Analgesic efficacy and safety of four different anesthesia/postoperative analgesia protocols in patients following total hip arthroplasty

© 2017, Institut za Vojnomedicinske Naucne Informacije/Documentaciju. All rights reserved. Background/Aim. Hip replacement surgery can initiate significant postoperative pain caused by bone alterations, implant, and soft tissue or nerve injuries. Postoperative analgesia using regional techniques has been shown to have numerous advantages over the intravenous use of morphine. However, numerous side effects and complications of postoperative continuous epidural analgesia have been reported recently. The aim of this prospective, randomized study was to investigate whether continuous lumbar plexus block can be a safe and efficacious alternative for postoperative analgesia in comparison with epidural analgesia and patient-controlled analgesia with morphine (PCA morphine) for hip arthroplasty. Methods. This prospective study included 60 patients, scheduled for total hip arthroplasty. Patients were randomized into 4 groups: the group central nerve block - epidural (CNB), the group peripheral nerve block - lumbar plexus block (PNB), the group spinal anesthesia-PCA morphine (SAM) and the group general anesthesia-PCA morphine (GAM). The quality of analgesia and side effects (hypotension, nausea, vomiting, urinary retention) were recorded in all groups at 4 h, 12 h, and 24 h after surgery. Pain scores were assessed using Visual Analogue Scale (VAS), both at rest and on moving. Results. Our findings demonstrated that the use of a continuous lumbar plexus block provides effective analgesia at rest and on moving, during 24 h after hip arthroplasty. Pain scores varied significantly among the groups 4 h postoperatively (F = 21.827; p < 0.01), 12 h postoperatively (F = 41.925; p < 0.01) and 24 h postoperatively (F = 33.768; p < 0.01) with the highest scores ≥ 3 in the GAM group. Patients from the PNB group had satisfactory analgesia, comparable with patients from the CNB group. The incidence of nausea was significantly lower in the PNB group 12 h after the operation (χ2 = 9.712; p < 0.01). The incidence of urine retention was significantly different 12 h after the operation, with a presence only in the CNB group, with the incidence of 33.3% (χ2 = 16.365; p < 0.01). In all studied groups, the incidence of hypotension was not significantly different postoperatively. Conclusion. Administration of postoperative analgesia using continuous lumbar plexus block produces satisfactory analgesia with a low incidence of side effects when compared to epidural analgesia or parenteral opioids following hip arthroplasty

Mortality after surgery in Europe: a 7 day cohort study

Background: Clinical outcomes after major surgery are poorly described at the national level. Evidence of heterogeneity between hospitals and health-care systems suggests potential to improve care for patients but this potential remains unconfirmed. The European Surgical Outcomes Study was an international study designed to assess outcomes after non-cardiac surgery in Europe.Methods: We did this 7 day cohort study between April 4 and April 11, 2011. We collected data describing consecutive patients aged 16 years and older undergoing inpatient non-cardiac surgery in 498 hospitals across 28 European nations. Patients were followed up for a maximum of 60 days. The primary endpoint was in-hospital mortality. Secondary outcome measures were duration of hospital stay and admission to critical care. We used χ² and Fisher’s exact tests to compare categorical variables and the t test or the Mann-Whitney U test to compare continuous variables. Significance was set at p&lt;0·05. We constructed multilevel logistic regression models to adjust for the differences in mortality rates between countries.Findings: We included 46 539 patients, of whom 1855 (4%) died before hospital discharge. 3599 (8%) patients were admitted to critical care after surgery with a median length of stay of 1·2 days (IQR 0·9–3·6). 1358 (73%) patients who died were not admitted to critical care at any stage after surgery. Crude mortality rates varied widely between countries (from 1·2% [95% CI 0·0–3·0] for Iceland to 21·5% [16·9–26·2] for Latvia). After adjustment for confounding variables, important differences remained between countries when compared with the UK, the country with the largest dataset (OR range from 0·44 [95% CI 0·19 1·05; p=0·06] for Finland to 6·92 [2·37–20·27; p=0·0004] for Poland).Interpretation: The mortality rate for patients undergoing inpatient non-cardiac surgery was higher than anticipated. Variations in mortality between countries suggest the need for national and international strategies to improve care for this group of patients.Funding: European Society of Intensive Care Medicine, European Society of Anaesthesiology

Management practices for postdural puncture headache in obstetrics: a prospective, international, cohort study

© 2020 British Journal of AnaesthesiaBackground: Accidental dural puncture is an uncommon complication of epidural analgesia and can cause postdural puncture headache (PDPH). We aimed to describe management practices and outcomes after PDPH treated by epidural blood patch (EBP) or no EBP. Methods: Following ethics committee approval, patients who developed PDPH after accidental dural puncture were recruited from participating countries and divided into two groups, those receiving EBP or no EBP. Data registered included patient and procedure characteristics, headache symptoms and intensity, management practices, and complications. Follow-up was at 3 months. Results: A total of 1001 patients from 24 countries were included, of which 647 (64.6%) received an EBP and 354 (35.4%) did not receive an EBP (no-EBP). Higher initial headache intensity was associated with greater use of EBP, odds ratio 1.29 (95% confidence interval 1.19–1.41) per pain intensity unit increase. Headache intensity declined sharply at 4 h after EBP and 127 (19.3%) patients received a second EBP. On average, no or mild headache (numeric rating score≤3) was observed 7 days after diagnosis. Intracranial bleeding was diagnosed in three patients (0.46%), and backache, headache, and analgesic use were more common at 3 months in the EBP group. Conclusions: Management practices vary between countries, but EBP was more often used in patients with greater initial headache intensity. EBP reduced headache intensity quickly, but about 20% of patients needed a second EBP. After 7 days, most patients had no or mild headache. Backache, headache, and analgesic use were more common at 3 months in patients receiving an EBP

Management practices for postdural puncture headache in obstetrics : a prospective, international, cohort study

Background: Accidental dural puncture is an uncommon complication of epidural analgesia and can cause postdural puncture headache (PDPH). We aimed to describe management practices and outcomes after PDPH treated by epidural blood patch (EBP) or no EBP. Methods: Following ethics committee approval, patients who developed PDPH after accidental dural puncture were recruited from participating countries and divided into two groups, those receiving EBP or no EBP. Data registered included patient and procedure characteristics, headache symptoms and intensity, management practices, and complications. Follow-up was at 3 months. Results: A total of 1001 patients from 24 countries were included, of which 647 (64.6%) received an EBP and 354 (35.4%) did not receive an EBP (no-EBP). Higher initial headache intensity was associated with greater use of EBP, odds ratio 1.29 (95% confidence interval 1.19-1.41) per pain intensity unit increase. Headache intensity declined sharply at 4 h after EBP and 127 (19.3%) patients received a second EBP. On average, no or mild headache (numeric rating score <= 3) was observed 7 days after diagnosis. Intracranial bleeding was diagnosed in three patients (0.46%), and backache, headache, and analgesic use were more common at 3 months in the EBP group. Conclusions: Management practices vary between countries, but EBP was more often used in patients with greater initial headache intensity. EBP reduced headache intensity quickly, but about 20% of patients needed a second EBP. After 7 days, most patients had no or mild headache. Backache, headache, and analgesic use were more common at 3 months in patients receiving an EBP