Feasibility, safety, and patient-reported outcomes 90 days after same-day total knee arthroplasty: a matched cohort study.

BACKGROUND AND PURPOSE: Despite increased attention to and acceptance of fast-track procedures, there is a lack of studies concerning discharge on the day of surgery (DOS) following total knee arthroplasty (SD-TKA). We evaluated the feasibility of SD-TKA, and compared safety and patient-reported outcomes (PROs) between patients undergoing SD-TKA and patients undergoing standard TKA. PATIENTS AND METHODS: A SD-TKA group (n = 101) was matched 1:1 to a standard TKA group (n = 101) on age, sex, and ASA score. Feasibility (being discharged on DOS), safety (unplanned contacts and complications evaluated by telephone calls (2 weeks), outpatient visits (2 weeks), and readmission (90 days)) were assessed. Further, Oxford Knee Score (OKS) and Visual Analogue Scale (VAS) (pain at rest and activity) were reported (90 days). RESULTS: 89 of 101 SD-TKA patients were discharged on DOS. The number of telephone calls (≤ 83) and outpatient visits (12) were similar in the 2 groups. The number of readmissions was ≤ 3 in both groups, and only 1 of the readmissions was related to TKA surgery. No differences were found at 90-day follow-up in terms of OKS (34 in both groups) or VAS (rest: SD-TKA = 7 and standard TKA = 8; activity: SD-TKA = 17 and standard TKA = 15). INTERPRETATION: SD-TKA is feasible in a selected group of patients, and safety and PROs are comparable to patients undergoing standard TKA.

Effect of Intravenous or Intraosseous Calcium vs Saline on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial.

Importance: It is unclear whether administration of calcium has a beneficial effect in patients with cardiac arrest. Objective: To determine whether administration of calcium during out-of-hospital cardiac arrest improves return of spontaneous circulation in adults. Design, Setting, and Participants: This double-blind, placebo-controlled randomized clinical trial included 397 adult patients with out-of-hospital cardiac arrest and was conducted in the Central Denmark Region between January 20, 2020, and April 15, 2021. The last 90-day follow-up was on July 15, 2021. Interventions: The intervention consisted of up to 2 intravenous or intraosseous doses with 5 mmol of calcium chloride (n = 197) or saline (n = 200). The first dose was administered immediately after the first dose of epinephrine. Main Outcomes and Measures: The primary outcome was sustained return of spontaneous circulation. The secondary outcomes included survival and a favorable neurological outcome (modified Rankin Scale score of 0-3) at 30 days and 90 days. Results: Based on a planned interim analysis of 383 patients, the steering committee stopped the trial early due to concerns about harm in the calcium group. Of 397 adult patients randomized, 391 were included in the analyses (193 in the calcium group and 198 in the saline group; mean age, 68 [SD, 14] years; 114 [29%] were female). There was no loss to follow-up. There were 37 patients (19%) in the calcium group who had sustained return of spontaneous circulation compared with 53 patients (27%) in the saline group (risk ratio, 0.72 [95% CI, 0.49 to 1.03]; risk difference, -7.6% [95% CI, -16% to 0.8%]; P = .09). At 30 days, 10 patients (5.2%) in the calcium group and 18 patients (9.1%) in the saline group were alive (risk ratio, 0.57 [95% CI, 0.27 to 1.18]; risk difference, -3.9% [95% CI, -9.4% to 1.3%]; P = .17). A favorable neurological outcome at 30 days was observed in 7 patients (3.6%) in the calcium group and in 15 patients (7.6%) in the saline group (risk ratio, 0.48 [95% CI, 0.20 to 1.12]; risk difference, -4.0% [95% CI, -8.9% to 0.7%]; P = .12). Among the patients with calcium values measured who had return of spontaneous circulation, 26 (74%) in the calcium group and 1 (2%) in the saline group had hypercalcemia. Conclusions and Relevance: Among adults with out-of-hospital cardiac arrest, treatment with intravenous or intraosseous calcium compared with saline did not significantly improve sustained return of spontaneous circulation. These results do not support the administration of calcium during out-of-hospital cardiac arrest in adults. Trial Registration: ClinicalTrials.gov Identifier: NCT04153435.

Effects of popliteal plexus block after total knee arthroplasty: a randomized clinical trial.

BACKGROUND AND OBJECTIVES: Motor-sparing peripheral nerve blocks enhance multimodal opioid-sparing strategies after total knee arthroplasty. We hypothesized that adding a popliteal plexus block to a femoral triangle block could reduce 24-hour opioid consumption after total knee arthroplasty, compared with standalone femoral triangle block or adductor canal block. METHODS: This patient- and assessor-blinded, randomized controlled trial allocated 165 patients into three equally sized parallel groups, receiving either 1) popliteal plexus block+femoral triangle block, 2) femoral triangle block, or 3) adductor canal block. Intravenous oxycodone was administered via patient-controlled analgesia pumps. The primary outcome was 24-hour postoperative opioid consumption. Secondary outcomes were preoperative maximum voluntary isometric contraction and manual muscle tests of knee and ankle movement assessed before and after the nerve block procedure together with postoperative pain scores, mobilization, and 12-hour opioid consumption. RESULTS: 24-hour postoperative intravenous oxycodone consumption varied significantly between groups (p<0.01), with medians (IQR) of 6 mg (2-12) in the popliteal plexus block+femoral triangle block group, 10 mg (8-16) in the femoral triangle block group, and 12 mg (6-18) in the adductor canal block group. Median consumption in the popliteal plexus block+femoral triangle block group was reduced by -4 mg (95% CI -7.4 to -1.0, p<0.01) and -6 mg (95% CI -8.3 to -1.3, p=0.01) compared with groups of femoral triangle block and adductor canal block, respectively. No differences were found in pain scores, mobilization, or changes in preoperative muscle strength. Post hoc analysis revealed successful 24-hour opioid-free postoperative care among 12 patients with popliteal plexus block+femoral triangle block, as compared with two with femoral triangle block and six with adductor canal block. CONCLUSION: Adding a popliteal plexus block to a femoral triangle block resulted in a statistically significant reduction of 24-hour postoperative opioid consumption after total knee arthroplasty. However, no differences were found in pain scores. Popliteal plexus block did not impair the lower leg muscles.

Differences and similarities of morphine and oxycodone.

This review summarises the current knowledge of the effects of morphine and oxycodone. The analgesic effect is estimated to be equal. However, the relative potency of oxycodone is variably higher which increases the risk of over- and underdosing. The time to onset of analgesia following intravenous or oral administration of oxycodone is shorter than the one of morphine. This, among other factors, may lead to a higher risk of addictive behaviour.

Prognostic factors of knee pain and function 12 months after total knee arthroplasty: A prospective cohort study of 798 patients.

BACKGROUND: Approximately 20% of patients undergoing total knee arthroplasty (TKA) do not experience long-term improvements. Our aim was to identify prognostic factors of knee pain and function 12 months after TKA. METHODS: In a prospective cohort study, 1026 patients underwent primary TKA between 2018 and 2020. Main outcome was measured by the Oxford Knee Score (OKS) categorized in five categories (0-9, 10-19, 20-29, 30-39 and 40-48). Potential prognostic factors obtained at baseline included sex, age, baseline OKS, pain catastrophizing scale, EuroQol 5 dimensions, previous surgery, BMI, ASA classification, opioid consumption, living and employment conditions as well as educational level. Ordinal logistic regression analysis was used to identify prognostic factors of OKS. RESULTS: A total of 915 patients completed follow up (89%), and patients with complete data were included (n = 798). Patients with a baseline OKS between 10-19 and 20-29 had 2.5 (CI 1.6;4.0) and 1.6 (CI 1.1;2.4) higher odds, respectively, of no improvement or deterioration to a lower post-operative OKS category, compared with patients with a baseline score between 30 and 39. Female patients had 1.5 (CI 1.1;2.0) and patients receiving social benefits compared with retired patients had 2.0 (CI 1.1;3.5) higher odds of no improvement or deterioration to a lower OKS category. CONCLUSION: Baseline level of pain and function, sex and employment status were significant prognostic factors of OKS 12 months after TKA. Overall, the regression analysis only explained 4% of the outcome, indicating that it is difficult to predict 12-month TKA outcome prior to surgery.

Effect of calcium vs. placebo on long-term outcomes in patients with out-of-hospital cardiac arrest.

OBJECTIVE: The Calcium for Out-of-hospital Cardiac Arrest (COCA) trial was a randomized, placebo-controlled, double-blind trial of calcium for out-of-hospital cardiac arrest. The primary and secondary outcomes have been reported previously. This article describes the long-term outcomes of the trial. METHODS: Patients aged ≥18 years were included if they had a non-traumatic out-of-hospital cardiac arrest during which they received adrenaline. The trial drug consisted of calcium chloride (5 mmol) or saline placebo given after the first dose of adrenaline and again after the second dose of adrenaline for a maximum of two doses. This article presents pre-specified analyses of 6-month and 1-year outcomes for survival, survival with a favorable neurological outcome (modified Rankin Scale of 3 or less), and health-related quality of life. RESULTS: A total of 391 patients were analyzed. At 1 year, 9 patients (4.7%) were alive in the calcium group while 18 (9.1%) were alive in the placebo group (risk ratio 0.51; 95% confidence interval 0.24, 1.09). At 1 year, 7 patients (3.6%) were alive with a favorable neurological outcome in the calcium group while 17 (8.6%) were alive with a favorable neurological outcome in the placebo group (risk ratio 0.42; 95% confidence interval 0.18, 0.97). Outcomes for health-related quality of life likewise suggested harm of calcium but results were imprecise with wide confidence intervals. CONCLUSIONS: Effect estimates remained constant over time suggesting harm of calcium but with wide confidence intervals. The results do not support calcium administration during out-of-hospital cardiac arrest. TRIAL REGISTRATION: ClinicalTrials.gov-number, NCT04153435.

An Obturator Nerve Block does not Alleviate Postoperative Pain after Total Hip Arthroplasty: a Randomized Clinical Trial.

BACKGROUND AND OBJECTIVES: A substantial group of patients suffer from moderate to severe pain following elective total hip arthroplasty (THA). Due to the complex innervation of the hip, peripheral nerve block techniques can be challenging and are not widely used. Since the obturator nerve innervates both the anteromedial part of the joint capsule as well as intra-articular nociceptors, we hypothesized that an obturator nerve block (ONB) would decrease the opioid consumption after THA. METHODS: Sixty-two patients were randomized to receive ONB or placebo (PCB) after primary THA in spinal anesthesia. Primary outcome measure was opioid consumption during the first 12 postoperative hours. Secondary outcome measures included postoperative pain score, nausea score and ability to ambulate. RESULTS: Sixty patients were included in the analysis. Mean (SD) opioid consumption during the first 12 postoperative hours was 39.9 (22.3) mg peroral morphine equivalents (PME) in the ONB group and 40.5 (30.5) mg PME in the PCB group (p=0.93). No difference in level of pain or nausea was found between the groups. Paralysis of the hip adductor muscles in the ONB group reduced the control of the operated lower extremity compared with the PCB group (p=0.026). This did, however, not affect the subjects' ability to ambulate. CONCLUSIONS: A significant reduction in postoperative opioid consumption was not found for active versus PCB ONB after THA. TRIAL REGISTRATION NUMBER: NCT03064165 and 2017-000068-14.

Analgesia of Combined Femoral Triangle and Obturator Nerve Blockade Is Superior to Local Infiltration Analgesia After Total Knee Arthroplasty With High-Dose Intravenous Dexamethasone.

BACKGROUND AND OBJECTIVES: High-dose intravenous dexamethasone reduces the postoperative opioid requirement and is often included in the multimodal analgesia strategy after total knee arthroplasty (TKA). Combined obturator nerve and femoral triangle blockade (OFB) reduces the opioid consumption and pain after TKA better than local infiltration analgesia (LIA). The question is whether preoperative high-dose intravenous dexamethasone would cancel out the superior analgesic effect of OFB compared with LIA. The aim was to evaluate the analgesic effect of OFB versus LIA after TKA when all patients received high-dose intravenous dexamethasone. METHODS: Eighty-two patients were randomly assigned either to OFB or LIA after primary unilateral TKA. All patients received 16 mg dexamethasone. Primary outcome was morphine consumption via patient-controlled analgesia during the first 20 postoperative hours. Secondary outcomes were pain, nausea, dizziness, and length of hospital stay. RESULTS: Seventy-four patients were included in the analysis. Median total intravenous morphine consumption during the first 20 postoperative hours was 6 mg (interquartile range [IQR], 2-18 mg) in the OFB group and 20 mg (IQR, 12-28 mg) in the LIA group. The 14-mg difference (95% confidence interval, 6.4-18.0 mg) was significant (P < 0.001). There was no difference in pain score at rest at 20 hours postoperatively: 2 (IQR, 1-4) in the OFB group and 3 (IQR, 2-5) in the LIA group. CONCLUSIONS: Combined OFB reduces morphine consumption better than LIA after TKA even when all patients received high-dose intravenous dexamethasone. CLINICAL TRIAL REGISTRATION: This study was registered at ClinicalTrials.gov, identifier NCT02374008.

The Spread of Ultrasound-Guided Injectate From the Adductor Canal to the Genicular Branch of the Posterior Obturator Nerve and the Popliteal Plexus: A Cadaveric Study.

BACKGROUND AND OBJECTIVES: The popliteal nerve plexus contributes to afferent knee-pain conduction. It is mainly formed by genicular branches from the posterior obturator and the tibial nerves, innervating the intra-articular and posterior knee region. A subinguinal obturator nerve block alleviates pain after total knee arthroplasty. Reduced hip adductor motor function could be avoided by a posterior obturator nerve block inside the popliteal fossa.The aim of this study was to evaluate the spread of dye after a distal adductor canal (AC) injection to the popliteal fossa and coloring of the popliteal plexus and the genicular branch of the posterior obturator nerve by dissection. We also assessed the spread of dye into the popliteal fossa after a distal femoral triangle injection. METHODS: Ten milliliters of dye was injected into the distal part of the AC in 10 cadaver sides and into the distal part of the femoral triangle in 3 sides. Dissection was used to assess the spread of the injectate and coloring of the popliteal plexus and the genicular branch of the posterior obturator nerve, as well as the saphenous and medial vastus nerves. RESULTS: The popliteal plexus and the genicular branch of the posterior obturator nerve were dyed in all 10 dissections after AC injections. No dye spread into the popliteal fossa after femoral triangle injections. CONCLUSIONS: Injection of 10 mL of dye into the distal part of the AC spreads into the popliteal fossa and colors the popliteal plexus and the genicular branch of the posterior obturator nerve.

Four ways to ventilate during cardiopulmonary resuscitation in a porcine model: a randomized study.

BACKGROUND: The optimal method for out-of-hospital ventilation during cardiopulmonary rescue (CPR) is controversial. The aim of this study was to test different modes of ventilation during CPR for a prolonged period of 60 min. METHODS: Pigs were randomized to four groups after the induction of ventricular fibrillation, which was followed by one hour of mechanical cardiac compressions. The study comprised five pigs treated with free airways, five pigs treated with ventilators, six pigs treated with a constant oxygen flow into the tube, and six pigs treated with apnoeic oxygenation. RESULTS: The free airway group was tested for 1 h, but in the first 15 min, the median PaO2 had already dropped to 5.1 kPa. The ventilator group was tested for 1 h and still had an acceptable median PaO2 of 10.3 kPa in the last 15 min. The group was slightly hyperventilated, with PaCO2 at 3.8 kPa, even though the ventilator volumes were unchanged from those before induction of cardiac arrest. In the group with constant oxygen flowing into the tube, one pig was excluded after 47 min due to blood pressure below 25 mmHg. For the remaining 5 pigs, the median PaO2 in the last 15 min was still 14.3 kPa, and the median PaCO2 was 6.2 kPa. The group with apnoeic oxygenation for 1 h had a resulting median PaO2 of 10.2 kPa and a median PaCO2 of 12.3 kPa in the last 15 min. DISCUSSION: Except for the free airway group, the other methods resulted in PaO2 above 10 kPa and PaCO2 between 3.8 and 12.3 kPa after one hour. CONCLUSION: Constant oxgen flow and apnoeic oxygenation seemed to be useable alternatives to ventilator treatment.

The Analgesic Effect of Obturator Nerve Block Added to a Femoral Triangle Block After Total Knee Arthroplasty: A Randomized Controlled Trial.

BACKGROUND AND OBJECTIVES: Total knee arthroplasty (TKA) is associated with severe pain, and effective analgesia is essential for the quality of postoperative care and ambulation. The analgesic effects of adding an obturator nerve block (ONB) to a femoral triangle block (FTB) after TKA have not been tested previously. We hypothesized that combined ONB and FTB will reduce opioid consumption and pain compared with those of a single FTB or local infiltration analgesia (LIA). METHODS: Seventy-eight patients were randomized to combined ONB and FTB, single FTB, or LIA after primary unilateral TKA. The primary outcome was morphine consumption during the first 24 postoperative hours. Secondary outcomes included morphine consumption during the first 48 postoperative hours, pain at rest and passive knee flexion, nausea and vomiting, cumulated ambulation score, and Timed Up and Go test. RESULTS: Seventy-five patients were included in the analysis. The total intravenous morphine consumption during the first 24 postoperative hours was 2 mg (interquartile range [IQR], 0-15) in the combined ONB and FTB group, 20 mg (IQR, 10-26) in the FTB group (P = 0.0007), and 17 mg (IQR, 10-36) in the LIA group (P = 0.002). The combined ONB and FTB group displayed reduced pain, nausea, and vomiting compared with the other groups. The ambulation tests showed no statistically significant differences between the groups. CONCLUSIONS: Addition of ONB to FTB significantly reduced opioid consumption and pain after TKA compared with a single FTB or LIA, without impaired ambulation.