Day-One Pain Reductions After Hip and Knee Replacement When Buprenorphine-Clonidine-Dexamethasone Is Added to Bupivacaine Nerve/Plexus Blocks: A Randomized Clinical Trial.

OBJECTIVE: To compare pain outcome reports of patients undergoing hip or knee replacement who received single-injection nerve/plexus blocks with plain bupivacaine (BPV) with those of patients who received injections of buprenorphine-clonidine-dexamethasone (BCD) admixed with BPV. DESIGN: Prospective, parallel-arm, randomized, double-blind trial. SETTING: A single veterans' hospital. SUBJECTS: Ninety-eight veterans scheduled for total hip or knee replacement surgery with spinal as the primary anesthetic. METHODS: Participants were randomized to BPV-BCD or plain BPV groups. They underwent nerve/plexus blocks in the L2-L4 and L4-S3 distributions in advance of joint replacement surgery. The primary outcome was change in pain from baseline during the postoperative day, as assessed by the total pain score on the short-form McGill Pain Questionnaire-v2 (SF-MPQ-2). Secondary outcomes were pain during movement, pain interference, range of motion, mobility, and quality of recovery. RESULTS: On postoperative day one, the SF-MPQ-2 total score for the BPV-BCD group demonstrated greater pain reduction than that of the plain BPV group (mean difference 1.8 points, 95% confidence interval 0.6 to 3.0, P = 0.003). The BPV-BCD group also had larger reductions in pain during movement in the surgical joint and less pain interference, along with increased range of hip and knee flexion, compared with the plain BPV group. Outcomes of mobility and quality of recovery were not different between groups. CONCLUSIONS: Preoperative BPV-BCD blocks in the L2-L4 and L4-S3 nerve distributions for hip and knee replacements led to less pain on postoperative day one and increased knee and hip range of motion, compared with plain BPV blocks. TRIAL REGISTRATION: ClinicalTrials.gov ID NCT02891798.

Perioperative stroke-related mortality after non-cardiovascular, non-neurological procedures: A retrospective risk factor evaluation of common surgical comorbidities.

BACKGROUND: Perioperative stroke-related mortality in the non-cardiovascular, non-neurological surgery population is an uncommon, yet devastating outcome. A combination of emboli and hypoperfusion may cause large vessel occlusions leading to perioperative strokes and mortality. Identifying independent risk factors for perioperative stroke-related mortality may enhance risk-stratification algorithms and preventative therapies. OBJECTIVES: This study utilised cause-of-death data to determine independent risk scores for common surgical comorbidities that may lead to perioperative stroke-related mortality, including atrial fibrillation and asymptomatic carotid stenosis. METHODS: This retrospective, IRB-exempt, case-control study evaluated non-cardiovascular, non-neurological surgical patients in a claims-based database. ICD-10-CM and ICD-9-CM codes identified cause of death and comorbidity incidences, respectively. A multivariate regression analysis then established adjusted independent risk scores of each comorbidity in relation to perioperative stroke-related mortality. RESULTS: Patients with atrial fibrillation were more likely (1.7 aOR, 95% CI (1.1, 2.8) p = 0.02) to die from perioperative stroke-related mortality than from other causes. No association was found with asymptomatic carotid stenosis. Further, in-hospital strokes (25.9 aOR, 95% CI (16.0, 41.8) p < 0.001) or diabetes (1.8 aOR, 95% CI (1.1, 2.9) p = 0.02) may increase perioperative stroke-related mortality risk. CONCLUSIONS: Atrial fibrillation, diabetes and in-hospital strokes may be independent risk factors for perioperative stroke-related mortality in the non-cardiovascular, non-neurological surgery population.

Extended Perineural Analgesia After Hip and Knee Replacement When Buprenorphine-Clonidine-Dexamethasone Is Added to Bupivacaine: Preliminary Report from a Randomized Clinical Trial.

OBJECTIVE: We tested the hypothesis that buprenorphine-clonidine-dexamethasone (BCD) extends perineural analgesia compared with plain bupivacaine (BPV) nerve blocks used for hip and knee replacement surgery. DESIGN: Prospective, parallel-arms, randomized, double-blind trial. SETTING: A single veterans' hospital. SUBJECTS: Seventy-eight veterans scheduled for total hip or knee replacement with plans for spinal as the primary anesthetic. METHODS: Participants underwent nerve/plexus blocks at L2-L4 and L4-S3 in advance of hip or knee joint replacement surgery. Patients were randomized to receive BPV-BCD or plain BPV in a 4:1 allocation ratio. Patients answered four block duration questions (listed below). Time differences between treatments were analyzed using the t test. RESULTS: Significant (P < 0.001) prolongation of the time parameters was reported by patients after the BPV-BCD blocks (N = 62) vs plain BPV (N = 16). The time until start of postoperative pain was 26 vs 11 hours (mean difference = 15 hours, 95% CI = 8 to 21). The time until no pain relief from the blocks was 32 vs 15 hours (mean difference = 17 hours, 95% CI = 10 to 24). The time until the numbness wore off was 37 vs 21 hours (mean difference = 16 hours, 95% CI = 8 to 23). The time until the worst postoperative pain was 39 vs 20 hours (mean difference = 19 hours, 95% CI = 11 to 27). CONCLUSIONS: BPV-BCD provided 26-39 hours of perineural analgesia in the L2-L4 and L4-S3 nerve distributions after hip/knee replacement surgery, compared with 11-21 hours for plain BPV.

Disease progression in contralateral carotid artery is common after endarterectomy.

OBJECTIVE: Although the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the Asymptomatic Carotid Atherosclerosis Study (ACAS) have helped to define the role of carotid endarterectomy (CEA) for both symptomatic and asymptomatic lesions, the role of surveillance of the contralateral carotid artery remains unclear. The purpose of this study was to determine the progression of contralateral carotid artery disease with serial duplex ultrasound scans after CEA compared with the recurrent stenosis rate for the carotid artery ipsilateral to the CEA. METHODS: From January 1990 to December 2000, 473 CEA procedures were performed at a Veterans Affairs Medical Center. From this group we identified 279 patients who had undergone first-time CEA, as well as preoperative duplex scanning and postoperative duplex scanning at least once, in the vascular laboratory. At each visit stenosis of the internal carotid artery (ICA) was categorized as none (0%-14%), mild (15%-49%), moderate (50%-79%), severe (80%-99%), or occluded. Analysis of probability of freedom from progression was determined. Progression was defined as an increase in ICA stenosis 50% or greater or increase to a higher category of stenosis if baseline was 50% or greater. The Cox proportional hazards model was used for data analysis. RESULTS: Mean patient age was 65.7 years (range, 33-100 years). The 1024 carotid duplex ultrasound scanning examinations performed (mean, 3.7; range, 2-13) included the last study done before the index CEA and all studies done after the CEA. Mean follow-up was 27 months (range, 1-137 months). Forty-six patients were found to have contralateral carotid occlusion at initial duplex scanning, and were therefore excluded from the contralateral progression analysis. Contralateral progression was more frequent than ipsilateral recurrent stenosis at long-term follow-up (P <.01). Annual rates of "any progression" and "progression to severe stenosis or occlusion" were 8.3% and 4.4%, respectively, for contralateral arteries, and 4.3% and 2.4%, respectively for ipsilateral arteries. As a result of surveillance, 43 contralateral CEAs (19% of initial cohort) were performed. Carotid stenosis regressed in 25 arteries (10.7%). Baseline clinical and demographic factors did not predict disease progression. Baseline contralateral stenosis did not predict time to "any progression," but was a strong predictor of "progression to severe stenosis or occlusion" (P <.001). CONCLUSIONS: After CEA, we identified an 8.3% annual rate of progression of contralateral carotid artery stenosis and a 4.4% annual rate of progression to severe stenosis or occlusion. Baseline contralateral stenosis was significantly predictive of progression to severe stenosis or occlusion. Clinical and demographic factors were not helpful in predicting which patients would have disease progression. These data may help in assessing the cost effectiveness of duplex scanning surveillance after CEA.