Routine postoperative blood tests in all patients undergoing Total Hip Arthroplasty as part of an enhanced recovery pathway: Are they necessary?

INTRODUCTION: The increasing demand for Total Hip replacement (THR)/Total Hip Arthroplasty (THA) continues to place significant financial pressure on the National Health Service (NHS). Many institutions undertake post-operative blood tests routinely in this group of patients. The aim of this study was to identify if such routine blood tests (Full Blood Count (FBC) and Urea and Electrolytes(U&Es)) are required in all THR patients post-operatively. METHODS: Single institute, Multi-surgeon, retrospective observational study of consecutive patients who underwent primary elective THR done from Jan 2014 to Dec 2018.Post-operative blood tests and medical records were reviewed to identify derangement in haemoglobin (Hb) level and renal function requiring clinical intervention. RESULTS: Over the period of 4 years, 353 patients underwent elective THR with mean age of 70 years (range: 42-90). There were 203 Males and 150 Females. Mean pre-operative Hb was 134.7 g/l. Mean post-operative drop in Hb was 22.3 g/l. None of the patients in ASA grade 1 and 2 with age ≤70 years required blood transfusion post operatively.6.4% of patients (n = 18/280) with an ASA of 1-2 had postoperative blood results requiring intervention of which only four (1.2%) were ≤70 years of age compared to 17.8% of patients (n = 14/73) with ASA 3-4.Overall none of the patients in ASA grade 1 and 2 with age ≤70 years required blood transfusion post operatively nor had electrolyte disturbance. 1.2% had deranged renal function that needed minor clinical intervention. CONCLUSION: Routine post-operative blood analyses may not required for all patients undergoing THA. Young and healthier patients seldom have significant abnormalities on routine post-operative blood analyses which requires clinical intervention.

Choice of opioid supplementation for day-case rigid bronchoscopy:a randomized placebo-controlled comparison of a bolus of remifentanil and alfentanil.

OBJECTIVE: To compare the efficacy of different bolus doses of remifentanil, alfentanil, and saline at controlling the hemodynamic responses to day-case rigid bronchoscopy under general anesthesia. DESIGN: Prospective, randomized, double-blind, placebo-controlled study. SETTING: Tertiary referral cardiothoracic hospital, single center. PARTICIPANTS: Eighty consenting adults scheduled for elective day-case rigid bronchoscopy under general anesthesia. INTERVENTIONS: Patients were randomized to receive a bolus of 10 micro g/kg of alfentanil, 1 micro g/kg of remifentanil, 2 micro g/kg of remifentanil or saline. After this, anesthesia was induced and maintained with a target-controlled propofol infusion (TCI) and succinylcholine was used for muscle relaxation. Heart rate and noninvasive arterial pressure were measured at 1-minute intervals throughout. MEASUREMENTS AND MAIN RESULTS: Patients' characteristics were similar in all 4 groups. There were no differences in time to return of spontaneous ventilation, wake-up times, or use of rescue vasopressors, and no patients complained of postoperative nausea. Remifentanil provided greater hemodynamic stability than alfentanil and a bolus of remifentanil of 2 micro g/kg significantly attenuated the rise in heart rate and was the most effective in preventing a rise in blood pressure. CONCLUSIONS: A bolus of 2 micro g/kg of remifentanil successfully attenuated the hemodynamic response to rigid bronchoscopy without delaying recovery.

Gastroesophageal reflux and tracheal aspiration in the thoracotomy position: should ranitidine premedication be routine?

UNLABELLED: Aspiration of gastric contents may contribute to pulmonary complications after thoracotomy. The incidence of gastroesophageal reflux (GER) and tracheal acid aspiration in patients undergoing thoracotomy in the lateral position is unknown. Ranitidine premedication reduces gastric volume, increases gastric pH, and may reduce GER. We used continuous intraluminal esophageal and tracheal pH monitoring probes to investigate the effect of ranitidine on the incidence of GER and tracheal aspiration in 80 adult patients undergoing thoracotomy. The study was placebo-controlled, randomized, and double-blinded. Patients at high risk of GER were excluded from the study. The incidence of acid GER in the placebo and ranitidine groups was 28.2% and 2.5%, respectively (P = 0.006). Multiple episodes of GER occurred in some patients in the placebo group only. The total number of episodes of GER in the placebo and ranitidine groups was 16 and 1, respectively (P = 0.002). The incidence of tracheal acid aspiration in the placebo and ranitidine groups was 7.7% and 2.5%, respectively (not significant). Patients undergoing thoracotomy are therefore at high risk of acid GER, which may lead to tracheal acid aspiration in an appreciable proportion. Premedication with ranitidine significantly reduces, but does not eliminate, the incidence of this potentially life-threatening complication. IMPLICATIONS: Gastroesophageal reflux (GER) and tracheal aspiration of acid may increase morbidity and mortality in patients undergoing thoracotomy. This randomized, double-blinded, placebo-controlled study demonstrates frequent incidences of both acid GER and tracheal acid aspiration during surgery that are significantly reduced by premedication with ranitidine.

Suprascapular nerve block for ipsilateral shoulder pain after thoracotomy with thoracic epidural analgesia: a double-blind comparison of 0.5% bupivacaine and 0.9% saline.

UNLABELLED: Despite receiving thoracic epidural analgesia, severe ipsilateral shoulder pain is common in patients after thoracotomy. We recruited 44 patients into a double-blinded randomized placebo-controlled study to investigate whether suprascapular nerve block would treat postthoracotomy shoulder pain effectively. All patients received a standard anesthetic with a midthoracic epidural. Thirty patients who experienced shoulder pain within 2 h of surgery were randomly assigned to receive a suprascapular nerve block with either 10 mL of 0.5% bupivacaine or 10 mL of 0.9% saline. Shoulder pain was assessed before nerve blockade, at 30 min, and then hourly for 6 h after the block using a visual analog scale (VAS) and a 5-point verbal ranking score (VRS). The incidence of shoulder pain before nerve block was 78%. There was no significant decrease in either VAS or VRS in the Bupivacaine group. These results suggest that this pain is unlikely to originate in the shoulder and lead us to question the role of a somatic afferent in referred visceral pain. We conclude that suprascapular nerve block does not treat ipsilateral shoulder pain after thoracotomy in patients with an effective thoracic epidural. IMPLICATIONS: This randomized, double-blinded, placebo-controlled trial showed that suprascapular nerve block does not treat the severe ipsilateral shoulder pain that patients experience after thoracotomy. This has implications for established theories of referred pain and indicates that this pain is unlikely to originate in the shoulder.