Percutaneous hamstring lengthening in cerebral palsy and the risk of neurovascular transection.

PURPOSE: Percutaneous hamstring lengthening is increasingly popular due to its simplicity, fast recovery rate, and low morbidity. Neurovascular anatomy changes due to knee flexion contracture and the precise proximity of peroneal nerve and Biceps femoris tendon are not well established. This study examined (1) the coronal distance between the peroneal nerve and lateral hamstring tendon ("PLD"), and (2) the distance between the popliteal vessels and medial hamstring tendons ("VMD") to determine the safe distance for percutaneous hamstring lengthening. METHODS: This prospective study recruited cerebral palsy patients aged under 15 who needed hamstring lengthening. Ultrasonography was performed after the patients were anesthetized. PLDs and VMDs at popliteal angles (PAs) of 40°, 60°, and 80° knee flexions were collected. RESULTS: Sixteen patients (32 knees) were enrolled. The mean minimum PLDs at PAs of 40°, 60°, and 80° were 3.5, 4.1, and 3.1 mm, respectively. The peroneal nerve physically touched the lateral hamstring tendon in 5/32 knees (15.6%). The mean minimum VMDs at PAs of 40°, 60°, and 80° were 19, 18.3, and 16.4 mm, respectively. One spastic diplegic patient had a minimum VMD < 3 mm on both sides. Changing the PAs demonstrated no statistical significance for both PLD and VMD (P value = 0.105 and 0.779, respectively). CONCLUSIONS: Percutaneous medial hamstring lengthening should be done with caution. We recommend open biceps femoris surgery, with preoperative ultrasonography (to check the PLD) or peroneal nerve palpation to reduce the risk of peroneal nerve transection.

Adding a low-concentration sciatic nerve block to total knee arthroplasty in patients susceptible to the adverse effects of non-steroidal anti-inflammatory drugs (NSAIDs): a randomized controlled trial.

BACKGROUND: This study compared the effects of adductor canal blocks with those of a low concentration of popliteal-sciatic nerve block (SNB) and dexamethasone as an adjunctive technique for total knee arthroplasties (TKA) in patients susceptible to the adverse effects of NSAIDs. METHODS: A prospective, double-blinded, randomized controlled trial was performed in 50 patients susceptible to the adverse effects of NSAIDs undergoing unilateral TKAs. All patients received spinal anesthesia, adductor canal blocks, and periarticular infiltration. The 25 patients in the intervention group received SNB (0.125% bupivacaine [20 ml] and dexamethasone [5 mg]). RESULTS: The SNB group significantly had lower median resting pain scores at 6, 12, and 18 h: the control group, 1 (0-4.5), 3 (0-5), and 3 (2-5); the intervention group, 0 (0-0), 0 (0-3), and 1 (0-3); p-values, 0.012, 0.021, and 0.010, respectively. Movement-evoked pain scores at 6, 12, and 18 h were also lower: control group, 3 (0-5.5), 5 (2.5-6.5), and 7 (4-9); intervention group, 0 (0-1.5), 2 (0-4), and 3 (2-5); p-values, 0.019, 0.005, and 0.001, respectively. There were no differences in motor function. Moreover, the mean morphine consumption 24 h was also reduced in the SNB group: control group, 3.80 ± 2.48 mg; intervention group, 1.96 ± 2 mg; p-value, 0.005. CONCLUSION: For patients susceptible to the adverse effects of NSAIDs, a low concentration of SNB and dexamethasone is an effective adjunctive technique for early postoperative pain control (especially on movement) following TKAs, without an increase in motor weakness. TRIAL REGISTRATION: ClinicalTrials.gov , NCT03486548 , Registered 3 April 2018.

Local Ketorolac Injection vs Popliteal Sciatic Nerve Blockade as an Adjuvant to a Spinal Block in Hindfoot Arthrodesis.

BACKGROUND: Popliteal nerve blocks reduce pain and markedly improve postoperative outcomes during foot and ankle surgery; however, several potential complications may arise from nerve block procedures. The purpose of this study was to investigate local infiltration analgesia with ketorolac as a convenient alternative for pain relief. METHODS: A total of 80 patients scheduled for hindfoot arthrodesis were randomly allocated to one of 2 anesthetic groups: a spinal block augmented with either a popliteal nerve block (n = 40) or local ketorolac and Marcaine infiltration (n = 40). Clinical assessment included postoperative visual analog scale (VAS) pain scores at 4, 8, 12, 24, and 48 hours, total morphine consumption, time to incision (time in operating room to incision), operative time, length of hospital stay, and complications. RESULTS: Despite similar morphine consumption between groups (P = .28), VAS scores were significantly lower at 24 hours (1.6 ± 2.2 cm vs 2.7 ± 3.0 cm, P = .01) and 48 hours (0.2 ± 0.7 cm vs 1.0 ± 1.5 cm, P < .01) after surgery using local ketorolac injection. Although time from entry into the operating room to incision was also reduced after local ketorolac injection (19.0 ± 5.3 minutes vs 31.4 ± 14.6 minutes, P < .001), the length of operative time (P = .38), hospital stay (P = .43), and number of complications (P = .24) were similar between groups. CONCLUSION: Ketorolac local injection provided effective pain control in hindfoot arthrodesis and markedly reduced VAS pain scores up to 48 hours after surgery compared with popliteal nerve block. In addition, ketorolac local injection also reduced time in the operating room compared with popliteal nerve blockade. LEVEL OF EVIDENCE: Level 1, randomized controlled trial.

Factors Related to Delayed Extubation in Cervical Spine Surgery in an Academic Hospital: A Retrospective Study of 506 Patients

Objective: The incidence of airway obstruction has been reported to be 1.2­6.1% after cervical spine surgery and up to 27% in posterior occipito-cervical spinal fusion. Communication between the anesthesiologist, surgeon, and staff responsible for postoperative care, and the identifi cation of patients at risk of airway complications are important. We aimed to determine the incidences of delayed extubation and reintubation, and the factors related to delayed extubation after cervical spine surgery. Methods: A review was conducted of the medical records of patients who underwent cervical spine surgery in the orthopedic and neurosurgery units, Siriraj Hospital, between January 2012 and May 2017. The data included demographics, perioperative airway management, postoperative airway complications (delayed extubation and reintubation), and outcomes. Results: Of the 506 patients analyzed, delayed extubation occurred in 116 (22.9%), and 15 (3.0%) were reintubated. The independent related factors for delayed extubation were blood loss ≥ 300 mL (odds ratio [OR], 2.71; 95% confi dence interval [CI], 1.33­5.49); intraoperative fl uid administration ≥ 2,000 mL (OR, 2.17; 95% CI, 1.08­4.36); anesthetic time of ≥ 300 min (OR, 3.74; 95% CI, 1.83­7.63); and case fi nished after service hours (OR, 3.18; 95% CI, 1.73­5.88). Conclusion: The incidence of delayed extubation in cervical spine surgery patients was high, and reintubation was common. Anesthesiologists should be cognizant of the related risk factors before deciding between immediate or delayed extubation.

Allogeneic red cell transfusion and its influence on relevant humoral and cellular immunological parameters: A prospective observational trial.

BACKGROUND: It is assumed that transfusion of allogeneic red cells is associated with increased peri-operative mortality and morbidity. Also assumed is the theory of transfusion-related immunomodulation. OBJECTIVE: The aim of this study was to investigate the hypothesis that red cell transfusion specifically leads to an immunological response in surgical patients. DESIGN: Prospective observational study. SETTING: Departments of Orthopedic Surgery and Anaesthesia, University Hospital, Thailand. PATIENTS: Low-risk, noncancer patients, aged 18 to 75 years undergoing elective major spine surgery, with and without red cell transfusion therapy. INTERVENTIONS: Blood specimens were withdrawn four times (prior to surgery and on days 1, 3 and 5). MAIN OUTCOME MEASURES: Assessment of immunocompetent cells and cytokines in transfused and nontransfused patients using flow cytometry and multiplex ELISA. RESULTS: From a total of 78 patients, 61 met the requirements and were analysed in three groups: 19 with no transfusion and 26 and 16 transfused intra-operatively and on day 1 or 2, respectively. No patient experienced peri-operative haemorrhage. Postoperative infection or thrombosis occurred in 5.5% of nontransfused patients and 16.6% of transfused patients; the difference was not significant. There was no significant immunomodulatory effect of red cell transfusion: of 45 immunological parameters, only five little-relevant cytokines were significantly affected, although slightly and nonspecifically. CONCLUSION: Our data indicate that red cell transfusion alone does not create an immunological response in otherwise healthy surgical patients. Our findings do not generally contradict the transfusion-related immunomodulation phenomenon, which has, however, primarily been observed in patients with an already weakened or procedure-deteriorated immune system, such as from malignant disease, significant comorbidity, extensive abdominal/thoracic surgery and cardiopulmonary bypass. TRIAL REGISTRATION: The study was registered on 15 May 2014, before enrolment of the first patient, at www.ClinicalTrials.gov, NCT02140216.

Perioperative Factors Associated with Severe Pain in Post-Anesthesia Care Unit after Thoracolumbar Spine Surgery: A Retrospective Case-Control Study.

STUDY DESIGN: A retrospective case-control study. PURPOSE: To evaluate the effect of nitrous oxide and anesthetic and operative factors associated with severe pain in the early postoperative period after thoracolumbar spine surgery. OVERVIEW OF LITERATURE: Thoracolumbar spine surgery is the most common procedure in spine surgery, and up to 50% of the patients suffer from moderate to severe pain. Nitrous oxide has analgesic, anxiolytic, and anesthetic effects; nevertheless, its benefits for early postoperative pain control and opioid consumption remain to be established. METHODS: The medical records of eligible participants who underwent thoracolumbar spine surgery between July 2016 and February 2017 were reviewed. Enrolment was performed consecutively until reaching 90 patients for the case (severe pain) group (patients with a pain score of >7 out of 10 at least once during the post-anesthesia care unit [PACU] admission), and 90 patients for the control (mild-to-moderate pain) group (patients with a pain score of <7 in every PACU assessment). The data collected comprised patient factors, anesthetic factors, surgical factors, PACU pain score, and PACU pain management. RESULTS: A total of 197 patients underwent thoracolumbar spine surgery with an incidence of early postoperative severe pain of 53.3%. The case-control study revealed no differences in the factors related to pain intensity. A subgroup analysis was performed for failed back surgery syndrome (FBSS), spinal stenosis, and spondylolisthesis. After multivariate analyses, only the age group of 19-65 years and the baseline Oswestry Disability Index (ODI) were found to be significant risk factors for early postoperative severe pain in the PACU (odds ratio [OR], 2.86; 95% confidence interval [CI], 1.32-6.25; OR, 1.03; 95% CI, 1.01-1.05, respectively). CONCLUSIONS: Nitrous oxide, anesthetic agents, and surgical techniques did not affect the early postoperative pain severity. Age under 66 years and the baseline ODI were the significant risk factors for pain intensity during the early postoperative period of the FBSS, spinal stenosis, and spondylolisthesis subgroups.

Femoral Nerve Block versus Intra-Articular Infiltration: A Preliminary Study of Analgesic Effects and Quadriceps Strength in Patients Undergoing Arthroscopic Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Adequate analgesia and early rehabilitation is necessary for arthroscopic anterior cruciate ligament reconstruction (A CLR) surgery. OBJECTIVE: To compare analgesia and quadriceps strength after femoral nerve block (FNB) with intra-articular infiltration (IA) using 0.25% bupivacaine for ACLR with patella tendon graft. MATERIAL AND METHOD: Forty patients were randomized to receive FNB under ultrasound guidance with 20 mL of bupivacaine or IA with 15 mL of bupivacaine into the knee joint and 5 mL infiltrated along the incision sites including portal sites at the end of surgery. All patients received intravenous ketorolac at wound closure. Data regarding demographic, time to first pain, time to first morphine requirement, morphine usage, pain scores and quadriceps strength were recorded. RESULTS: Significant difference in quadriceps strength was shown. Ninety percent of patients in Group IA and fifty-five percent of patients in Group FNB had good ability to extend knee at 24 hours after surgery (p = 0.013). No differences were found in demographic data, time to first pain, time to first morphine requirement, post operative pain scores and morphine consumption, CONCLUSION: The preliminary results demonstrated that IA has an effect on quadriceps strength less than FNB while provide comparable postoperative analgesia after patellar tendon graft ACLR.

An Equivalence Trial Comparing Labetalol and Diltiazem in Controlling Emergence Hypertension after Supratentorial Tumor Surgery.

BACKGROUND: Hypertension and tachycardia during emergence from anesthesia for craniotomy could increase risks of cerebral complications. Several anesthetic, sedative, and antihypertensive drugs have been suggested that may be successful at suppressing these unwanted hemodynamic consequences. OBJECTIVE: To study the equivalent efficacy and side effects of two antihypertensive drugs, diltiazem and labetalol. MATERIAL AND METHOD: A block randomized control trial was performed in 184 patients who developed emergence hypertensive response after craniotomyfor supratentorial tumor removal. Systolic blood pressure (SBP) of each patient was suppressed by 2.5 mg of study drugs and repeated with fix dosage of 2.5 mg every two to three minutes to maintain SBP lower than 140 mmHg with a cumulative dose within 20 mg. Data regarding demographic, successful rate in controlling hypertension, drug dosage, and incidence of side effects were analyzed. RESULTS: The success rate of treatment of labetalol was equivalent to diltiazem (87.1% and 80.2% respectively) [p = 0.003, 95% CI = 6.88 (-2.06 to 15.8)]. There was no statistical significant difference on dosage of drugs used or incidence ofside effect (hypotension, bradycardia, heart block, and bronchospasm). Median (minimum-maximum) dosage of labetalol and diltiazem were 10 mg (2.5-20 mg) and 10 mg (2.5-20 mg) respectively. The expense for labetalol was 1/6 of diltiazem. CONCLUSION: Labetalol has equivalent efficacy to diltiazem. Both drugs used low median dosage giving low incidence of side-effects. Labetalol is a good alternative drug to control hypertensive response during emergence from anesthesia for post-craniotomy.

Femoral nerve block using 0.25% or 0.5% bupivacaine for analgesia after arthroscopic anterior cruciate ligament reconstruction.

BACKGROUND: Femoral nerve block (FNB) with varying concentrations of bupivacaine is often used for postoperative analgesia after anterior cruciate ligament (ACL) reconstruction. OBJECTIVE: To determine whether FNB using 0.25% or 0.5% bupivacaine provided better analgesia with less effect on quadriceps strengths after ACL reconstruction. MATERIAL AND METHOD: One hundred patients were randomized to receive FNB with 20 mL of 0.25% or 0.5% bupivacaine. Data regarding demographic, effectiveness of FNB, time to first pain, time to first analgesic, pain scores, morphine use, and recovery of sensory and motor function were recorded. RESULTS: Median time to first morphine requirement was 12 hours in 0.5% bupivacaine group and 10 hours in 0.25% bupivacaine group (p = 0.048). Pain score at 18 hours was lower in 0.5% bupivacaine group compared with 0.25% bupivacaine group (p = 0.001). When specify to the patellar tendon graft subgroup, the patients requiring morphine were 70% in 0.5% bupivacaine group and 90% in 0.25% bupivacaine group (p = 0.03). No differences were found in demographic data, effectiveness of FNB, time to first pain, morphine consumption, and recovery of sensorimotor function. CONCLUSION: FNB with 0.5% bupivacaine provided longer time to first analgesic and lower narcotic requirements after patellar tendon graft ACL reconstruction when compared to 0.25% bupivacaine. Both concentrations showed similar effect on quadriceps strengths.

Transurethral resection of the prostate (TURP) with low dose spinal anesthesia in outpatients: a 5 year review.

INTRODUCTION: Spinal anesthesia for ambulatory transurethral resection of the prostate (TURP) is a well established technique. The following study examines data over a 5 year period at a major Canadian tertiary academic center. The purpose of the study is to review our experience and complications associated with spinal anesthesia using combined low dose local anesthetic + narcotic for ambulatory TURP procedures. METHODS: Medical records were reviewed retrospectively on all ambulatory TURP patients over a 5 year period between January 2000 and September 2005 in our Surgical Day Care Center. All spinal anesthetics were reviewed and based on dosage, classified into low dose bupivacaine (< 10 mg; Group LD-B), conventional dose lidocaine (> 35 mg; Group CD-L) or low dose lidocaine (≤ 35 mg; Group LD-L). Primary end points of interest were duration of spinal block and duration of postanesthesia care unit (PACU) stay. RESULTS: A total of 1064 TURPs were performed during the study period. Within this cohort of 334 spinal anesthetics administered, 27 were excluded for lack of data leaving 307 cases for analysis. Patient demographics were normally distributed. Mean doses of spinal local anesthetics administered were: Group LD-B 7.3 ± 2 mg, Group CD-L 52.2 ± 13 mg and Group LD-L 29 ± 5.2 mg. Intrathecal fentanyl was often added to the local anesthetic as an adjunct. Block regression times (Group LD-B 273 ± 98 mins, Group CD-L 174 ± 47 mins and Group LD-L 159 ± 45 mins) and discharge times (Group LD-B 309 ± 94 mins, Group CD-L 230 ± 71 mins and Group LD-L 227 ± 75 mins) were significantly lesser in both lidocaine groups compared to Group LD-B (p <0.05). The frequency of prolonged spinal blocks (> 3 hr) in Groups LD-L, CD-L and LD-B was 23%, 43% and 83% respectively (p < 0.05). CONCLUSION: Low dose spinal anesthesia with bupivacaine and lidocaine were well tolerated for short duration TURP. Low dose bupivacaine and conventional dose lidocaine were associated with significantly longer block duration, longer PACU stay and higher frequency of prolonged blocks compared with low dose lidocaine for spinal anesthesia.

Cost-effectiveness of thoracic patient-controlled epidural analgesia using bupivacaine with fentanyl vs bupivacaine with morphine after thoracotomy and upper abdominal surgery.

OBJECTIVES: To compare the effectiveness and cost of thoracic patient-controlled epidural analgesia (TPCEA) using bupivacaine with fentanyl (BF) vs bupivacaine with morphine (BM) solution. MATERIAL AND METHOD: In a blinded, randomized controlled trial, 90 adult patients who were scheduled for thoracotomy or upper abdominal surgery were enrolled. All patients were anesthetized by a combined general/epidural technique. Intraoperative and postoperative analgesia was provided by TPCEA using bupivacaine 0.0625% with either fentanyl (group BF) or morphine (group BM) solution. The occurrence and severity of side effects, visual analogue scale (VAS) for pain at rest and during movement, patients' satisfaction score as well as charged cost of pain and side effect management were recorded for 48 hrs. RESULTS: Demographic data of both groups were not significantly different. No statistical differences were noted with respect to efficacy of pain relief between the 2 groups. Only 28.5% of the patients in group BM required supplemental systemic analgesia within 24 hours after epidural catheter removal compared with 51.4% in the group BE Patients' satisfaction and the severity of epidural analgesia related side effects, using itching and nausea/vomiting score, of both groups were not significantly different except the median nausea/ vomiting scores of group BM at 18 and 24 hours were statistically higher than those of group BF (P = 0.047 and 0.02, at 18 and 24 hour respectively) but not clinically different. The mean charged cost of medication used in group BM (470.64 +/- 160.54 baht) was lower than that in group BF (814.15 +/- 217.51 baht). CONCLUSION: TPCEA using BF and BM solution resulted in similar pain relief and side effect profiles but with higher charged cost of medication in group BF Morphine appears to be a more cost-effective choice than fentanyl for TPCEA after thoracotomy or upper abdominal surgery.