Application of Tourniquet Does Not Influence Early Clinical Outcomes After Total Knee Arthroplasty.

Introduction The use of a tourniquet during total knee arthroplasty (TKA) is still a topic of debate, given the conflicting results in the literature with respect to complications, pain, functional outcome, and blood loss. However, due to a lack of convincing data on early patient-reported outcomes (PROMS), this study aims to compare pain and functional outcomes in total knee arthroplasty patients with and without a tourniquet. Methods A randomized controlled trial was set up at a tertiary care hospital that spanned from 1st February 2015 to 31st July 2018. We included all primary total knee arthroplasties performed for patients aged between 50 and 80 years. Oxford Knee Score (OKS), Numerical Pain Rating Score (NPRS), Visual Analogue Scale (VAS) for satisfaction, active range of knee motion, and Short Form-12 Survey (SF-12) scores were collected pre-surgery and then at six-weeks and six-months interval with a p-value of 0.05 considered to be significant. Results Two hundred and forty patients participated in the study; 117 patients were randomized to surgery with the tourniquet inflated and 123 to surgery with the tourniquet deflated. There were 43.4% males, and 56.6% females in the tourniquet inflated group with an average age of 62.29±9.63 years while in tourniquet deflated group, there were 46.7% males and 53.3% females with a mean age of 65.41±9.042 years (p-value for age is 0.404; the p-value for gender is 0.086).  Despite the increase in intraoperative blood loss in both the groups, there was no significant increase in blood transfusions as both groups recorded the need for postoperative blood transfusion - 12 patients in the tourniquet group and 19 in the non-tourniquet group, but this difference was statistically insignificant (p=0.231). The perioperative blood loss was significantly lower (p<0.001) in the tourniquet group (490.29±47.752) compared to in the non-tourniquet group (526.18±12.796), while the duration of surgery was comparable in both groups (p=0.156). The length of stay for the two groups did not statistically differ (p=0.976) - the mean length of stay for the tourniquet group was 6.16±2.38 days and for the non-tourniquet group it was 6.18±2.34 days. There were no significant differences between the two groups regarding patient-reported outcomes (PROMS) at six-weeks and six-months. However, during the in-hospital stay, only the NPRS score for knee pain showed that the non-tourniquet patients had a lower NPRS compared to the tourniquet group and this difference was statistically significant (p=0.02). During the postoperative hospital stay, there was no significant difference among the two treatment groups for VAS, OKS, SF-12, and range of motion (flexion/extension). At the six weeks follow-up, both groups had similar outcomes for the range of movements and pain scores. Besides, no difference was noted among the tourniquet and non-tourniquet groups even after a follow-up of six months. Regarding complications, 27 patients in the tourniquet group did complain of numbness during the study period compared to 10 in the non-tourniquet group (p=0.001). Conclusion In conclusion, a tourniquet application helps minimize intraoperative blood loss and results in a faster procedure. Furthermore, the application of the tourniquet is safe and effective and does not affect the functional outcomes and pain scale in total knee arthroplasty.

Association of Pulmonary Hypertension With End-Stage Renal Disease Among the Obese Population.

Introduction Pulmonary hypertension (PH) is a known complication that occurs in patients of end-stage renal disease (ESRD) that have an arteriovenous fistula (AVF) for hemodialysis (HD). It is defined as pulmonary artery pressure (PAP) of greater than 30 mmHg on echocardiography. The presence of PH in ESRD is an independent risk factor and decreases the survival likelihood among HD patients. Unexplained PH is frequently seen in ESRD following AVF. Obesity can lead to various complications, such as sleep apnea, cardiac complications, pulmonary hypertension, and mortality. Data on the prevalence of coexisting PH and obesity are scarce. Obese patients often have increased albumin excretion rates (AER) that can lead to early renal impairment and an increase in intraglomerular pressure, which may increase the risk of cardiovascular (CV) morbidity and mortality. Therefore, the study aimed to evaluate and compare the associated PH and obesity separately and collectively among ESRD patients. Methods This comparative cross-sectional study was conducted in a tertiary care public sector hospital with the approval of the medical ethics review board committee. The study enrolled all consecutive patients with ESRD as defined by having an estimated glomerular filtration rate (GFR) of <15 mL/min/1.7 3 m2 from April 2017 till March 2019, who presented to our facility. These patients underwent dialysis twice or thrice a week, each session lasting three to four hours approximately. On initial encounter, trans-thoracic echocardiography (TTE) was done by the cardiologist to diagnose pulmonary hypertension. In addition, body mass index (BMI) was calculated for all patients, and the patients were categorized into underweight, normal, overweight, or obese. All patients underwent post-dialysis TTE at one hour or when patients were at the optimal dry weight. Systolic PAP and ejection fraction were measured, and pulmonary hypertension was defined as a PAP of 30 mmHg or greater on TTE. ESRD patients that were diagnosed with PH prior to hemodialysis or had primary PH were excluded from the study. Only ESRD patients developing secondary PH after hemodialysis were included in the study. The chi-square test was used to see the correlation of gender, ambulation status, smoking status, obesity, pulmonary hypertension, body mass index (BMI), and pulmonary hypertension and obesity combined on the final outcome. A p-value of 0.05 was considered significant. Odds ratio (OR) and relative risk (RR) were calculated for pulmonary hypertension and obesity combined, obesity, and pulmonary hypertension in the final outcome. Results The study enrolled 204 patients with a mean age of 46.23 (±20.45 SD) having higher female participation of 108 (52.9%), whereas 96 (47.1%) were males. The average weight of the cohort was 66.78 kg (±22.98 SD) with a mean BMI of 29.91 kg/m2 (±13.29SD), 52 (25.5%) patients were underweight, 40 (19.6%) had a normal BMI, 29 (14.2%) were overweight, and 83 (40.7%) patients were obese. Pulmonary hypertension and obesity combined were observed in 48 (23.5%) of the cases and there was a 4.60 relative risk of death among these individuals, with an odds ratio of 13.35 and a p-value of 0.00. Conclusion The study shows a strong synergistic effect of pulmonary hypertension and obesity towards the final survival outcome in ESRD patients who are on hemodialysis.

Echocardiographic Changes in Chronic Kidney Disease Patients on Maintenance Hemodialysis.

Introduction Chronic kidney disease (CKD) carries a significant association with cardiac diseases, which suggests a minor reduction in the glomerular filtration rate (GFR) can act as an independent risk factor for causing cardiovascular abnormalities. Patients of CKD having cardiovascular disease (CVD) had three to thirty times higher risk of mortality as compared to the general population. In addition, mortality among cardiovascular patients has been found to be twofold higher in CKD stage 2 patients and three-fold higher in patients with stage 3 CKD, when collated to patients with normal renal function. Furthermore, cardiomyopathy among hemodialysis (HD) is due to the presence of coronary artery obstruction, reduction in coronary reserves, and left ventricular (LV) physiological-structural abnormalities secondary volume and pressure overload. Echocardiography is a gold standard diagnostic modality for the identification of cardiac structural and functional abnormalities. Therefore, the evaluation of echocardiographic parameters in patients of CKD can help to determine the risk and prognosis of CVD in patients of CKD. In the present study, we evaluated the echocardiographic findings in patients of CKD on maintenance hemodialysis. Methods This cross-sectional study was conducted in the nephrology unit of Jinnah Postgraduate Medical Center between March 2019 to October 2019. A total of 100 patients who were on maintenance for more than one year were included in the analysis. Two-dimensional transthoracic echocardiography was done in each patient for the determination of cardiac structural and functional parameters such as LV hypertrophy, LV systolic dysfunction, and LV diastolic dysfunction. Results The mean age of the patients was 46.9±12.8 years. There was male dominance with male/female ratio 63/37. There were 39% hypertensive and 62% anemic patients. LV dysfunction was diagnosed in 31% of patients, LV diastolic dysfunction in 47% patients, and left ventricular hypertrophy (LVH) in 55% of patients. LVH was found in 74.3% hypertensive patients versus only 42.6% non-hypertensive patients (p-value 0.001). LV systolic dysfunction was also high in hypertensive patients, 46.1% versus 21.3% patients in non-hypertensive patients (p-value 0.008).  Conclusion There is a high frequency of cardiac functional and structural abnormalities in CKD patients on HD especially in patients having concomitant hypertension. LVH is the most common structural defect and LV diastolic dysfunction is the most common functional cardiac defect in CKD patients on hemodialysis.