Hip and knee replacement surgery are a common and effective procedure for the relief of pain and loss of function. The number of procedures is increasing and great interest is given how to improve ...outcome following hip and knee replacement surgery. Last two decades have been characterized by many innovations in hip and knee replacement surgery including minimally invasive technique but also by improvements in anesthetic technique and blood management. The patients undergoing hip and knee replacement surgery are commonly elderly and have cos-existing organ dysfunctions. These procedures are characterized by great perioperative disturbances including cardiovascular complications, high incidence of thromboembolic complications, possible significant perioperative blood loss, possible bone cement effect and high level of postoperative pain. Anesthetic assessment of patients include preoperative preparations, intraoperative and postoperative care. In this article, all problems of perioperative blood management are discussed. The recent data of advantages of blood management for every patient are outlined. Blood management include preoperative preparation, use of autologous blood in perioperative period and administration of drugs for minimizing intraoperative blood loss. The final result of improvements in blood management is reducing in blood loss and need for allogeneic blood and significant reduction in perioperative morbidity.
Anterior section of the hip joint capsule is innervated by femoral nerve and obturator nerve, and posterior section is innervated by the nerve to quadratus femoris muscle and occasionally by the ...superior gluteal (posterolateral region) and sciatic nerve (posterosuperior region). One of the regional anesthesia options for hip surgery is the fascia iliaca compartment block (FICB) that affects nerves important for hip innervation and sensory innervation of the thigh - femoral, obturator and lateral femoral cutaneous nerve. FICB can be easily performed and is often a good solution for management of hip fractures in emergency departments. Its use reduces morphine pre-operative requirement for patients with femoral neck fractures and can also be indicated for hip arthroplasty, hip arthroscopy and burn management of the region. Quadratus lumborum block (QLB) is a block of the posterior abdominal wall performed exclusively under ultrasound guidance, with still unclarified mechanism of action. When considering hip surgery and postoperative management, the anterior QLB has shown to reduce lengthy hospital stay and opioid use, it improves perioperative analgesia in patients undergoing hip and proximal femoral surgery compared to standard intravenous analgesia regimen, provides early and rapid pain relief and allows early ambulation, thus preventing deep vein thrombosis and thromboembolic complications etc. However, some nerve branches responsible for innervation of the hip joint are not affected by QLB, which has to be taken into consideration. QLB has shown potential for use in hip surgery and perioperative pain management, but still needs to be validated as a reliable treatment approach.
Hip replacement surgery is a common and effective procedure for the relief of pain and loss of function. The number of procedures is increasing and great interest is shown for the manner of outcome ...improvement following hip replacement surgery. Last decade (2001-2010) is declared as the Bone and Joint Decade and has been characterized by many innovations in hip replacement surgery including minimally invasive technique but also by improvements in anesthetic technique. However there is no consensus about most appropriate anesthetic and analgesic techniques to use. Total hip replacement is procedure characterized by great perioperative disturbances including cardiovascular complications, high incidence of thromboembolic complications, possible significant perioperative blood loss, possible bone cement effect and high level of postoperative pain. Anesthetic assessment of patients include preoperative preparations, intraoperative and postoperative care. Most important factors determining outcome of patients include preoperative assessment and planning in order to minimize potential anesthetic problems, optimize co-morbidity and provide the most appropriate anesthetic for the patient. In this article all problems of preoperative assessment are discussed. The recent data of advantages of regional anesthetic technique are outlined. All the problems of intraoperative course and how to avoid them are presented. The possible techniques of postoperative pain therapy are also presented. The importance of thromboprophylaxis is outlined and recent guidelines for thromboprophylaxis are given including recommendations for new antithrombotic drugs. Our recommendation is to always prepare a patient for this procedure, analyse preoperative status, choose optimal anesthetic technique, provide thromboprophylaxis and multimodal pain therapy according to accepted guidelines.
Fondaparinux has been shown to be as effective as low molecular weight heparin
in orthopedic surgery, with no cases of heparin induced thrombocytopenia proven until today. The
main goal of this ...prospective randomized controlled trial was to define whether thromboprophylaxis
in patients with primary osteoarthritis of the knee undergoing total knee arthroplasty (TKA) influences
clinical parameters in the same manner in patients receiving fondaparinux as in those receiving
nadroparin during the first 7 postoperative days. Sixty patients with primary knee osteoarthritis underwent
unilateral TKA performed by the same surgeon and were randomized into two groups of 30
patients receiving either fondaparinux or nadroparin thromboprophylaxis. Patients were compared
according to the duration of operation, perioperative blood loss, laboratory results and clinical evaluation
of the edema during the early postoperative period. No differences were found between the
groups in the mean duration of surgery, perioperative blood loss, and most of laboratory results. The
level of urea was significantly lower in the nadroparin group on the first and second postoperative day.
No cases of heparin induced thrombocytopenia, deep vein thrombosis or pulmonary embolism were
noted during the study. Study results showed both fondaparinux and nadroparin to have the same
influence on clinical parameters during the first 7 postoperative days in patients undergoing TKA.
Postoperative delirium or acute confusional state is common after major surgery. The objective of this article is to provide an overview of the current knowledge of the risk factors and the ...importance of anesthetic technique in postoperative delirium. The risk factors for postoperative delirium include patient characteristics such as advanced age, poor preoperative functional state, depression, and abnormal serum levels of sodium, potassium, glucose and albumin. The type of surgery is also important, so delirium is common after high operative stress procedures. Perioperative risk factors also include blood loss, postoperative hematocrit, hypotension and hypoxemia, pain and polypharmacy. Anesthetic technique is a potentially modifiable risk factor. Although administration of many drugs can be avoided or limited with regional anesthetic techniques and reduction in the prevalence of postoperative delirium has been analyzed in many studies, the results are inconsistent. Literature data were analyzed to determine whether type of anesthesia determines the incidence of postoperative delirium. According to PubMed, there are several studies comparing postoperative delirium after regional or general anesthesia. Many of these studies showed a trend toward increased postoperative delirium with general anesthesia, but the difference was not significant. On interpreting these results, it should be taken in consideration that many of these studies were retrospective and nonrandomized with a small number of participants, so further large, multicenter, randomized trials are needed to make any firm conclusion on the influence of anesthetic technique on postoperative delirium. Although the pathophysiology of delirium is not fully understood, it appears that multiple metabolic and neurochemical insults disrupt neuronal functioning in susceptible patients. Prevention and optimal treatment consist of minimizing or correcting these metabolic and other insults. Early detection of coexisting postoperative medical problems, pain, infections, or other complications is crucial. Regional anesthetic techniques have many potential advantages such as reduced stress response and good postoperative analgesia, but further investigations are needed to confirm these observations.
Several methods have been found to be successful in reducing the need for allogeneic transfusion among the patients undergoing total hip replacement. The purpose of this prospective study was to ...analyse the quality and evaluate the effect of postoperative autotransfusion on the need for allogeneic transfusion following total hip replacement. The prospective study was performed in two groups of patients undergoing total hip replacement. Before the operative procedure all patients in both groups predonated two doses of autologous blood. In GROUP 1. the system for postoperative collection and transfusion of shed blood was used. In GROUP 2. the patients underwent total hip replacement without blood salvage system. Standard suction collection sets were used postoperatively. In this group shed blood was not transfused to the patients. The samples of preoperative donated autologus blood, allogeneic blood and postoperative collected autologous blood were analysed for number of red cells, hemoglobin, hematocrit, platelets, white blood cells, values of potassium, sodium, free hemoglobin and acid base status. The postoperatively blood salvage significantly reduced the use of allogeneic transfusion among patients managed with total hip replacement (allogeneic transfusion received 12% patients in Group 1 and 80% patients in Group 2; p<0.001). The values of red blood cells are significantly lower in postoperative collected autotransfusion blood compared with preoperative collected autologous blood and allogeneic blood (p<0.001). The values of potassium and acid base status were in normal range in postoperatively collected autotransfusion blood. These values in preoperatively collected autologous blood and allogeneic blood were out of normal range; (p<0.001). In addition to reducing the risk of complications that are associated with allogeneic transfusion, postoperative blood salvage may offer benefits including reducing the need for allogeneic blood. Our study confirmed that postoperative collection and transfusion of drainaged blood is simple and safe method that significantly reduce the need for allogeneic transfusion in patients underwent total hip replacement. The blood collected and transfused postoperatively has lower values of red blood cells and normal values of potassium and acid base balance. The transfusion of this blood caused no complications in our patients.
Brachial plexus block using axillary approach is a simple and safe method of regional anesthesia often used for elbow, forearm and hand surgery. Different techniques can be used to achieve brachial ...plexus block. On using perivascular approach to brachial plexus, we neither searched for paresthesia nor used nerve stimulator to identify the correct needle position within the neurovascular sheet. Axillary artery was palpated and a mixture of local anesthetic agents was injected into the neurovascular sheet above and below axillary artery at the site of strongest artery pulsation. The local anesthetic solution comprised equal volumes of lidocaine 2% and bupivacaine 0.5% without adrenaline, in a total volume of 30-40 mL, depending on body mass. This technique is used in more than 150 patients per year at our department. In the present study, 158 patients undergoing upper extremity surgery under brachial plexus block were retrospectively assessed. Successful anesthesia was achieved in 135 (85.0%) patients using brachial plexus block alone, 19 (12.5%) patients required additional medication, two patients required supplementation with intravenous regional anesthesia, and another two patients required general anesthesia. The incidence of successful blocks, latency time of onset, local and systemic complications or allergic skin reactions were investigated. There were no significant complications attributed to the anesthetic technique.
Hip and knee replacement surgery are a common and effective procedure for the relief of pain and loss of function. The number of procedures is increasing and great interest is given how to improve ...outcome following hip and knee replacement surgery. Last two decades have been characterized by many innovations in hip and knee replacement surgery including minimally invasive technique but also by improvements in anesthetic technique and blood management. The patients undergoing hip and knee replacement surgery are commonly elderly and have cosexisting organ dysfunctions. These procedures are characterized by great perioperative disturbances including cardiovascular complications, high incidence of thromboembolic complications, possible significant perioperative blood loss, possible bone cement effect and high level of postoperative pain. Anesthetic assessment of patients include preoperative preparations, intraoperative and postoperative care. In this article, all problems of perioperative blood management are discussed. The recent data of advantages of blood management for every patient are outlined. Blood management include preoperative preparation, use of autologous blood in perioperative period and administration of drugs for minimizing intraoperative blood loss. The final result of improvements in blood management is reducing in blood loss and need for allogeneic blood and significant reduction in perioperative morbidity. Keywords: joint replacement surgery, blood management, autologous blood, tranexamic acid. Ugradnja umjetnih zglobova kuka i koljena je cesta i uspjesna metoda lijecenja kod poremecaja velikih zglobova pracenih boli i gubitkom normalne funkcije. Broj ovih operacija je u stalnom porastu te se velika paznja posvecuje poboljsanju perioperacijskog lijecenja. U zadnja dva desetljeca mnoge inovacije kao minimalno invazivna kirurska tehnika su uvedene u klinicku praksu, a doslo je i do znatnog napretka u anetezioloskom i transfuzijkom lijecenju. Bolesnici kojima se ugraduje endoproteza kuka i koljena su cesto starije zivotne dobi i imaju znacajan komorbiditet. Operacijski zahvat karakteriziraju znacajni perioperacijski poremecaji kao kardiovaskularne promjene, velika ucestalost tromboembolijskih komplikacija, moguceje znacajno perioperacijsko krvarenje, poremecaji uzrokovani kostanim cementom te visok nivo postoperacijske boli. Posebna paznja posvecuje se problemima znacajnog perioperacijskog krvarenja i provodenju metoda kojima se smanjuje perioperacijsko krvarenje te potrosnja alogene krvi. U ovom clanku pokazuju se postupci koji se provode prijeoperacijski (korekcija anemije postupci prijeoperacijske autologne donacije), intraoperacijski (akutna normovolemicka hemodilucija i intraoperacijska autrotransfuzija) te postoperacijski (postoperacijska autotransfuzija). Posebno se opisuje primjena lijekova (antifibrinolitici) koji smanjuju intraoperacijsko i postoperacijsko krvarenje. Konacan rezultat napretka u anesteziji i transfuzijskom lijecenju je smanjenje perioperacijskog krvarenja i potrosnje alogene krvi, te posljedicno smanjenje perioperacijskog morbiditeta, krace vrijeme hospitalizacije kao i brzi oporavak bolesnika. Kljucne rijeci: endoproteze kuka i koljena, autotransfuzija, traneksamicna kiselina.
Prikazujemo svoje iskustvo u anesteziranju bolesnika s osteogenesis imperfectom u sklopu ortopedskoga kirurškog liječenja prijeloma i deformacija kostiju. Učinjena je retrospektivna analiza ...dokumentacije bolesnika liječenih u našoj Klinici od 1980. do 2012. godine. Analizirani su demografski podaci, komorbiditeti, prijeoperacijske osobitosti, vrste anestezije, anestetika i lijekova te intraoperacijske i poslijeoperacijske komplikacije. U navedenom razdoblju liječeno je 26 bolesnika s navedenom dijagnozom. Zabilježene su 103 operacije, odnosno 103 anesteziološka postupka. Najviše zahvata, njih 68, učinjeno je u dobnoj skupini od 0 do 10 godina. Najviše bolesnika bolovalo je od tipa III osteogenesis imperfecte, najtežeg oblika ove bolesti spojivog sa životom. U 99 operacija zabilježen je ASA (American society of anesthesiologists) status II bolesnika. U 89 slučajeva učinjena je opća anestezija, u 14 regionalna. Zabilježeno je 14 intraoperacijskih komplikacija, najviše otežanih intubacija te 6 slučajeva poslijeoperacijske kardiovaskularne nestabilnosti. Uz kvalitetnu pripremu i predviđanje mogućih komplikacija anestezija u ovih bolesnika sigurna je procedura.
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