Randomised controlled study comparing general and spinal anaesthesia with and without a tourniquet on the outcomes of total knee arthroplasty: study protocol

Rantasalo, Mikko; Palanne, Riku; Juutilainen, Katarina; Kairaluoma, P.; Linko, Rita; Reponen, Elina; Helkamaa, Teemu; Vakkuri, Anne; Olkkola, Klaus T.; Madanat, Rami; Skants, Noora

doi:10.1136/bmjopen-2018-025546

Cited by 13 publications

(49 citation statements)

References 60 publications

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“…A study on 151 fast-track TKA verified the effectiveness of a tourniquet on post-operative bleeding and rehabilitation together with suction drainage application.Suction drain was associated to lower Hb levels, higher transfusion rate, higher pain and slower functional recovery, while short-term tourniquet did not influence postoperative bleeding and rehabilitation program [92]. (*)However, a protocol for another RCT aims to verify the effectiveness of a tourniquet on patient’s recovery after fast-track TKA, in association to the anaesthetic regimen.Primary outcome is cumulative intravenous oxycodone consumption by patient-controlled analgesia during the first 24 postoperative hours.Secondary outcomes include postoperative nausea and vomiting, the length of hospital stay, the duration of the surgery, blood loss, demand for surgical unit resources, complications, readmissions, postoperative knee function, range of motion, health-related quality of life, prolonged pain, and mortality [93]. AnesthesiaIn order to provide guidelines for fast-track TKA, it was conducted a survey on anaesthetic techniques [94].…”

Section: Resultsmentioning

confidence: 99%

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Blood management in fast-track orthopedic surgery: an evidence-based narrative review

et al. 2019

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Background and purpose: Innovations able to maintain patient safety while reducing the amount of transfusion add value to orthopedic procedures. Opportunities for improvement arise especially in elective procedures, as long as room for planning is available. Although many strategies have been proposed, there is no consensus about the most successful combination. The purpose of this investigation is to identify information to support blood management strategies in fast-track total joint arthroplasty (TJA) pathway, to (i) support clinical decision making according to current evidence and best practices, and (ii) identify critical issues which need further research. Methods and materials: We identified conventional blood management strategies in elective orthopedic procedures. We performed an electronic search about blood management strategies in fast-track TJA. We designed tables to match every step of the former with the latter. We submitted the findings to clinicians who operate using fast-track surgery protocols in TJA at our research hospital. Results: Preoperative anemia detection and treatment, blood anticoagulants/aggregants consumption, transfusion trigger, anesthetic technique, local infiltration analgesia, drainage clamping and removals, and postoperative multimodal thromboprophylaxis are the factors which can add best value to a fast-track pathway, since they provide significant room for planning and prediction. Conclusion: The difference between conventional and fast-track pathways does not lie in the contents of blood management, which are related to surgeons/surgeries, materials used and patients, but in the way these contents are integrated into each other, since elective orthopedic procedures offer significant room for planning. Further studies are needed to identify optimal regimens.

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Section: Resultsmentioning

confidence: 99%

“…Secondary outcomes include postoperative nausea and vomiting, the length of hospital stay, the duration of the surgery, blood loss, demand for surgical unit resources, complications, readmissions, postoperative knee function, range of motion, health-related quality of life, prolonged pain, and mortality [93].…”

Section: Resultsmentioning

confidence: 99%

Blood management in fast-track orthopedic surgery: an evidence-based narrative review

et al. 2019

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“…A small amount of analgesic could be delivered by the patients pressing the button when they most need it. Usually, opioids are used in PCA, such as oxycodone, morphine, fentanyl, and hydromorphone. Therefore, PCA is associated with some adverse effects caused by opioids, including nausea, vomiting, respiratory depression, and urinary retention.…”

Section: Postoperative Analgesic Regimensmentioning

confidence: 99%

Postoperative Pain Management in Total Knee Arthroplasty

Xiao

2019

Orthopaedic Surgery

243

165

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Total knee arthroplasty (TKA) is one of the most common surgeries performed to relieve joint pain in patients with end‐stage osteoarthritis or rheumatic arthritis of the knee. However, TKA is followed by moderate to severe postoperative pain that affects postoperative rehabilitation, patient satisfaction, and overall outcomes. Historically, opioids have been widely used for perioperative pain management of TKA. However, opioids are associated with undesirable adverse effects, such as nausea, respiratory depression, and retention of urine, which limit their application in daily clinical practice. The aim of this review was to discuss the current postoperative pain management regimens for TKA. Our review of the literature demonstrated that multimodal analgesia is considered the optimal regimen for perioperative pain management of TKA and improves clinical outcomes and patient satisfaction, through a combination of several types of medications and delivery routes, including preemptive analgesia, neuraxial anesthesia, peripheral nerve blockade, patient‐controlled analgesia and local infiltration analgesia, and oral opioid/nonopioid medications. Multimodal analgesia provides superior pain relief, promotes recovery of the knee, and reduces opioid consumption and related adverse effects in patients undergoing TKA.

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“…We excluded patients who were unable to understand written study information in Finnish or Swedish, and patients who were cognitively impaired, under guardianship, or pregnant. 29…”

Section: Participantsmentioning

confidence: 99%

“…Subjects were medicated, anaesthetised, operated on, monitored, cared for, and discharged according to a standardised protocol previously described in detail. 29 Spinal anaesthesia was induced with 15 mg isobaric bupivacaine (Bicain spinal 5 mg ml À1 ; Orion, Espoo, Finland), and patients were lightly sedated with propofol infusion (maximum of 4 mg kg À1 h À1 ). General anaesthesia was managed with target-controlled infusions of propofol (Schnider formula, effect site target 4 mg ml À1 adjusted to 3e8 mg ml À1 to achieve GE Entropy level of 30e50; GE Healthcare Finland Oy, Helsinki, Finland) and remifentanil (Minto formula, effect site target 1 ng ml À1 , adjusted to 1e8 ng ml À1 according to heart rate and blood pressure).…”

Section: Perioperative Carementioning

confidence: 99%

Effects of anaesthesia method and tourniquet use on recovery following total knee arthroplasty: a randomised controlled study

Palanne

Rantasalo

Vakkuri

et al. 2020

British Journal of Anaesthesia

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Background: We investigated the effects of spinal and general anaesthesia and surgical tourniquet on acute pain and early recovery after total knee arthroplasty (TKA). Methods: Patients (n¼413) were randomised to four parallel groups: spinal anaesthesia with or without tourniquet, and general anaesthesia with or without tourniquet. The primary outcome was patient-controlled i.v. oxycodone consumption over 24 postoperative hours. Results: Results from 395 subjects were analysed. Median i.v. oxycodone consumption did not differ between the four groups (spinal anaesthesia without [36.6 mg] and with tourniquet [38.0 mg], general anaesthesia without [42.3 mg] and with tourniquet [42.5 mg], P¼0.42), between spinal (37.7 mg) and general anaesthesia (42.5 mg) groups (median difference e3.1, 95% confidence interval [CI] e7.4 to 1.2, P¼0.15) and between tourniquet and no-tourniquet groups (40.0 vs 40.0 mg, median difference e0.8, CI e5.1 to 3.5, P¼0.72). Vomiting incidence was higher with spinal than with general anaesthesia (21% [42/200] vs 13% [25/194], CI 1.05 to 3.1, P¼0.034). The mean haemoglobin decrease was greater without than with tourniquet (e3.0 vs e2.5 g dl À1 , mean difference e0.48, CI e0.65 to e0.32, P<0.001). No differences were observed in pain, pain management, incidences of blood transfusions, in-hospital complications, or length of hospital stay. Conclusions: For TKA, spinal and general anaesthesia with or without tourniquet did not differ in 24-h postoperative opioid consumption, pain management, blood transfusions, in-hospital complications, and length of hospital stay. Vomiting incidence was higher in the spinal than in the general anaesthesia group. Tourniquet use caused smaller decreases in haemoglobin levels. Clinical trial registration: EudraCT 2016-002035-15.

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Randomised controlled study comparing general and spinal anaesthesia with and without a tourniquet on the outcomes of total knee arthroplasty: study protocol

Cited by 13 publications

References 60 publications

Blood management in fast-track orthopedic surgery: an evidence-based narrative review

Blood management in fast-track orthopedic surgery: an evidence-based narrative review

Postoperative Pain Management in Total Knee Arthroplasty

Effects of anaesthesia method and tourniquet use on recovery following total knee arthroplasty: a randomised controlled study

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