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PubMed1995

Combination fentanyl and diazepam for pediatric conscious sedation.

OBJECTIVES: To evaluate the safety and to describe the use of combination IV diazepam and fentanyl in the pediatric emergency department (PED) as outpatient conscious sedation (CS) for orthopedic procedures. METHODS: A retrospective chart review of a standardized protocol for CS administered to 133 consecutive patients requiring CS for outpatient orthopedic procedures. The patients were continuously monitored for heart rate, respiratory rate, and arterial O2 saturation (Sao2) by pulse oximetry. The study was conducted at a large urban PED and regional referral center. RESULTS: A total of 133 children (mean age 8.5 years) received 138 orthopedic procedures. Mean (+/- SD) total diazepam dose was 0.12 +/- 0.05 mg/kg; mean total fentanyl dose was 3.18 +/- 1.04 micrograms/kg. Mean time intervals were 4.6 minutes from initial drug administration to start of procedure, 15.5 minutes to end of procedure, and 56 minutes to meeting criteria for release home. Complications included Sao2 < 90% for 15 patients (11%, 95% CI 6.4-17.4%), vomiting for one (0.7%, 95% CI 0.1-4.2%), and severe pruritus for one (0.7%, 95% CI 0.1-4.2%). An episode of Sao2 < 90% was associated with a higher initial mean fentanyl dose (2.60 vs 1.95 micrograms/kg; p = 0.0005), but was not associated with a higher initial mean diazepam dose (p = 0.28). Parenteral opioid use for pain management prior to CS was not associated with an increased risk for Sao2 < 90% (p = 0.42). Heart rate, respiratory rate, and blood pressure were stable during the observational period. No patient required naloxone, flumazenil, artificial airway control, or admission to the hospital. CONCLUSIONS: At the doses given in the study, the use of combination diazepam and fentanyl for outpatient CS of PED patients during orthopedic procedures was not associated with serious complications. A higher initial fentanyl dose was associated with episodes of Sao2 < 90%. Therefore, an initial dose of < or = 2.0 micrograms/kg fentanyl titrated to effect is recommended.

Anesthetics, Intravenous↗
PubMed1998

Intraoperative pacemaker dysfunction caused by the use of electrocautery during a total hip arthroplasty.

Pacemaker dysfunction encountered during orthopedic procedures is a rare but potentially life-threatening complication. With an increasing number of orthopedic procedures performed on the aging population, it is not uncommon to encounter patients with pacemakers requiring major orthopedic intervention. Most, if not all, major orthopedic procedures performed today require the use of electrocautery for hemostasis. In this article we review the literature for pacemaker complications and report a case of pacemaker failure after a single use of the unipolar electrocautery on a patient undergoing a total hip replacement.

Aged↗
PubMed1985

An evaluation of cefoxitin in the prevention of postoperative infections following orthopedic surgical procedures.

An open, nonrandomized study of 25 patients was conducted to evaluate the efficacy of cefoxitin in the prevention of postoperative infection following orthopedic surgical procedures. Cefoxitin was administered in a 2 g dose preoperatively and continued postoperatively at a dose of 2 g every six hours for 72 hours. The mean peak serum level achieved ten minutes after the preoperative dose was 153.7 mcg/ml. The mean bone level in samples taken during the procedure was 10.14 mcg/ml. All patients were monitored postoperatively and at intervals of six weeks, four months and six months for signs of early or late morbidity. No signs of major morbidity were observed in the study group.

Adult↗
PubMed2001

Propofol and remifentanil pharmacodynamic interaction during orthopedic surgical procedures as measured by effects on bispectral index.

STUDY OBJECTIVE: To identify and quantify the interaction between propofol and remifentanil during surgical procedures with a bispectral index (BIS) of 50 that was chosen as a continuous surrogate measure for "adequate depth" of anesthesia. DESIGN: Prospective, open-label study. SETTING: Department of orthopedics of a university hospital. PATIENTS: 20 patients undergoing orthopedic surgery. INTERVENTIONS: Anesthesia was induced and maintained with propofol and remifentanil, both administered by target-controlled infusion (TCI). Initial target concentrations of propofol (1.5-8 microg/mL) and remifentanil (2-15 ng/mL) were chosen and alternated in order to maintain the BIS between 45 and 55. If constant target concentrations had been maintained for 20 minutes and the BIS did not depart from the desired range, blood samples were taken to determine propofol concentrations, and the BIS value was recorded. Isobolographic interaction models were fitted to the infusion rates of remifentanil and propofol, predicted target concentrations of both drugs, and measured propofol concentrations versus predicted remifentanil concentrations. MAIN RESULTS: The isobole for the interaction of propofol and remifentanil in the concentration range investigated (propofol 1.5-8 microg/mL and remifentanil 1-30 ng/mL) is a concave up hyperbola ((0.15. C(prop))(3.13). C(rem) = 1) with C(prop) = propofol plasma concentration [microg/mL] and C(rem) = remifentanil blood concentration [ng/mL]). Use of predicted (=TCI target) concentrations or the respective infusion rates did not alter the general shape of the interaction isobole. CONCLUSIONS: The interaction between propofol and remifentanil for maintenance of a BIS value between 45 and 55 during surgery is synergistic. This finding applies regardless of whether measured concentrations (for propofol), predicted concentrations of the infusion device, or infusion rates are used as model input. Notably, the interaction isobole of the (clinically readily available) infusion rates provides a useful dosing recommendation for the coadministration of propofol and remifentanil during maintenance of anesthesia.

Adult↗
PubMed2004

Perioperative pain management of a complex orthopedic surgical procedure with double continuous nerve blocks in a burned child.

UNLABELLED: The use of catheters for continuous nerve blocks has been established in children, although in most series only one catheter was used. We report a case of a 3-yr-old child who underwent a toe-to-finger transfer managed with 2 regional catheters: axillary and sciatic. A pain score of 0 was noted during the entire study period. The total dose of bupivacaine was limited to an acceptable range, and the child recovered completely. This report adds to growing evidence in favor of the safety and efficacy of continuous peripheral nerve blocks in pediatric patients. IMPLICATIONS: Double continuous nerve blocks allow optimal analgesia in burned children after complex orthopedic surgery without major adverse events. Plasma concentrations of bupivacaine remained small during the study period.

Bupivacaine↗
PubMed2002

Detection and removal of fat particles from postoperative salvaged blood in orthopedic surgery.

BACKGROUND: Although transfusion or return of salvaged shed blood has become popular in major orthopedic procedures, this blood-saving method is still controversial because shed blood may be contaminated with chemical and tissular debris, such as fat particles, which may increase the risk of fat embolism after bone surgery. STUDY DESIGN AND METHODS: In an effort to find an easy, reliable method for determination of both fat particle content and removal from shed blood, analyses of perioperative blood samples were performed with a cell counter (Technicon H3 [H3]) in orthopedic patients undergoing spinal fusion in which postoperative shed blood was collected and returned with a blood collection canister. A screen or surface filter was intercalated in the return line to eliminate microaggregates, fat particles, and/or WBCs. RESULTS: Fat particles in shed blood are clearly detected as a condensed, sigmoidal-shaped area at the right-hand side of the PMN zone in the channel in which the H3 measures particles according to their degree of lobularity. This signal can be reproduced by the addition of animal or vegetable fat to venous blood, but not by the addition of activated platelets or RBC membranes. Fat particles, together with WBCs and microaggregates, in shed blood were effectively removed by surface filters, whereas screen filters were not effective. CONCLUSION: The use of the TH3 seems to be an easy, reliable, and low-cost approach for monitoring fat particle content and removal from postoperative salvaged shed blood in orthopedic procedures.

Blood↗
PubMed1999

Technical pitfalls of meniscal surgery.

Meniscal surgery is one of the most common orthopedic procedures performed today. Orthopedic surgeons must be familiar with the indications for meniscal excision versus repair and comfortable with the diverse instrumentation used for both techniques. Numerous pitfalls exist in diagnosis, indication, and technical aspects of surgery but can be minimized or avoided by careful preoperative planning and attention to detail during the surgical procedure.

Arthroscopes↗
PubMed1995

Postoperative toxic shock syndrome.

PURPOSE: To determine risk factors for postoperative toxic shock syndrome (PTSS), a rare, rapidly progressive, and potentially fatal syndrome associated with postoperative wound infections. Components of PTSS include fever, rash, desquamation, hypotension, and multisystem organ dysfunction. METHODS: We conducted a retrospective review of all cases of PTSS occurring in 2 community hospitals from 1981 to 1993, following 390,000 surgical procedures. RESULTS: There were 12 cases of PTSS among the procedures reviewed (0.003%). Orthopedic procedures included excision of accessory navicular and patellar realignment. Wounds ranged from those with scant superficial exudates to those with gross purulence; all cultures yielded Staphylococcus aureus. All tested isolates were susceptible to methicillin or cephalothin. Mean time from surgery to onset of symptoms was 4 days. All patients had sudden onset of fever; mean maximal temperature was 40 degrees C. All patients displayed a rash, most in a truncal "sunburn" pattern. Eleven of 12 patients desquamated. All patients required vigorous fluid resuscitation. All patients survived. No correlation could be demonstrated between PTSS and patient age, sex, preoperative skin preparation or antibiotics, members of surgical team, or duration of procedure. CONCLUSIONS: Early recognition and treatment of PTSS are essential. No risk factors for PTSS have been identified. PTSS should be considered in the postoperative, acutely febrile, systemically ill patient, though surgical wounds may be deceptively benign in appearance.

Adolescent↗
PubMed1996

Gang warfare: the medical repercussions.

Gang related violence in Los Angeles County has increased, with homicides increasing from 205 in 1982 to 803 in 1992. This study examines the medical and financial consequences of such violence on a level I trauma center. Of 856 gunshot injuries over a 29-month period, 272 were gang related. There were 55 pediatric and 217 adult patients. Eighty-nine percent were male and 11% were female. Trauma Score averaged 14.7 +/- 3.1, Glasgow Coma Scale average score was 13.7 +/- 3.4, and the mean Injury Severity Score was 10.8 +/- 14. Twenty-two percent of the gunshots were to the head and neck, 20% to the chest, 20% to the abdomen, 6% had a peripheral vascular injury, and 33% sustained an extremity musculoskeletal injury. Emergency surgery was performed on 43%, including laparotomy 58 (49%), craniotomy 16 (13%), laparoscopy 14 (12%), vascular procedures 10 (8%), orthopedic procedures 6 (5%), head and neck endoscopies 4 (3%), thoracotomies 2 (2%), and 10 (8%) unspecified. There were 25 deaths (9%), primarily caused by head injuries and exsanguinating hemorrhage. Eighty-six percent entered the hospital during the hours of minimal staffing that preempted the use of facilities for other emergent patients. Charges totaled $4,828,828 (emergency room, surgical procedures, intensive care, and surgical ward stay) which equated to $5,550 per patient per day. Fifty-eight percent had no third party reimbursement, 22% had Medi-Cal, and 20% had medical insurance. Because of dismal reimbursement rates, the costs of gang violence are passed on to the tax payer. The cost of gang related violence cannot be derived from hospital charges only, because death, disability, and pain are not entered into the calculation. Education, increased social programs, and strict criminal justice laws and enforcement may decrease gang related violence and the drain it has on financial and medical resources.

Adolescent↗
PubMed2004

Effect of selective dorsal rhizotomy on need for orthopedic surgery for spastic quadriplegic cerebral palsy: long-term outcome analysis in relation to age.

OBJECT: The authors performed a long-term evaluation of gait status to determine the frequency with which orthopedic operations for cerebral palsy are conducted before and after selective dorsal rhizotomy (SDR) and the relation between pre- and post-SDR orthopedic surgery and age. METHODS: Fifty-two patients with spastic quadriplegia were prospectively followed for 5 to 9 years. All children were evaluated and underwent SDR at St. Louis Children's Hospital. Preoperative scores for gait function and details of previous orthopedic procedures were recorded for two age groups: those 2 to 5 (Group 1) and those 6 to 14 years of age (Group 2). Data were collected from parents who completed a questionnaire a mean of 7.5 years after SDR. Relations between gait status and the number/type of pre- and post-SDR orthopedic procedures, rate of improvement after SDR, benefit of operation according to parents, and return of spasticity were analyzed. Forty-nine percent of patients in Group 1 and 25% of those in Group 2 had improved gait scores. The interaction between pre- or post-SDR time frame and walking mode was statistically significant (p = 0.004). Among those children who had not undergone orthopedic surgery before SDR, the incidence of surgery post-SDR was higher in the older children (Group 2) than the younger children (Group 1 [70% compared with 34%]). Parents of 75% of the Group 1 patients and 88% of the Group 2 patients felt that their children benefited from SDR. CONCLUSIONS: The results of this study highlight the effect of SDR on gait status in children with spastic quadriplegic cerebral palsy. The percentage of patients needing orthopedic operations was not as high as reported previously. Parents indicated that SDR was beneficial to their children.

Adolescent↗
PubMed1996

[Transfusion strategy in programmed hemorrhagic orthopedic surgery].

OBJECTIVES: Prospectively assess autologous blood transfusion for programmed orthopedic procedures. METHODS: From January 1 to December 31 1993, 307 patients underwent programmed orthopedic procedures: total hip replacement (n = 191), total knee replacement (n = 83) and osteotomy (n = 33). General (94%) or spinal anesthesia (6%) was used. The anesthesist explained transfusion techniques and patients gave informed consent for inclusion in an autologous transfusion protocol including differed autologous transfusion, intentional normovolemic hemodilution and intraoperative transfusion of shed blood. RESULTS: A total of 269 autologous transfusion were performed among the 307 patients (87.6%). This was sufficient in 242 cases (78.8%) and in 65 (21.2%) homologous transfusion was required. Among the 269 patients given autologous transfusion, differed transfusion was used in 145 (53.9%), intentional normovolemic hemodilution in 124 (46%) and intraoperative transfusion of shed blood in 222 (82.5%). Among the patients given a differed autologous transfusion, 9 (6.2%) required a homologous transfusion and among the 40 patients in which all 3 techniques were used, only 2 (5%) received homologous blood, both due to secondary complications. CONCLUSION: These findings show that when differed autologous transfusion is included in the transfusion strategy, less than 10% of the patients require homologous blood. In addition, when the 3 autologous transfusion techniques are used, the rate of homologous blood transfusion approaches zero.

Adolescent↗
PubMed2002

The anesthetic management of a patient with Emery-Dreifuss muscular dystrophy for orthopedic surgery.

PURPOSE: To report a patient with Emery-Dreifuss muscular dystrophy (EDMD) coming for an orthopedic procedure, with potential problems of sudden cardiac death, difficult airway, and neuromuscular disorders who was managed successfully by permanent pacemaker insertion, total iv anesthesia (TIVA), laryngeal mask insertion (LMA) insertion and continuous epidural blockade. CLINICAL FEATURES: A 22-yr-old man with known EDMD presented for triple arthrodesis of his right foot and fractional lengthening of his hamstrings bilaterally. Anesthesia was induced with a TIVA technique, and maintained throughout the operative period. A suspected difficult airway was managed by the use of a LMA, and analgesia for the peri-, and postoperative period provided by a continuous epidural infusion. The patient's perioperative course was uneventful. CONCLUSION: EDMD is a rare disorder. However, anesthesia is often required for orthopedic procedures. This case report illustrates the many potential difficulties that may be encountered. Regional anesthesia combined with light general anesthesia offers a method of avoiding many of these difficulties.

Adult↗
PubMed1991

Ambulatory surgery and prepared discharges. Effects on orthopedic patients and nursing practice.

Orthopedic medical and nursing practice has changed dramatically partly as a result of three trends: cost containment, technology, and consumer activism. Many orthopedic procedures previously requiring inpatient hospital stays are routinely performed on an outpatient, day-surgery basis. it is imperative that nurses working in the ambulatory surgery environment be diligent in practicing the nursing process to ensure comprehensive patient care. Patients requiring hospitalization for orthopedic procedures now have shorter lengths of stay. The brevity of stay means that a great deal of coordination, education, and referral efforts are necessary before the patient's discharge. Prepared discharge programs, with the nurse assuming the coordinator role, are one way of ensuring that patients are ready to make the transition from the hospital to their postdischarge environment.

Ambulatory Surgical Procedures↗
PubMed1995

Blood management in orthopedic surgery.

The orthopedic surgeon has several options available for blood conservation. Preoperative autologous donation (PAD) of blood is a cost-effective measure when the cost of managing transfusion-transmitted infectious disease is considered; overuse and underuse are expensive problems, however. Hemodilution, while used successfully in prostate surgery, is logistically impractical in joint replacement centers. Intraoperative blood salvage, although costly, is useful in orthopedic procedures when the anticipated blood loss is > 1,000 mL. Reinfusion of postoperative drainage that has been filtered and washed is being used in some orthopedic procedures. Studies are under way to determine whether this method of blood conservation alters transfusion requirements. Recombinant human erythropoietin (Epoetin alfa) has a role in elective procedures with significant blood loss, including complex revision joint replacement, bilateral joint arthroplasty, and spinal fusion. Preoperative Epoetin alfa administration enhances preoperative autologous blood collection and increases perioperative red blood cell mass.

Blood Loss, Surgical↗
PubMed2003

A model for clinical estimation of perioperative hemorrhage.

The purpose of this study was to assess the accuracy of estimated blood loss (EBL) as a reliable predictor of actual blood loss during orthopedic procedures. Between 1999 and 2002, 198 orthopedic cases were reviewed. A retrospective review compiled preoperative and postoperative demographic and laboratory data from the surgical patients. Estimated blood loss data was collected from the perioperative and anesthesia reports. Statistical analysis of EBL vs. change in hemoglobin yielded a correlation coefficient of 0.189 and a p value of 0.008. We used multiple linear regression to obtain a model to predict change in hemoglobin based on EBL and the intravenous fluids received. The model is as follows: predicted change in hemoglobin = 1.001 x estimated blood loss (in liters) + 0.441 x intravenous fluids received (in liters) + 2.334. The study population included 198 patients, 126 males and 72 females, who met our inclusion criteria. The mean age was 68.1 years (range: SD 12.5), including 126 males (64%) and 72 females (37%). The mean amount of perioperative intravenous fluids given was 1,732 mL (SD: 773). The mean surgical time was 64.8 minutes (SD: 23.1). The mean preoperative hematocrit and hemoglobin levels were 40.9 g/dL (SD: 4.3) and 13.9 g/dL (SD: 1.6), respectively. The mean postoperative hematocrit and hemoglobin levels were 32.0 g/dL (SD: 6.0) and 10.7 g/dL (SD: 1.6), respectively. The mean difference of preoperative hemoglobin vs. postoperative hemoglobin was 3.3 g/dL (SD 2.1). In this retrospective study, clinical estimation of blood loss was closely correlated with actual change in perioperative hemoglobin. Accurately predicting the postoperative hemoglobin level may prevent many unnecessary blood transfusions and related complications.

Aged↗