IntroductionTotal hip replacement is one of the most commonly performed major orthopaedic operations. Goal-directed therapy (GDT) using haemodynamic monitoring has previously demonstrated outcome benefits in high-risk surgical patients under general anaesthesia. GDT has never been formally assessed during regional anaesthesia.MethodsPatients undergoing total hip replacement while under regional anaesthesia were randomised to either the control group (CTRL) or the protocol group (GDT). Patients in the GDT group, in addition to standard monitoring, were connected to the FloTrac sensor/Vigileo monitor haemodynamic monitoring system, and a GDT protocol was used to maximise the stroke volume and target the oxygen delivery index to > 600 mL/minute/m2.ResultsPatients randomised to the GDT group were given a greater volume of intravenous fluids during the intraoperative period (means ± standard deviation (SD): 6,032 ± 1,388 mL vs. 2,635 ± 346 mL; P < 0.0001), and more of the GDT patients received dobutamine (0 of 20 CTRL patients vs. 11 of 20 GDT patients; P < 0.0003). The GDT patients also received more blood transfused during the intraoperative period (means ± SD: 595 ± 316 mL vs. 0 ± 0 mL; P < 0.0001), although the CTRL group received greater volumes of blood replacement postoperatively (CTRL patients 658 ± 68 mL vs. GDT patients 198 ± 292 mL; P < 0.001). Overall blood consumption (intraoperatively and postoperatively) was not different between the two groups. There were an increased number of complications in the CTRL group (20 of 20 CTRL patients (100%) vs. 16 of 20 GDT patients (80%); P = 0.05). These outcomes were predominantly due to a difference in minor complications (20 of 20 CTRL patients (100%) vs. 15 of 20 GDT patients (75%); P = 0.047).ConclusionsGDT applied during regional anaesthesia in patients undergoing elective total hip replacement changes intraoperative fluid management and may improve patient outcomes by decreasing postoperative complications. Larger trials are required to confirm our findings.Trial registrationSRCTN11616985

BackgroundThe aim of this study was to evaluate pre- and post-operative brain natriuretic peptide (BNP) levels and compare the power of this test in predicting in-hospital major adverse cardiac events (MACE: atrial fibrillation, flutter, acute heart failure or non-fatal/fatal myocardial infarction) in patients undergoing elective prosthesis orthopedic surgery to that of the Revised Cardiac Risk Index (RCRI) and American Society of Anesthesiology (ASA) class, the most useful scores identified to date.MethodsThe study was an observational study of consecutive patients undergoing elective prosthesis orthopedic surgery. Surgical risk was established using RCRI score and ASA class criteria. Venous blood was sampled before surgery and on postoperative day 1 for the measurement of BNP. The intraoperative data collected included details of the surgery and anesthesia and any MACE experienced up until hospital discharge.ResultsMACE occurred in 14 of the 227 patients treated (6.2%). Age was statistical associated with MACE (p < 0.004). Preoperative BNP levels were higher (p < 0.0007) in patients who experienced MACE than in event-free patients (median values: 92 and 35 pg/mL, respectively). Postoperative BNP levels were also greater (p < 0.0001) in patients sustaining MACE than in event-free patients (median values: 165 and 45 pg/mL, respectively). ROC curve analysis demonstrated that for a cut-off point ≥ 39 pg/mL, the area under the curve for preoperative BNP was equal to 0.77, while a postoperative BNP cut-off point ≥ 69 pg/mL gave an AUC of 0.82.ConclusionsBoth pre- and post-operative BNP concentrations are predictors of MACE in patients undergoing elective prosthesis orthopedic surgery.

Objective: To investigate the prevalence and risk factors associated with chronic pain and other symptoms related to breast cancer 6 months after surgery. Methods: In an observational study of 261 female breast cancer survivors treated between January 2017 and January 2018, patients were asked about their pain symptoms using a questionnaire that utilized the Numeric Rating Score (NRS) and the Douleur Neuropathique Score (DN4) for neuropathic pain; it also addressed phantom sensations and functional disorders on the ipsilateral shoulder. A total of 218 women completed the survey. Results: A total of 105 patients (48.17%) reported chronic pain. Of these, 64% rated the pain with an NRS of 1–3 and 35% with an NRS >3. Neuropathic pain was reported in 65% of the sample, phantom sensations in 12%, disorders of shoulder function in 16%, and web syndrome in 2%. Multivariable analyses showed that chronic pain (odds ratio [OR], 2.55; 95% confidence interval [CI], 1.094–5.942; p < 0.05) and neuropathic pain (OR, 2.988; 95% CI, 1.366–6.537; p < 0.05) were positively associated with surgical adverse events; phantom sensations were statistically associated with the weight of removed breast tissue (OR, 1.003; 95% CI, 1.001–1.005; p < 0.05). Conclusions: Our study highlights the need to employ specific tools capable of detecting different kinds of chronic pain after breast cancer surgery to improve pain prevention and treatment. Surgical complications and the weight of removed breast tissue emerged as 2 of the risk factors for chronic and neuropathic pain development in breast cancer survivors.

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