The effect of pre-incisional wound site infiltration with multimodal analgesia on postoperative pain in total knee arthroplasty

Background: Though Total knee arthroplasty (TKA) is an effective treatment method for osteoarthritis, insuffient postoperative pain management affects paitents satisfaction and functional results. To an effective postoperative pain management, several methods are used for analgesia. Aim of this study was to evaluate the effect  of the application of pre-incisional wound site infiltration on postoperative analgesia, additional to multi-modal analgesia methods for the provision of analgesia following Total Knee Arthroplasty. Material and methods: Total of 80 patients aged ≥55 years posted to undergo TKA were randomly separated into 2 groups. Pre-incisional injection was administered to the skin for the group I patients, wherreas patiemts of group II were not administered pre-incisional injection. For postoperative pain management additional multi-modal analgesia methods were applied in both groups. To evaluate the level of postoperative pain, a Visual Analog Scale (VAS) score at rest and dynamic VAS (DVAS) during activity were used. The time of requirement for first analgesia and the amount of analgesia required were recorded. The patients were monitored throughout the operation and in the postoperative period for side-effects. Results: Postoperative VAS scores of Group I were found to be statistically significantly lower than those of Group II (p<0.05). The DVAS scores which were evaluated together with mobilisation, determined to be statistically significantly lower in Group I (p<0.05). The time of requirement for analgesia was determined to be later in Group I and the total amount of analgesia administered in the postoperative period was lower in Group I. No statistically significant difference was determined between the two groups in side-effects. Conclusion: The application of pre-incisional infiltration can be considered to be a safe and effective method, which is easy to apply and has low potential for side-effects, while increasing the efficacy of multi-modal analgesia.

Isolated Cerebral Fat Embolism After Lower Extremity Fracture: Case Report

Fat embolism syndrome (FES) is characterized with petechiae, mental confusion, and respiratory failure, occurs generally after lower extremity long bone fractures or orthopedic surgery within 24-72 hours. Isolated cerebral fat embolism occurs at a rate of 0.9-2.2% that is a fatal event. The clinical diagnosis of isolated cerebral fat embolism is difficult since neurological symptoms are variable. On the other hand methemoglobinemia is a rare complication occurring after administration of local anesthetics. We aimed to present a case in whom isolated cerebral fat embolism and methemoglobinemia caused by intraoperative high dose of local anesthetic agents and who was taken to operation in the first 24 hours because of the left femoral diaphysis fracture in this study

Acute kidney disease beyond day 7 after major surgery: a secondary analysis of the EPIS-AKI trial

Purpose: Acute kidney disease (AKD) is a significant health care burden worldwide. However, little is known about this complication after major surgery. Methods: We conducted an international prospective, observational, multi-center study among patients undergoing major surgery. The primary study endpoint was the incidence of AKD (defined as new onset of estimated glomerular filtration rate (eCFR) < 60 ml/min/1.73 m2 present on day 7 or later) among survivors. Secondary endpoints included the relationship between early postoperative acute kidney injury (AKI) (within 72 h after major surgery) and subsequent AKD, the identification of risk factors for AKD, and the rate of chronic kidney disease (CKD) progression in patients with pre-existing CKD. Results: We studied 9510 patients without pre-existing CKD. Of these, 940 (9.9%) developed AKD after 7 days of whom 34.1% experiencing an episode of early postoperative-AKI. Rates of AKD after 7 days significantly increased with the severity (19.1% Kidney Disease Improving Global Outcomes [KDIGO] 1, 24.5% KDIGO2, 34.3% KDIGO3; P < 0.001) and duration (15.5% transient vs 38.3% persistent AKI; P < 0.001) of early postoperative-AKI. Independent risk factors for AKD included early postoperative-AKI, exposure to perioperative nephrotoxic agents, and postoperative pneumonia. Early postoperative-AKI carried an independent odds ratio for AKD of 2.64 (95% confidence interval [CI] 2.21-3.15). Of 663 patients with pre-existing CKD, 42 (6.3%) had worsening CKD at day 90. In patients with CKD and an episode of early AKI, CKD progression occurred in 11.6%. Conclusion: One in ten major surgery patients developed AKD beyond 7 days after surgery, in most cases without an episode of early postoperative-AKI. However, early postoperative-AKI severity and duration were associated with an increased rate of AKD and early postoperative-AKI was strongly associated with AKD independent of all other potential risk factors

Epidemiology of surgery associated acute kidney injury (EPIS-AKI): a prospective international observational multi-center clinical study

Purpose: The incidence, patient features, risk factors and outcomes of surgery-associated postoperative acute kidney injury (PO-AKI) across different countries and health care systems is unclear. Methods: We conducted an international prospective, observational, multi-center study in 30 countries in patients undergoing major surgery (> 2-h duration and postoperative intensive care unit (ICU) or high dependency unit admission). The primary endpoint was the occurrence of PO-AKI within 72 h of surgery defined by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Secondary endpoints included PO-AKI severity and duration, use of renal replacement therapy (RRT), mortality, and ICU and hospital length of stay. Results: We studied 10,568 patients and 1945 (18.4%) developed PO-AKI (1236 (63.5%) KDIGO stage 1500 (25.7%) KDIGO stage 2209 (10.7%) KDIGO stage 3). In 33.8% PO-AKI was persistent, and 170/1945 (8.7%) of patients with PO-AKI received RRT in the ICU. Patients with PO-AKI had greater ICU (6.3% vs. 0.7%) and hospital (8.6% vs. 1.4%) mortality, and longer ICU (median 2 (Q1-Q3, 1-3) days vs. 3 (Q1-Q3, 1-6) days) and hospital length of stay (median 14 (Q1-Q3, 9-24) days vs. 10 (Q1-Q3, 7-17) days). Risk factors for PO-AKI included older age, comorbidities (hypertension, diabetes, chronic kidney disease), type, duration and urgency of surgery as well as intraoperative vasopressors, and aminoglycosides administration. Conclusion: In a comprehensive multinational study, approximately one in five patients develop PO-AKI after major surgery. Increasing severity of PO-AKI is associated with a progressive increase in adverse outcomes. Our findings indicate that PO-AKI represents a significant burden for health care worldwide