospective Lundbeck Foundation Database for Fast-track Hip and Knee Replacement introduced preoperative methylprednisolone (MP) 125 mg as part of a multimodal analgesic protocol in TKA. We analysed the risk of length of hospital stay (LOS) >4 days, 30 and 90 day readmissions in patients with MP vs patients having TKA before the use of MP and adjusted for comorbidity and place of surgery. An unadjusted comparison was specifically done to evaluate deep prosthetic infections. Results: Of a total of 3927 TKA procedures, 1442 received MP. Median LOS was 2 days in both groups, but the fraction with LOS >4 days was 6.0% vs 11.5% (P<0.001) in patients with MP vs those without, and with a reduced risk of LOS >4 days in adjusted analysis [odds ratio (OR) 0.51; confidence interval (CI) 0.39-0.68; P <0.001]. Readmission rates were 5.6% (CI 4.5-6.9) vs 4.4% ( P =0.095) and 7.8% vs 7.3% ( P =0.53) at 30 and 90 days with and without MP, respectively. Conclusions: In this detailed prospective cohort study, preoperative high-dose glucocorticoid administration was not associated with LOS >4 days, readmissions or infectious complications in TKA patients without contraindications.