There was a consensus within the literature that steroids, intraoperative hypotension, intraoperative cooling, and head elevation postoperatively decrease postoperative edema and ecchymosis, whereas nasal packing and periosteal elevation before osteotomy increased these postoperative morbidities. Studies of herbal supplements may be incorporated into practice with minimal risk to the patient. More studies must be performed before recommending an external or internal approach to lateral osteotomy.
SummaryTarget-controlled infusion systems have been shown to result in the administration of larger doses of propofol, which may result in delayed emergence and recovery from anaesthesia. The aim of this study was to investigate if this was due to a difference in the depth of hypnosis (using the bispectral index monitoring) between the manual and target controlled systems of administration. Fifty unpremedicated patients undergoing elective surgery were randomly allocated to have their anaesthesia maintained with manual or target-controlled propofol infusion schemes. In both groups, the rate of propofol administration was adjusted according to standard clinical criteria while bispectral index scores were recorded by an observer not involved in the delivery of anaesthesia. The total dose of propofol used was higher in the target controlled group (mean 9.9 [standard deviation 1.6] compared with 8.1 [1.0] mg.kg)1 in the manual group [p < 0.0001]). The times to emergence and recovery end-points were comparable between the two groups. The difference in the total dosage of propofol was mainly due to higher rate of propofol administration in the first 30 min in the target controlled infusion group. The bispectral index scores were lower in the target controlled group during this time, being significantly so over the first 15 min of anaesthesia. We conclude that propofol administration by a target controlled infusion system results in the administration of higher doses of propofol and lower bispectral index values mainly in the initial period of anaesthesia.
Changes in blood coagulation are believed to be involved in the aetiology of postoperative thromboembolism. Antithrombin III (AT III) is the most important natural inhibitor of thrombin activation and hence thrombogenesis. This study investigated the nature of a hypercoagulable state in total hip replacement by measurement of AT III in the perioperative period, giving a quantitative assessment of coagulation. Antithrombin III levels fell in all patients after surgery. However, the degree of the fall and the timing of the fall were variable. Eight percent of patients had abnormally low AT III prior to operation, indicating that this proportion of our patients are in a procoagulant state even before surgery. One third of patients had a clinically significant reduction (below 70% of normal) in AT III level after surgery. In this group the fall in AT III was maximal at 2 hours after division of the femoral neck. Careful correction for haemodilution provided new evidence for active consumption of antithrombin III in the perioperative period. By 24 hours after surgery the level of AT III was not significantly different from preoperative levels (p>0.7), even in the group with a clinically important reduction. These findings support only a transient period of hypercoagulability after total hip replacement. The “at-risk” period of venous thrombosis has been shown to be at least several weeks after surgery and the transient nature of the fall in AT III suggests that venous thrombosis is unlikely to be due to hypercoagulability alone.
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