Purpose: To compare unilateral and conventional bilateral bupivacaine spinal block in outpatients undergoing knee arthroscopy.Methods: One hundred healthy, premedicated patients randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 0.5%. A lateral decubitus position after spinal injection was maintained in unilateral group for 15 min. Times from spinal injection to readiness for surgery, block resolution, and home discharge were recorded.Results: Three patients in each group were excluded due to failed block. Readiness for surgery required 13 min (5 -25 min) with bilateral and 16 min (15 -30) with unilateral spinal block (P = 0.0005). Sensory and motor blocks on the operated limb were T 9 (T 12 -T 2 ) with a Bromage score 0/1/2/3: 0/2/0/45 in the unilateral group and T 7 (T 12 -T 1 ) with Bromage score 0/1/2/3: 4/1/6/36 with bilateral block (P = 0.026 and P= 0.016, respectively). Vasopressor was required only in five bilateral patients (P = 0.02). Two segment regression of sensory level and home discharge required 81 ± 25 min and 281 ± 83 min with bilateral block, and 99 ± 28 min and 264 ± 95 min with unilateral block (P = 0.002 and P = 0.90, respectively). Conclusion:Seeking unilateral distribution of spinal anesthesia provided more profound and longer lasting block in the operated limb, less cardiovascular effects, and similar home discharge compared with bilateral spinal anesthesia, with only a slight delay in preparation time.Objectif : Comparer le bloc rachidien unilatéral au bloc bilatéral traditionnel chez des patients ambulatoires qui subissent une arthroscopie du genou.Méthode : Cent patients sains ont reçu une prémédication et, de façon aléatoire, une rachianesthésie bilatérale traditionnelle (n = 50) ou unilatérale (n = 50) avec 8 mg de bupivacaïne hyperbare à 0,5 %. Après l'injection, les patients du groupe unilatéral ont été maintenus en décubitus latéral pendant 15 min. On a enregistré : le temps écoulé entre l'injection et le début de l'opération, le temps nécessaire à la résolution du bloc et le moment de la sortie du service.Résultats : Trois patients ont été exclus dans chaque groupe à cause de l'échec du bloc. Il a fallu 13 min (5 -25 min) de préparation à l'opération avec le bloc bilatéral et 16 min (15 -30) avec le bloc unilatéral (P = 0,0005). Les blocs sensitif et moteur sur le membre opéré ont été de T 9 (T 12 -T 2 ) avec des scores de 0/1/2/3: 0/2/0/45 à l'échelle de Bromage dans le groupe unilatéral et de T 7 (T 12 -T 1 ) et des scores de Bromage de 0/1/2/3: 4/1/6/36 avec le bloc bilatéral (P = 0,026 et P = 0,016, respectivement). Des vasopresseurs ont été nécessaires chez cinq patients seulement du groupe bilatéral (P = 0,02). Le temps nécessaire à la régression de deux segments du bloc sensitif et au congé a été de 81 ± 25 min et de 281 ± 83 min avec le bloc bilatéral, et de 99 ± 28 min et 264 ± 95 min avec le bloc unilatéral (P = 0,002 et P = 0,90, respectivement).Conclusion : La rachianesthésie unilatérale, compar...

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Using a prospective audit, we have evaluated the efficacy of an integrated autotransfusion regimen which comprised predepositing and intra- and postoperative blood salvage in major orthopaedic surgery. We examined prospectively the records of 1785 patients (1198 females, 5867 males, mean age 62 (range 16-90) yr, preoperative haemoglobin concentration 13.4 (SD 1.4) g dl-1) undergoing total hip arthroplasty (THA, 1229 patients), THA after removal of internal fixation devices (RFD + THA, 18 patients), total knee arthroplasty (TKA, 263 patients), revision surgery of the hip (HR cup + stem revision, 197 patients; cup revision, 53 patients; stem revision, 16 patients) and total knee revision (TKR, nine patients). We estimated that the number of predonations (MSBOS = maximum surgery blood order schedule) was 2 u. for THA, TKA and TKR, and 3 u. for partial or total hip revision and total hip arthroplasty with fixation removal. We found that it was possible to obtain the MSBOS in 1597 patients (89.5%). Homologous red blood cell (HRBC) transfusions were carried out in 131 patients (7.3%). We found that the need to use HRBC was significantly associated with failure to meet the number of MSBOS, female sex, lower preoperative haemoglobin concentration, use of calcium heparin for antithrombosis prophylaxis, more extensive surgery, higher ASA rating and co-existing diseases such as coronary artery disease.

This study analyzed the efficacy of venous thromboembolism prophylaxis in knee arthroscopy in 509 patients who received Parnaparin (Alfa Wassermann, Bologna, Italy), 3200 IU to 4250 IU daily, after minor arthroscopic knee surgery. No proximal deep venous thrombosis or other thromboembolic events occurred. Adverse events related to the treatment with Parnaparin were observed in 2 of 172 patients treated with 3200 IU/d and in 6 of 337 patients treated with 4250 IU/d, without any evidence of dose-proportionality in the incidence. Prophylaxis with a low-molecular-weight heparin such as Parnaparin should be considered in all patients who will be undergoing a procedure in which a tourniquet is used. If Parnaparin is used, it should be started immediately after knee arthroscopy at doses of 3200 to 4250 IU/d, according to the characteristics of the patients. Depending on the patient's risk factors, postoperative prophylaxis for 10 days may be appropriate.

The aim of this multicenter, randomized, double-blind study performed in patients undergoing elective hip surgery was to compare the efficacy and safety of prophylaxis with low-molecular-weight heparin (LMWH) (Nadroparin, 7,500 anti-Xa IC units for the first 3 days and 10,000 from the fourth day on, s.c. o.i.d.) begun in one group shortly after surgery and in the other 12 h before operation, as is usually recommended. Preoperative administration (drug or placebo) was the only difference between the two groups. Deep vein thrombosis (DVT) was detected by bilateral venography 10-15 days after surgery. The study investigated 179 patients (55 men), 40-80 years old, in seven Italian orthopedic centers. In 131 patients efficacy analysis was possible because of adequate bilateral venography. All 179 patients were evaluated for bleeding complications. The prevalence of thrombotic complications was similar in the two groups. Proximal DVT was found in 8.4% of patients (10.8% and 6.1% in the preop and postop groups, respectively ; difference not statistically significant). Distal DVT was recorded in 30.5% of patients (30.8% and 30.3% in the pre-and postop groups, respectively). DVTs were more common in patients ≥65 years old (54.2% versus 28.4%, p < 0.05); no significant differences were detected in terms of other characteristics. No significant differences were recorded in the number or type of bleeding complications: major (nonfatal) bleeding episodes were reported in five patients (2.8%, two and three in the preand postop groups); minor bleeding was noted in 25 (13.9%, 14 and 11 in the pre-and postop groups). In conclusion, the present study suggests that a LMWH regimen started postoperatively is no less effective in preventing DVT in elective hip replacement than the classical regimen started preoperatively. Surprisingly, postoperative commencement offered no significant advantage in terms of bleeding complications.

The aim of this study was to describe a system of salvaging and reinfusing chyle which accumulated in the right pleural cavity of a patient after a thoracic duct lesion caused by a closed chest injury associated with amyelic fracture of the dorsal spine D10-D11. The chyle was collected in a reservoir (BT 844 Dideco), transferred by an electronic pump (BT 797 recovery Dideco) to a storage bag, microfiltered and then reinfused to the patient A solution was needed to prevent the patient with severe chylothorax, from having immunological and metabolic imbalance. The long period of conservative treatment with our system was imposed by the onset of acute post-traumatic myocardic infarction which delayed surgery. From experience gained, we can say that using total parenteral nutrition, chyle can not only be salvaged but also reinfused, respecting the strict rules of hygiene.

It has been suggested that the benefits of transfusion are currently greatly overrated, with physicians reflexively administering blood in the nearly unchallenged view that failure to transfuse would have dire consequences. As a matter of fact, the tolerability and safety of normovolemic anemia have been well documented for many years in several anesthesiologic settings. Objective: To assess the impact of normovolemic hemodilution on blood bank resources and in-hospital mortality in major elective orthopedic surgery. Methods: The authors therefore retrospectively analyzed in-hospital mortality of patients submitted to elective surgery for total hip replacement in the Rizzoli Institute since 1979. From 1979 to 1983, 1488 patients underwent a standard treatment (without normovolemic hemodilution), whereas 4653 patients submitted to surgery from 1984 to 1993 underwent normovolemic hemodilution-up to extreme accepted values of hemoglobin > 6 g/dL. Results: Homologous blood transfusion was required in 1220/1488 patients of Group I and in 977/4653 patients of Group II (82% vs 21%, P < .001). The number of blood units required for each transfused patient was 2.8 in the 1220 transfused patients of Group I, and 2.1 in the 977 transfused patients of Group II (P < .001). There were 6 deaths in Group I and 7 deaths in Group II (0.4% vs 0.15%, P < .05). The overall incidence of fatal pulmonary thromboembolism was 4/1488 in Group I and 1/4653 in Group 11 (0.27% vs 0.02%, P < .001). Conclusions: Normovolemic hemodilution was extremely well tolerated in patients undergoing major elective orthopedic surgery and allowed substantial sparing of blood bank resources. It had no detectable unfavorable effect on surgical outcome, but rather it was associated with a dramatic decrease in perioperative mortality of patients under-going total hip replacement, owing to a thirteen-fold reduction in fatal pulmonary thromboembolism.

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