Comparison of General and Spinal Anaesthesia on Systemic Inflammatory Response in Patients Undergoing Total Knee Arthroplasty: A Propensity Score Matching Analysis.

Background and Objectives: Some of the postoperative complications following orthopaedic surgeries are associated with a systemic inflammatory response (SIR), which varies depending on the anaesthetic technique. We aimed to compare the effects of general and spinal anaesthesia on the SIR after total knee arthroplasty (TKA), based on C-reactive protein (CRP) levels, the platelet-lymphocyte ratio (PLR), and the neutrophil-lymphocyte ratio (NLR). Materials and Methods: Patients who underwent TKA between January 2014 and December 2018 were included. Electronic medical records of the patients were retrospectively reviewed and analysed. To reduce the impact of potential confounding factors, we performed propensity score matching according to the anaesthetic technique. Results: A total of 1311 TKA cases were analysed. After propensity score matching, the maximal CRP value and changes in CRP levels in the general anaesthesia group were higher than those in the spinal anaesthesia group. However, the maximal NLR and PLR and the changes in NLR and PLR were not different between the two groups. There were no differences in postoperative clinical outcomes. Conclusion: Spinal anaesthesia tended to induce a lower inflammatory response than general anaesthesia when considering CRP levels in patients undergoing TKA. However, the effects of anaesthetic techniques on the overall outcomes were not significant.

Treatment of chronic lumbosacral radicular pain using adjuvant pulsed radiofrequency: a randomized controlled study.

OBJECTIVES: The objective of this study was to determine the effects of combining pulsed radiofrequency (PRF) treatment and transforaminal epidural injection (TFEI) to treat patients with chronic refractory lumbar radicular pain caused by lumbar spinal stenosis. STUDY DESIGN: Randomized control trial. SETTINGS: Interventional pain management practice. METHOD: Sixty-two patients were assigned to the study groups (PRF group = 31; control group = 31). Under fluoroscopic guidance, the RF needle was positioned close to the lumbar dorsal root ganglion. The PRF group received 3 cycles of PRF treatment, and sensory stimulation without RF lesioning was applied to the control group. After PRF or sham lesioning, a local anesthetic with steroid was injected. The primary outcome of a successful response was defined as: 1) ≥50% or 4-point pain reduction in the numerical rating scale (NRS) without an increase in the Oswestry disability index (ODI) or medication quantification scale (MQS), or mean score <4 in the global perceived effect (GPE) scale; or 2) ≥30% or 2-point pain reduction in NRS with a simultaneous decrease in ODI, MQS, or ≥6 points in the GPE scale. RESULT: The number of patients with successful treatment results was higher in the PRF group at 2 months (P = 0.032) and 3 months (P = 0.018). No significant differences were observed in terms of the secondary outcome variables between the 2 groups. CONCLUSION: The TFEI provided significant short-term pain relief and PRF can be applied in conjunction with TFEI to achieve higher treatment efficacy compared with TFEI alone.

Low Psoas Lumbar Vertebral Index Is Associated with Mortality after Hip Fracture Surgery in Elderly Patients: A Retrospective Analysis.

The psoas-to-lumbar index (PLVI) has been reported as a simple and easy way to measure central sarcopenia. However, only few studies have evaluated the association between PLVI and survival in surgical patients. This study evaluated the association between preoperative PLVI and mortality in elderly patients who underwent hip fracture surgery. We retrospectively analyzed 615 patients who underwent hip fracture surgery between January 2014 and December 2018. The median value of each PLVI was calculated according to sex, and the patients were categorized into two groups on the basis of the median value (low PLVI group vs. high PLVI group). Cox regression analysis was performed to evaluate the risk factors for 1 year and overall mortalities. The median values of PLVI were 0.62 and 0.50 in men and women, respectively. In the Cox regression analysis, low PLVI was significantly associated with higher 1 year (hazard ratio (HR): 1.87, 95% confidence interval (CI): 1.18-2.96, p = 0.008) and overall mortalities (HR: 1.51, 95% CI: 1.12-2.03, p = 0.006). Low PLVI was significantly associated with a higher mortality. Therefore, PLVI might be an independent predictor of mortality in elderly patients undergoing hip fracture surgery.

Ultrasound-Guided Anterior Quadratus Lumborum Block Reduces Postoperative Opioid Consumption and Related Side Effects in Patients Undergoing Total Hip Replacement Arthroplasty: A Propensity Score-Matched Cohort Study.

Quadratus lumborum block (QLB) has been shown to be effective for pain relief after hip surgery. This study evaluated the efficacy of ultrasound-guided anterior QLB in pain control after total replacement hip arthroplasty (TRHA). A total of 115 patients receiving anterior QLB were propensity score-matched with 115 patients who did not receive the block. The primary outcome was opioid consumption at 24, 24-48, and 48 postoperative hours. Secondary outcomes included pain scores at the post-anesthesia care unit (PACU), 8, 16, 24, 32, 40, and 48 h length of hospital stay, time to first ambulation, and the incidence of opioid-related side effects. Postoperative opioid consumption 48 h after surgery was significantly lower in the QLB group. Resting, mean, worst, and the difference of resting pain scores compared with preoperative values were significantly lower in the QLB group during the 48 postoperative hours. The length of hospital stay was shorter in the QLB group. The incidence of postoperative nausea and vomiting was significantly lower in the QLB group during the 48 postoperative hours, except at the PACU. This study suggests that anterior QLB provides effective postoperative analgesia for patients undergoing THRA performed using the posterolateral approach.

Serratus anterior plane block combined with monitored anesthesia care for surgery of lateral side of breast -a case report.

BACKGROUND: In breast surgery, regional anesthesia rather than primary anesthesia has been mainly used for postoperative analgesia. Serratus anterior plane block is a new method for ultrasound-guided thoracic wall block. It is less invasive and relatively safer than conventional regional anesthetic techniques. CASE: We report a case of breast surgery under serratus anterior plane block as primary anesthesia with monitored anesthesia for a 78-year-old patient with a medical history of cardiopulmonary resuscitation due to stress-induced cardiomyopathy caused by pneumonia. CONCLUSIONS: Serratus anterior plane block might be simple and effective technique for breast surgery when a lesion is located on lateral side.

Complications in internal jugular vs subclavian ultrasound-guided central venous catheterization: a comparative randomized trial.

PURPOSE: The use of real-time ultrasound (US) has been shown to reduce complications of central venous (CV) catheterization. However, complication rates have not been compared according to insertion points for CV catheterization using US. Accordingly, this study aimed to compare the complication rates of internal jugular vein (IJV) with those of subclavian vein (SCV) catheterization. METHODS: Three tertiary academic hospitals in South Korea participated in this multicenter, randomized study. A total of 1484 patients were preoperatively randomized into two groups. The IJV group (n = 742) was cannulated via the right IJV, and the SCV group (n = 742) was cannulated via the right SCV under US guidance. The primary outcome measure was total complication rate. Secondary outcomes included access time for the first attempt, number of attempts, and catheter position. RESULTS: The total complication rate did not demonstrate a significant difference between the IJV (0.1%) and SCV (0.7%) groups (P = 0.248). In the IJV group, arterial puncture occurred in 0.1% of patients; in the SCV group, arterial puncture occurred in 0.6% and pneumothorax in 0.1%. The success rate on the first attempt was significantly higher in the IJV group (98.4%) than in the SCV group (95.9%) (P = 0.004). The access time for the first attempt (P < 0.001) and the median number of attempts (P = 0.006) were significantly lower in the IJV group than in the SCV group. More catheter misplacements were observed in the SCV group (5.9%) than in the IJV group (0.4%) (P < 0.001). CONCLUSION: Results demonstrated that the complication rates of IJV and SCV catheterizations using US are very low, showing no superiority of the SCV approach compared to the IJV.

A case report: the use of ultrasound guided peripheral nerve block during above knee amputation in a severely cardiovascular compromised patient who required continuous anticoagulation.

RATIONALE: Although lower-extremity surgeries are mainly performed under general or central neuraxial anesthesia, ultrasound-guided peripheral nerve block (PNB) can be a good alternative, especially for patients who require continuous anticoagulation treatment and present with poor cardiovascular conditions. PATIENTS CONCERNS: The patient required continuous anticoagulation treatment due to the high risk of thromboembolism and poor cardiovascular conditions. DIAGNOSES: The patient required lower-extremity amputation due to atherosclerotic and thromboembolic obstruction. INTERVENTIONS: We decided to progress the operation under peripheral nerve block. The sciatic, femoral, lateral femoral cutaneous nerve and anterior branch of the obturator nerve were blocked under ultrasound guidance. Sixty ml of a local anesthetic (equal mix of 1% lidocaine and 0.375% ropivacaine) was administered for the block. OUTCOMES: Sufficient sensory block at the area of amputation was obtained, and the patient's vital signs were stable throughout surgery. LESSONS: Ultrasound-guided peripheral nerve block can be an excellent anesthetic technique for patients receiving radical surgery at the proximal lower extremities, especially patients who are critically ill and considered high risk.

Delayed bilateral vocal cord paresis after a continuous interscalene brachial plexus block and endotracheal intubation: A lesson why we should use low concentrated local anesthetics for continuous blocks.

RATIONALE: Recurrent laryngeal nerve block is an uncommon complication that can occur after an interscalene brachial plexus block (ISB), which may lead to vocal cord palsy or paresis. However, if the recurrent laryngeal nerve is blocked in patients with a preexisting contralateral vocal cord palsy following neck surgery, this may lead to devastating acute respiratory failure. Thus, ISB is contraindicated in patients with contralateral vocal cord lesion. To the best of our knowledge, there are no reports of bilateral vocal cord paresis, which occurred after a continuous ISB and endotracheal intubation in a patient with no history of vocal cord injury or surgery of the neck. PATIENT CONCERNS: A 59 year old woman was planned for open acromioplasty and rotator cuff repair under general anesthesia. General anesthesia was induced following an ISB using 0.2% ropivacaine and catheter insertion for postoperative pain control. DIAGNOSES: While recovering in the postanesthesia care unit (PACU), however, the patient complained of a sore throat and hoarseness without respiratory insufficiency. On the morning of the first postoperative day, she still complained of mild dyspnea, dysphonia, and slight aspiration. She was subsequently diagnosed with bilateral vocal cord paresis following an endoscopic laryngoscopy examination. INTERVENTIONS: The continuous ISB catheter was immediately removed and the dyspnea and hoarseness symptoms improved, although mild aspiration during drinking water was still present. OUTCOMES: On the 4th postoperative day, a laryngoscopy examination revealed that the right vocal cord movement had returned to normal but that the left vocal cord paresis still remained. LESSONS: When ISB is planned, a detailed history-taking and examination of the airway are essential for patient safety and we recommend that any local anesthetics be carefully injected under ultrasound guidance. We also recommend the use of low concentration of local anesthetics to avoid possible paralysis of the vocal cord.

Encountering unexpected difficult airway: relationship with the intubation difficulty scale.

BACKGROUND: An unexpected difficult intubation can be very challenging and if it is not managed properly, it may expose the encountered patient to significant risks. The intubation difficulty scale (IDS) has been used as a validated method to evaluate a global degree of intubation difficulty. The aims of this study were to evaluate the prevalence and characteristics of unexpected difficult intubation using the IDS. METHODS: We retrospectively reviewed 951 patients undergoing elective surgery in a single medical center. Patients expected to have a difficult intubation or who had history of difficult intubation were excluded. Each patient was assessed by the IDS scoring system with seven variables. Total prevalence of difficult intubation and the contributing individual factors were further analyzed. RESULTS: For the 951 patients, the difficult intubation cases presenting IDS > 5 was 5.8% of total cases (n = 55). The prevalence of Cormack-Lehane Grade 3 or 4 was 16.2% (n = 154). Most of the difficult intubation cases were managed by simple additional maneuvers and techniques such as stylet application, additional lifting force and laryngeal pressure. CONCLUSIONS: Unexpected difficult airway was present in 5.8% of patients and most was managed effectively. Among the components of IDS, the Cormack-Lehane grade was most sensitive for predicting difficult intubation.

Unilateral postoperative visual loss in a patient undergoing hip arthroscopy in the supine position: a case report.

Micro-emboli have been reported to occur commonly during arthroscopic surgery, which is frequently performed as an orthopedic surgical procedure. We here report a patient who experienced unilateral postoperative visual loss after a hip arthroscopy using irrigation fluid in the supine position without any evidence of external compression to either eye throughout the surgical procedure. Retinal fundoscopy suggested that the patient had central retinal artery occlusion, one of the causes of the postoperative visual loss. This case suggests that arthroscopic surgery may pose a substantial risk for paradoxical air embolism, such as central retinal artery occlusion, and suggests the need to prevent the entry of micro-air bubbles during such a type of surgery.

Early postoperative albumin level following total knee arthroplasty is associated with acute kidney injury: A retrospective analysis of 1309 consecutive patients based on kidney disease improving global outcomes criteria.

Hypoalbuminemia has been reported to be an independent risk factor for acute kidney injury (AKI). However, little is known about the relationship between the albumin level and the incidence of AKI in patients undergoing total knee arthroplasty (TKA). The aim of our study was to assess incidence and risk factors for AKI and to evaluate the relationship between albumin level and AKI following TKA.The study included a retrospective review of medical records of 1309 consecutive patients who underwent TKA between January 2008 and December 2014. The patients were divided into 2 groups according to the lowest serum albumin level within 2 postoperative days (POD2_alb level < 3.0 g/dL vs ≥3.0 g/dL). Multivariate logistic regression analysis was used to assess risk factors for AKI. A comparison of incidence of AKI, hospital stay, and overall mortality in the 2 groups was performed using propensity score analysis.Of 1309 patients, 57 (4.4%) developed AKI based on Kidney Disease Improving Global Outcomes criteria. Factors associated with AKI included age (odds ratio [OR] 1.05; 95% confidence interval [CI] 1.01-1.09; P = 0.030), diabetes (OR 3.12; 95% CI 1.65-5.89; P < 0.001), uric acid (OR 1.51; 95% CI 1.26-1.82; P < 0.001), beta blocker use (OR 2.65; 95% CI 1.48-4.73; P = 0.001), diuretics (OR 16.42; 95% CI 3.08-87.68; P = 0.001), and POD2_alb level < 3.0 g/dL (OR 1.92; 95% CI 1.09-3.37; P = 0.023). After propensity score analysis, POD2_alb level<3.0 g/dL was associated with AKI occurrence (OR 1.82; 95% CI 1.03-3.24, P = 0.041) and longer hospital stay (P = 0.001).In this study, we demonstrated that POD2_alb level<3.0 g/dL was an independent risk factor for AKI and lengthened hospital stay in patients undergoing TKA.

Intravenous non-opioid analgesia for peri- and postoperative pain management: a scientific review of intravenous acetaminophen and ibuprofen.

Pain is a predictable consequence following operations, but the management of postoperative pain is another challenge for anesthesiologists and inappropriately controlled pain may lead to unwanted outcomes in the postoperative period. Opioids are indeed still at the mainstream of postoperative pain control, but solely using only opioids for postoperative pain management may be connected with risks of complications and adverse effects. As a consequence, the concept of multimodal analgesia has been proposed and is recommended whenever possible. Acetaminophen is one of the most commonly used analgesic and antipyretic drug for its good tolerance and high safety profiles. The introduction of intravenous form of acetaminophen has led to a wider flexibility of its use during peri- and postoperative periods, allowing the early initiation of multimodal analgesia. Many studies have revealed the efficacy, safety and opioid sparing effects of intravenous acetaminophen. Intravenous ibuprofen has also shown to be well tolerated and demonstrated to have significant opioid sparing effects during the postoperative period. However, the number of randomized controlled trials confirming the efficacy and safety is small and should be used in caution in certain group of patients. Intravenous acetaminophen and ibuprofen are important options for multimodal postoperative analgesia, improving pain and patient satisfaction.