Randomised controlled study comparing general and spinal anaesthesia with and without a tourniquet on the outcomes of total knee arthroplasty: study protocol.

INTRODUCTION: Total knee arthroplasty is a highly effective treatment for end-stage knee osteoarthritis, and it is usually performed under spinal or general anaesthesia with or without a surgical tourniquet. Some debate about the preferred mode of anaesthesia regarding patient outcomes remains. The aim of this study, which compares general and spinal anaesthesia with and without a tourniquet on the outcomes of total knee arthroplasty, is to determine the optimal type of anaesthesia regimen and assess the effect of a tourniquet on the patient's recovery following total knee arthroplasty. METHODS AND ANALYSIS: This study is a randomised, controlled, parallel-group, four-arm study comparing spinal and general anaesthesia with and without a tourniquet in 400 patients undergoing fast-track total knee arthroplasty, with a 12-month follow-up. The primary outcome is cumulative intravenous oxycodone consumption by patient-controlled analgesia during the first 24 postoperative hours. Secondary outcomes include postoperative nausea and vomiting, the length of hospital stay, the duration of the surgery, blood loss, demand for surgical unit resources, complications, readmissions, postoperative knee function, range of motion, health-related quality of life, prolonged pain and mortality. ETHICS AND DISSEMINATION: This study's protocol is in accordance with the declaration of Helsinki. The results of this study will be disseminated in international peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT03364088; Pre-results.

Randomized comparison of the feasibility of three anesthetic techniques for day-case open inguinal hernia repair.

STUDY OBJECTIVE: Comparison of local anesthetic infiltration (LAI), spinal anesthesia (SPIN) and total intravenous anesthesia (TIVA) for open inguinal herniorrhaphy. We hypothesized that patients receiving LAI could be discharged faster than SPIN and TIVA patients. DESIGN: Randomized, prospective trial. SETTING: University hospital day-surgery center. PATIENTS: 156 adult male patients (ASA 1-3) undergoing day-case open inguinal herniorrhaphy. INTERVENTIONS: Patients were randomized to either LAI (lidocaine+ropivacaine), SPIN (bupivacaine+fentanyl) or TIVA (propofol+remifentanil). Perioperative Ringer infusion was 1.5mL/h. Urinary bladder was scanned before and after surgery. Interviews were performed on postoperative days 1, 7 and 90. MEASUREMENTS: Duration of surgery, duration of the patients' stay in the operating room and time until their readiness for discharge home. Patient satisfaction and adverse effects were registered. MAIN RESULTS: Surgery lasted longer in LAI group (median 40min) than in SPIN group (35min) (P=.003) and TIVA group (33min) (P<.001). Although surgery was shortest in TIVA group, TIVA patients stayed longer in the operating room than LAI patients (P=.001). Time until readiness for discharge was shorter in LAI group (93min) than in TIVA (147min) and SPIN (190min) groups (P<.001). Supplementary lidocaine infiltration was given to 32 LAI patients, and IV fentanyl to 29 LAI and 4 SPIN patients. Ephedrine was required in 34 TIVA, 5 LAI and 5 SPIN patients. One SPIN and three LAI patients had to be given TIVA and another SPIN patient LAI to complete the operations. Urinary retention was absent. Discomfort in the scar (26%) three months postoperatively was not anesthesia-related. CONCLUSIONS: Logistically, LAI was superior because of the fastest recovery postoperatively. The anesthetic techniques were adequate for surgery in all but a few LAI and SPIN patients. Lack of urinary retention was probably related to the small IV infusion volumes.

Perioperative Paravertebral Regional Anaesthesia and Breast Cancer Recurrence.

AIM: Retrospective and basic science data suggest that perioperative regional anaesthesia (PRA) may reduce tumour recurrence after cancer surgery. This retrospective archive study tested the anti-metastatic effect of PRA. PATIENTS AND METHODS: We screened the database of the Helsinki University Hospital for patients with breast cancer who had either perioperative paravertebral block (PVB) or sham block (SHAM) in 2000-2003. The exclusion criteria were previous cancer, no cancer, and loss to follow-up. The end-points were disease-free (DFS), distant recurrence-free (DRFS), breast cancer-specific (BCSS) and overall (OS) survival. RESULTS: The median follow-up time of the 45 PVB and 41 SHAM patients analysed was 12 years. DFS was 79% and 83%, DRFS 84% and 92%, BCSS 81% and 95%, OS 74% and 93% in the PVB and SHAM groups, respectively (p-value for OS = 0.035). CONCLUSION: The results do not demonstrate any anti-metastatic effect of PRA.

Randomised comparison of hyperbaric articaine and hyperbaric low-dose bupivacaine along with fentanyl in spinal anaesthesia for day-case inguinal herniorrhaphy.

BACKGROUND AND OBJECTIVE: Low-dose mixture of hyperbaric bupivacaine and fentanyl is commonly used in day-case spinal anaesthesia. Using hyperbaric articaine, the onset may be faster and duration more predictable than with bupivacaine-fentanyl. We compared these two spinal anaesthetics for inguinal herniorrhaphy. METHODS: Adult patients were randomised to spinal anaesthesia with hyperbaric articaine 84 mg (group A, n = 40) or hyperbaric bupivacaine 7 mg along with fentanyl 10 µg (group B+F, n = 40). A blinded observer tested the block characteristics. Aiming at sensory block spread to T10 dermatome, the operating table was tilted head-end up or down 10° (once or twice), as required. Postoperative telephone interviews were performed. RESULTS: All patients in group A had a sensory block to T10 in a median time of 4 (range 2-20) min. In group B+F, the median onset time of T10 analgesia was 10 (2-30) min (P < 0.001), but T10 analgesia was not reached in seven of 40 B+F patients. A head-up tilt was needed in 37 of 40 group A patients to prevent from too extensive cephalad spread of block, and 34 of 40 group B+F patients needed a head-down tilt to enhance cephalad spread of analgesia. To treat hypotension, 6.4 mg of ephedrine was required, on average, in group A and 1.8 = mg in group B+F (P = 0.01). Median time to recovery from sensory block was significantly shorter in group A (2.5 h) than in group B+F (3 h; P = 0.002). General anaesthesia was needed in three patients (group A, two patients: sensory block too short; group B+F, one patient: sensory block too limited). CONCLUSION: Hyperbaric articaine leads to faster onset of block and faster recovery than bupivacaine along with fentanyl. Hypotension is more common with articaine. The onset and extension of the spinal block are unpredictable when using these techniques.

Is it possible to gain extra waiting time to liver transplantation in acute liver failure patients using albumin dialysis?

Hepatic encephalopathy (HE)-associated brain edema is a common cause of death in acute liver failure (ALF). Molecular Adsorbent Recirculating System (MARS) albumin dialysis detoxifies endogenous and exogenous toxins from blood and improves HE. In this study we assessed the effect of MARS on increasing the length of time available while waiting for liver graft. Thirty-seven patients with ALF who received a high-urgent liver transplant (LTx) were divided into three groups according to the amount of histological necrosis in the explanted liver: group I = 100% necrosis; group II = 80-99% necrosis; group III = less than 80% necrosis. MARS was used continuously until LTx. Median time (range) on MARS treatment prior to LTx in groups I-III was 7 days (2-26), 6 days (1-17), and 5 days (1-15), and the median time on the waiting list was 5 days (1-11), 3 days (0-13), and 1 day (0-12), respectively. The HE grade prior to and after MARS was similar in all groups. In two patients the HE grade decreased during MARS treatment, even though the explanted liver showed a complete lack of viable cells. Overall 30-day and one-year survival were 97% and 92%, respectively, without differences between the three groups. In ALF patients the liver cell damage progressed to total or near total necrosis of the liver when the waiting time was prolonged. Yet, with MARS treatment some patients with total hepatic necrosis showed an absence of encephalopathy. With MARS treatment some patients might be able to wait longer for a LTx with good results.

Epidural analgesia diminished pain but did not otherwise improve enhanced recovery after laparoscopic sigmoidectomy: a prospective randomized study.

BACKGROUND: The primary hypothesis for this study was that epidural analgesia reduces the use of opioids and thus advances bowel function and oral intake and shortens hospital stay after laparoscopic sigmoidectomy performed according to principles of enhanced recovery after surgery. METHODS: For this study, 60 patients with complicated diverticular disease were randomized to the epidural anesthesia group or the control group before surgery. Postoperative oxycodone consumption, pain, and recovery parameters were followed for 14 days. RESULTS: The epidural group needed less oxycodone than the control group until 12 h postoperatively. They experienced significantly less pain related to coughing and motion until postoperative day 2. In the epidural group, fewer patients experienced significant pain, and the duration of postoperative pain was shorter. Postoperative oral intake, bowel function, hospital stay, and overall complication rate were similar in the two groups. However, the control group had more postoperative hematomas. CONCLUSIONS: Epidural analgesia significantly alleviates pain, reducing the need for opioids during the first 48 h after laparoscopic sigmoidectomy. However, epidural analgesia does not alter postoperative oral intake, mobilization, or length of hospital stay.

Preincisional paravertebral block reduces the prevalence of chronic pain after breast surgery.

We reported earlier that preincisional paravertebral block (PVB) provides significant immediate postoperative analgesia after breast cancer surgery. In the same patients (n = 60), a 1-yr follow-up was performed to find out whether PVB could also reduce the prevalence of postoperative chronic pain. The follow-up consisted of a 14-day symptom diary and telephone interviews 1, 6, and 12 mo after surgery. The 14-day consumption of analgesics was similar in the 30 PVB and the 30 control patients. However, 1 mo after surgery, the intensity of motion-related pain was lower (P = 0.005) in the PVB group. Six months after surgery, the prevalence of any pain symptoms (P = 0.029) was lower in the PVB group. Finally, at 12 mo after surgery, in addition to the prevalence of pain symptoms (P = 0.003) and the intensity of motion-related pain (P = 0.003), the intensity of pain at rest (P = 0.011) was lower in the PVB group. These findings were independent of whether or not axillary dissection had been performed. The incidence of neuropathic pain was low (two and three patients in the PVB and control groups, respectively). In addition to providing acute postoperative pain relief, preoperative PVB seems to reduce the prevalence of chronic pain 1 yr after breast cancer surgery.

Single-injection paravertebral block before general anesthesia enhances analgesia after breast cancer surgery with and without associated lymph node biopsy.

Paravertebral block (PVB) seems to decrease postoperative pain and postoperative nausea and vomiting (PONV) after breast surgery, but the studies have not been placebo controlled. We studied 60 patients scheduled for breast cancer surgery randomly given single-injection PVB at T3 with bupivacaine 5 mg/mL (1.5 mg/kg) or saline before general anesthesia. The patient and attending investigators were blinded; the PVB or the sham block was performed behind a curtain by an anesthesiologist not involved in the study. The patients given PVB with bupivacaine needed 40% less IV opioid medication (primary outcome variable) in the postanesthesia care unit, had a longer latency to the first opioid dose, and had less pain at rest after 24 h than the control patients (P < 0.01). They also had less PONV in the postanesthesia care unit (P < 0.05), were less sedated until 90 min (P < 0.05), and performed better in the digit symbol substitution test at 90 min and the ocular coordination test 60-120 min after surgery (P < 0.05). The average peak bupivacaine plasma concentration was 750 ng/mL. One patient had bilateral convulsions immediately after bupivacaine injection. We conclude that PVB before general anesthesia for breast cancer surgery reduced postoperative pain, opioid consumption, and occurrence of PONV and improved recovery from anesthesia.