ABSTRACT
BACKGROUND: Patients undergoing Total Knee Arthroplasty (TKA) typically have early postoperative pain and decreased mobility, especially so in the first 24â¯h. Achieving a pain free knee in the immediate postoperative period and reducing complications using multimodal pain and blood management protocols forms a keystone in early mobilization and functional recovery. Enhanced Recovery after Surgery pathways (ERASp) since their inception, have significantly improved perioperative care and functional outcomes, thereby reducing the average length of stay (ALOS), complications and overall healthcare costs. ERASp modified suitably for TKA have had encouraging results. We have retrospectively analyzed the outcomes of the ERASp for TKA at our tertiary care centre with equal emphasis on pre-hospital preparations, in-hospital care, and post-hospital discharge. METHODS: All TKA patients operated by the senior author between July 2016 and January 2018 with a minimum one year follow up were included. The outcomes measured were: Visual Analogue Score (VAS) for pain at rest and on movement, milestones, transfusion requirements, postoperative complications, ALOS and functional scores at one year follow-up. RESULTS: 775 patients (392 unilateral TKA {UTKA} and 383 bilateral {BTKA}) met our inclusion criteria. Both groups were comparable demographically. Mean VAS pain scores at rest were 3.15⯱â¯2.15 on the day of surgery, 2.5⯱â¯1.86 on the first postoperative day and 2.08⯱â¯1.81 on the second day, and 6.2⯱â¯2.38, 5.77⯱â¯2.34 and 4.71⯱â¯2.48 on movement respectively in the UTKA group. In the BTKA group, the mean VAS pain scores at rest were 4.39⯱â¯2.25 on the day of surgery, 3.98⯱â¯2.36 on the first postoperative day and 3.05⯱â¯2.12 on the second day and 6.21⯱â¯2.38, 5.77⯱â¯2.34 and 4.71⯱â¯2.48 on movement respectively. 85.49% of UTKA and 77.22% of BTKA patients walked on the day of surgery. Decrease in haemoglobin and transfusion rates were 1.25⯱â¯0.41â¯g% and 0.5%, 1.85⯱â¯0.62 and 3.9% in the UTKA and BTKA groups respectively.The average length of hospital stay (LOS) was 3.98 days. LOS was 3.17 and 4.78 days with 1.55% and 6.05% major complications in the UTKA and BTKA groups respectively.There was a significant improvement in Oxford Knee and WOMAC scores at 3, 6 and 12 months in both groups. CONCLUSIONS: Pain following TKA is a major deterrent in early mobilization thereby delaying functional recovery and increasing ALOS. We recommend our multimodal interdisciplinary protocol to achieve early mobilization, better pain scores and minimize complications, resulting in overall reduced LOS.
ABSTRACT
Objective: Obstructive sleep apnoea hypopnoea syndrome associated with obesity poses major perioperative airway challenge. Drug-induced sleep endoscopy (DISE), is a real-time upper airway flexible fiberoptic nasoendoscopy in awake and sedation/anaesthesia-induced sleep. The aim of current study was to assess the correlation of bedside airway screening tests with level of obstruction during DISE. Methods: Study was performed in endoscopy suite. Parameters calculated in 40 study group patients were Berlin questionnaire responses, Apnea hypopnea index (AHI), interincisor distance, Mallampati classification (MPC), neck circumference (NC), thyromental distance (TMD), NC/TMD ratio, sternomental distance (SMD), upper lip bite test, lateral cephalometry derived gonial angle and mentohyoid distance (MHD), Muller's manoeuvre during awake nasoendoscopy, CroftPringle grade of airway obstruction during DISE and effect of jaw thrust. Results: All patients were American Society of Anesthesiologists physical status 1 and 2 with AHI > 30. Positive responses to Berlin questionnaire, body mass index and AHI increased with increasing grade of DISE. DISE grades 15 were observed in 0% (0), 5% (2), 37.5% (15), 27.5% (11) and 30% (12) patients respectively. Muller's manoeuvre showed lateral wall collapse in 40% (16) patients and concentric collapse in 40% (16) patients. Airway patency improved with jaw thrust in 60% (24) patients. Significant association of DISE was found with MPC (p = 0.028), TMD (p = 0.003), MHD (p = 0.008) and NC/TMD ratio (p = 0.002), effect of Muller's manoeuvre (p =0.002), and effect of jaw thrust (p = 0.000). Conclusions: Bedside screening tests MPC, TMD, NC/TMD ratio and MHD correlate significantly with level of obstruction during DISE.
Subject(s)
Airway Obstruction/diagnosis , Endoscopy/methods , Sleep Apnea, Obstructive/diagnosis , Sleep/drug effects , Adolescent , Adult , Aged , Female , Humans , Male , Middle Aged , Nose , Young AdultABSTRACT
Imbalances in the autonomic nervous system contribute to ventricular tachyarrhythmias. Sympatholysis with thoracic epidural analgesia or a stellate ganglion block attenuates myocardial excitability and the proarrhythmic effects of sympathetic hyperactivity.
