Can the inferior vena cava collapsibility index be useful in predicting hypotension during spinal anaesthesia in a spontaneously breathing patient? A mini fluid challenge.

The study was performed at the Department of Orthopaedics and Traumatology of the Kauno Klinikos Hospital of Lithuanian University of Health Sciences. BACKGROUND: Intravascular fluids are empirically administered to prevent hypotension induced by spinal anaesthesia. Ultrasound measurements of the inferior vena cava (IVC) and the IVC collapsibility index (IVC-CI) is a non-invasive method to evaluate the intravascular volume status. The aim of the study was to identify the prognostic value of the IVC collapsibility index in spontaneously breathing patients to predict severe intraoperative hypotension. MATERIALS AND METHODS: Sixty patients undergoing elective knee arthroplasty under spinal anaesthesia were included in the prospective study. The diameters of IVCex, IVCin, and IVC-CI were measured before and 15 min after spinal anaesthesia when administration of 500 ml of normal saline using infusion pump was finished. The haemodynamic parameters (heart rate, systolic, diastolic, and mean blood pressures, breathing rate) were collected. RESULTS: Severe arterial hypotension was noticed in 18.3% of the patients. No statistically significant differences were detected between changes in IVCex, IVCin, and IVC-CI comparing hypotensive and non-hypotensive patients at the baseline and after the interventions (p > 0.005). According to receiver operating characteristic (ROC) analysis, IVC-CI is not effective in the prediction of severe hypotension during spinal anaesthesia in spontaneously breathing patients: the area under the ROC curve for IVC-CI was <0.7, p > 0.05. CONCLUSIONS: IVC-CI is not an effective predictor of severe hypotension after induction of spinal anaesthesia followed by normal saline administration in spontaneously breathing patients undergoing elective knee arthroplasty. More trials, including different patient subgroups, will be needed.

Role of Multimodal Analgesia in the Evolving Enhanced Recovery after Surgery Pathways.

Enhanced recovery after surgery (ERAS) are specially designed multimodal perioperative care pathways which are intended to attain and improve rapid recovery after surgical interventions by supporting preoperative organ function and attenuating the stress response caused by surgical trauma, allowing patients to get back to normal activities as soon as possible. Evidence-based protocols are prepared and published to implement the conception of ERAS. Although they vary amongst health care institutions, the main three elements (preoperative, perioperative, and postoperative components) remain the cornerstones. Postoperative pain influences the quality and length of the postoperative recovery period, and later, the quality of life. Therefore, the optimal postoperative pain management (PPM) applying multimodal analgesia (MA) is one of the most important components of ERAS. The main purpose of this article is to discuss the concept of MA in PPM, particularly reviewing the use of opioid-sparing measures such as paracetamol, nonsteroid anti-inflammatory drugs (NSAIDs), other adjuvants, and regional techniques.

Measurements of Inferior Vena Cava Diameter for Prediction of Hypotension and Bradycardia during Spinal Anesthesia in Spontaneously Breathing Patients during Elective Knee Joint Replacement Surgery.

Background and objective: Hypotension and bradycardia are the most common hemodynamic disorders and side effects of spinal anesthesia (SA) on the cardiovascular system. SA-induced sympathetic denervation causes peripheral vasodilatation and redistribution of central blood volume that may lead to decreased venous return to the heart. The aim of the study was to evaluate the changes of inferior vena cava collapsibility index (IVC-CI) during SA in spontaneously breathing patients during elective knee joint replacement surgery to prognose manifestation of intraoperative hypotension and bradycardia. Materials and methods: 60 patients (American Society of Anesthesiologists (ASA) physical status I or II, no clinically significant cardiovascular pathology) of both sexes undergoing elective knee joint replacement surgery under SA were included in the prospective study. Inspiratory and expiratory inferior vena cava (IVCin, IVCex) diameters were measured using an ultrasound device in supine position before and immediately after SA, then 15 min, 30 min, and 45 min after SA was performed. The heart rate, along with systolic, diastolic, and mean arterial blood pressures were collected. The parameters were measured at the baseline and at the next four time points. Results: There were no significant changes in IVCin, IVCex, and IVC-CI compared to baseline and other time point measurements in hypotensive versus nonhypotensive and bradycardic versus nonbradycardic patients (p > 0.05). Changes in IVC diameter do not prognose hypotension and/or bradycardia during SA: the area under the curve (AUC) of the receiver operating characteristic (ROC) curve for IVC-CI at all measuring points was <0.7, p > 0.05. Conclusions: Reduction in IVC diameters and increase in IVC-CI do not predict hypotension and bradycardia during SA in spontaneously breathing patients undergoing elective knee joint replacement surgery.

Comparison of 2 Analgesia Modalities in Total Knee Replacement Surgery: Is There an Effect on Knee Function Rehabilitation?

BACKGROUND We compared the effects of continuous femoral nerve block (CFNB) and continuous intraarticular block (CIAB) on pain, functional recovery and adverse effects after total knee arthroplasty (TKA). MATERIAL AND METHODS We prospectively randomized 54 patients undergoing TKA into 2 groups: CFNB (Group F) and CIAB (Group I). Surgery was performed under spinal anesthesia. All patients received patient-controlled analgesia (PCA) with morphine, diclofenac, and acetaminophen for the first 72 h postoperatively. Pain was assessed with a visual analog scale (VAS), 48-h morphine consumption and 72-h local anesthetic dosage were recorded, motor blockade was assessed, maximum range of motion (ROM) was measured, and adverse effect profiles were recorded. RESULTS There was no significant difference in postoperative pain at rest, in passive motion, active motion, or active movement (2-min walk test (2MWT)) between study groups. Group I had less opioid usage in the first 24 h postoperatively (p<0.05). No significant difference was found between the groups in the postoperative local anesthetic dosage (p>0.05). Significantly lower scores of Bromage scale in Group I in 72 h after surgery (p<0.05) were found. Group I had superior passive maximum ROM in 1 month after surgery and superior active maximum ROM on day 7 and at 1 month after surgery (p<0.05). CONCLUSIONS Both CFNB and CIAB are effective postoperative analgesia methods after TKA. CIAB leads to lower postoperative opioid usage in the first 24 h, lower motor blockade in the first 72 h, and better knee function on day 7 and at 1 month after surgery.

A prospective, randomized clinical study of osteochondral autologous transplantation versus microfracture for the treatment of osteochondritis dissecans in the knee joint in children.

PURPOSE: The aim of this study was to compare the outcomes of the arthroscopic mosaic-type osteochondral autologous transplantation (OAT) and microfracture (MF) procedures for the treatment of osteochondritis dissecans (OCD) defects of the femoral condyles of the knee joint in children under the age of 18 years. TYPE OF STUDY: Prospective, randomized clinical study. METHODS: Between 2001 and 2005, a total of 50 children with a mean age of 14.3 years (12 to 18) and with symptomatic lesions of the OCD in the femoral condyle of the knee were randomized to undergo either the OAT or the MF procedure. Only those children with grade 3 or 4 (OCD) in the medial or lateral femoral condyle (according to International Cartilage Repair Society, ICRS) were included in the study. Forty-seven patients (94%) were available for follow-up. There were 25 patients in the OAT group and 22 patients in the MF group. The mean duration of symptoms was 23.54+/-4.24 months and the mean follow-up was 4.2 years (range from 3 to 6 y), and none of the children had prior surgical interventions to the affected knee. Children were evaluated using ICRS score, x-rays, magnetic resonance imaging, and second-look arthroscopies. RESULTS: After 1 year, both groups had significant clinical improvement (P<0.05) and the ICRS functional and objective assessment showed that 23 of 25 (92%) patients had excellent or good results after OAT compared with 19 of 22 (86%) after MF (NS), but 19 of 23 (83%) after OAT and only 12 of 19 (63%) after MF procedure maintained excellent or good results after 4.2 years (range from 3 to 6 y). The MF group showed significant deterioration over the 4.2 years follow-up (P<0.05), but still had significant clinical improvement compared with pretreatment evaluation (P=0.004). There were 9 of 22 (41%) failures in the MF group, and none in the OAT group. Magnetic resonance imaging evaluation according to the ICRS evaluation system showed excellent or good repairs in 19 of 21 patients (91%) after OAT compared with 10 of 18 (56%) after MF. CONCLUSIONS: At an average of 4.2 years follow-up, our prospective, randomized, clinical study in children under the age of 18 years has shown significant superiority of the mosaic-type OAT over MF for the treatment of osteochondritis dissecans defects in the knee. However, our study has shown that both MF and OAT give encouraging clinical results for children under the age of 18 years. LEVEL OF EVIDENCE: Level 1: randomized controlled trial, significant difference.

[A prospective comparison of double- and single-bundle anterior cruciate ligament reconstructions]. / Prospektyvusis dvieju ir vieno pluosto priekinio kryzminio raiscio rekonstrukcijos metodu palyginimas.

OBJECTIVE: A nonrandomized clinical study was performed to compare the clinical and radiological outcome between double-bundle and single-bundle anterior cruciate ligament (ACL) reconstructions with semitendinosus tendon in athletes. MATERIAL AND METHODS: We examined 70 patients with unilateral anterior cruciate ligament injury. They were followed up for a mean of 24 months. Each group of 35 patients underwent either double- or single-bundle ACL reconstruction. The mean age of the patients was 24.7 years (range, 18-35 years). There were no differences between two groups regarding age at surgery, sex, follow-up period, period before surgery, combined meniscus injuries, athletic activity level, and International Knee Documentation Committee (IKDC) and Tegner scores. All patients followed the same postoperative program. They were evaluated using manual knee laxity tests, knee extension and flexion strength testing. General knee condition was evaluated by the IKDC and Tegner scores. RESULTS: The results were excellent and good in 32 (91.4%) patients after double-bundle ACL reconstruction and in 30 (85.7%) patients after single-bundle ACL reconstruction, evaluating by IKDC system. However, statistical analysis showed no significant difference between the two groups regarding all IKDC-categorized data (P=0.87). The average scores of Tegner activity in double-bundle and single-bundle groups were 8.0 and 8.1, respectively. CONCLUSIONS: This trial showed no significant difference between the double and single-bundle ACL repairs.

[Hospital-acquired urinary tract infections]. / Hospitalines slapimo taku infekcijos.

Urinary tract infections are responsible for 40-60% of all hospital-acquired infections. Increased age of patients and comorbid diseases render hospitalized patients more susceptible to infection. Almost 80% of hospital-acquired urinary tract infections are associated with urinary catheters, and only 5-10% of urinary infections are caused by invasive manipulations in the urogenital tract. Pathogens of hospital-acquired urinary tract infections are frequently multi-resistant, and antibiotic therapy can only be successful when the complicating factors are eliminated or urodynamic function is restored. For treatment of complicated hospital-acquired urinary tract infections, the antibiotics must exhibit adequate pharmacodynamic and pharmacokinetic properties: high renal clearance of unmetabolized form with good antimicrobial activity in both acidic and alkaline urine. For selection of empirical treatment of hospital-acquired urinary tract infections, it is necessary to evaluate localization of infection, its severity, possible isolates, and the most frequent pathogens in the department where patient is treated. The best choice for the starting the antimicrobial therapy is the cheapest narrow-spectrum effective antibiotic in the treatment of urinary tract infection until microbiological evaluation of pathogens will be received. Adequate management of urinary tract infections lowers the rate of complications, requirements for antibacterial treatment, selection of multi-resistant isolates and is cost effective.

[Postoperative analgesia with intraarticular local anesthetic bupivacaine and alpha2-agonist clonidine after arthroscopic knee surgery]. / Intrasanarine vietinio anestetiko bupivakaino ir alpha2-adrenomimetiko klonidino analgezija po kelio sanario artroskopines operacijos.

OBJECTIVE: To evaluate the efficacy of intraarticular 0.5% 20 ml bupivacaine and compound of bupivacaine with alpha2-agonist clonidine for postoperative analgesia after arthroscopic knee surgery. A total of 48 patients, scheduled for knee arthroscopy, were enrolled in the study. Patients were randomly assigned to three different groups: placebo (group C), and two experimental groups that received one of the following double-blinded intraarticular solutions: 0.5% 20 ml of bupivacaine (group B) and 0.5% 20 ml of bupivacaine with l microg/kg of clonidine (group B+C). Patients were asked to evaluate on a visual analogy scale (VAS) the intensity of pain at rest and during motion, satisfaction with postoperative analgesia. Side effects and requirements for supplemental analgetics were recorded at the same time. RESULTS: Postoperative analgesia was good in the groups B and B+C (VAS<3). The pain was controlled most effectively in the patients of group B+C compared to placebo group (p<0.05). The demand for supplemental analgetics after surgery was also lower in this group. The patients of group B+C had shown the most satisfaction with postoperative analgesia. CONCLUSION: The compound of intraarticular bupivacaine and clonidine suppresses pain better than intraarticular injection of bupivacaine or use of usual systemic analgetics (p<0.05). Intraarticular analgesia assures satisfaction with anesthesiologic procedure.

[Interscalene brachial plexus block for shoulder surgery]. / Peties nervinio rezginio interskaleninis blokavimas darant peties srities operacijas.

OBJECTIVE: This study evaluates the clinical efficacy of interscalene brachial plexus block (according to G. Meier) for shoulder surgery. PATIENTS AND METHODS: Seventy-three patients, scheduled for the elective shoulder surgery, were included in this study. All patients received an interscalene block before surgery and a standard analgesia protocol after it. Minimal stimulating current, block performance time, the onset of sensory and motor blocks, duration of surgery and surgery type were recorded. The quality of nerve block was also evaluated by a surgeon. The duration of postoperative analgesia resulting from residual local anesthetic effect was expressed as the time to first requirement for post-operative pain medication. Satisfaction scores with a visual analog scale, side effects, circulatory and respiratory parameters were assessed. RESULTS: The success rate was 97%. For the nerve location a minimal stimulating current of 0.1 mA had been achieved. The median onset time of both motor and sensory blockade was <4 min. A complete muscle paralysis was observed after 21 (16-30) min. Duration of sensory blockade was 420 (240-840) min. The time from the block placement to the first request for pain medication was 8 (4-32) hours. Side effects were minor. Patient satisfaction was high. CONCLUSIONS: Single injection interscalene brachial plexus block is a reliable anesthetic and effective method of providing postoperative pain relief after shoulder surgery.

[Bupivacaine for continuous interscalene brachial plexus analgesia after shoulder surgery]. / Interskalenine peties nervinio rezginio analgezija ilgalaike bupivakaino infuzija.

OBJECTIVE: This study evaluates clinical efficacy of continuous interscalene brachial plexus block with bupivacaine 0.15% for postoperative analgesia after shoulder surgery. MATERIAL AND METHODS: Eighty patients, scheduled for elective shoulder surgery, were included in this study. All patients received an interscalene block before surgery. A perineural catheter was then introduced for continuous brachial plexus analgesia. Patients were prospectively randomized in a double-blinded fashion to receive either bupivacaine 0.15% or placebo postoperative infusion through an interscalene catheter. Pain was assessed with a visual analog scale at rest and also in motion. Duration of surgery and surgery type, satisfaction scores, supplemental analgesia, side effects, circulatory and respiratory parameters were recorded. RESULTS: The bupivacaine group showed less pain at rest and in motion than the placebo group (p<0.0001), except 4 and 6 h after the brachial plexus block; a requirement for supplemental analgesia was also lower. Side effects (except weakness in the arm, which was more frequent in bupivacaine group), circulatory and respiratory parameters were comparable in both groups. Satisfaction scores were higher in bupivacaine group. CONCLUSIONS: Continuous interscalene brachial plexus analgesia is a reliable and effective method of providing postoperative pain relief after shoulder surgery and is superior to the systemic analgesia.

[Minimally invasive arthroscopic treatment of shoulder impingement]. / Peties sanario ankstumo sindromo minimaliai invazinis artroskopinis gydymas.

Between 2000 and 2002 thirty four patients were evaluated after arthroscopic acromionplasty procedures. Patients had different shoulder pathology and were evaluated 15+/-1.2 months post operations through Constant scale and with x-rays. The mean age of patients was 42+/-6.5 years during operations. Twenty eight (82.3%) arthroscopic assisted acromionplasties results were good at the time of last follow-up. Final evaluation showed statistically significantly improvement of the Constant results from 26+/-6.24 preoperatively to 60+/-7.56 postoperatively (p<0.05).