Effects of Intravenous and Epidural Patient-Controlled Analgesia on Postoperative Pain and Knee Rehabilitation after a Unilateral Total Knee Replacement / 대한마취과학회지

BACKGROUND: Postoperative pain is a major concern after a total knee replacement (TKR). It hinders early intense physical therapy, the most influential factor for good postoperative knee rehabilitation. The purpose of this study was to compare intravenous patient-controlled analgesia (IV-PCA) using morphine and continuous ketorolac IV infusion with patient-controlled epidural analgesia (PCEA) using morphine and continuous bupivacaine infusion in terms of analgesic efficacy and postoperative knee rehabilitation after a unilateral TKR. METHODS: Eighteen patients undergoing a unilateral total knee replacement were randomly allocated to one of the two groups. In group IV-PCA (n = 9), 30 min before the end of surgery, patients received ketorolac 30 mg IV bolus followed by continuous infusion with ketorolac (5 mg/h) and IV-PCA with morphine (20microgram/kg, lockout 10 min). In group PCEA (n = 9), 30 min before the end of surgery, patients received 2 mg morphine bolus followed by continuous infusion with 0.1% bupivacaine (2 ml/h) and PCEA with morphine (1 mg, lockout 15 min). RESULTS: There were significant differences in visual analogue scale scores at the first 2-hours after the unilateral TKR, cumulative morphine consumption and number of postoperative days required to obtain 90o knee flexion. CONCLUSIONS: PCEA using a morphine-bupivacaine combination provided better pain relief and faci litated the continuous passive motion more than IV-PCA using a morphine-ketorolac combination. This results in possible faster postoperative knee rehabilitation.

Transesophageal Echocardiography Monitored Embolic Events during the Total Knee Replacement: Hemodynamic Changes and Embolic Composition / 대한마취과학회지

BACKGROUND: The present study was aimed to determine the alterations of hemodynamics and embolic composition during the course of total knee replacement. METHODS: A retrospective analysis was performed using data acquired from 20 patients who underwent 10 unilateral and 10 bilateral total knee replacement under general anesthesia. Transesophageal echocardiography and Swan-Ganze catheterization were placed following induction of anesthesia, then images and changes were recorded throughout the procedure. All patients were performed using fluted intramedullary rods inserted into an overdrilled femoral entrance hole in conjunction with the application of a tourniquet. RESULTS: We found echogenic emboli in 8 out of 20 patients during cannulation of the femoral canal and performing femoral and tibial saw cuts, then we detected echogenic emboli in all 20 patients during tourniquet deflation. Echogenic emboli consistently filled the right atrium and ventricle with very small size embolic materials for 19 7 minutes during total knee replacement. Heart rate exhibited no change, Mean arterial pressure decreased and mean pulmonary artery pressure increased after tourniquet deflation. After tourniquet deflation, free fatty acid increased in lipid profile. No patient had postoperative complications related echogenic emboli. CONCLUSION: All patients exhibited echogenic emboli during certain stages of total knee replacement. Although all patients were asymtomatic in our study, one should be cautioned when performing total knee replacement in patients with little physiologic reserve and large embolic events.