Mehmet İlke Büget

Hip fractures in patients older than 75 years old: Retrospective analysis for prognostic factors

BACKGROUND Proximal femoral fractures are often seen in older patients and are associated with high mortality. Introduction to old age population is latening due to advancements in medical sciences and increasing life expectancy. OBJECTIVES The aim of the study was to evaluate factors affecting mortality in patients above 75 years of age who had been operated because of proximal femur fractures. PATIENTS AND METHODS Patients with age 75 and over who suffers from post-fall proximal femoral fracture who underwent surgery with one of following three methods (hemiarthroplasty, proximal femoral nail or total hip arthroplasty) were evaluated retrospectively. Effects on mortality were examined for factors such as type of surgery, type of anesthesia, preoperative ASA score (American Society of Anesthesiologists Score), need for intensive care, need for blood transfusion, operation waiting time and hospitalization duration. 115 patients who met inclusion criterion were included in the study out of 224 overall. 75 patients were women and 40 were males. RESULTS Mortality rate after first year was found to be 40%. Patients over 85 years old had higher rates of mortality (p = 0,0003) than respectively younger patients (75-85). Sex was found to have no impact on mortality (p = 0.5039). There was no statistically significant difference in terms ASA score (p = 0.1518). Order of applied surgical methods with mortality risk rates was found to be total hip arthroplasty > hemiarthroplasty > proximal femoral nail (p = 0.0003). Type of anesthesia, the use of cement during arthroplasty, operation waiting time and hospitalization duration was not directly related with mortality rate (type of anesthesia p = 0.63, the use of cement during arthroplasty p = 0.223, operation waiting time p = 0.5 and hospitalization duration p = 0.19). CONCLUSIONS Age is the primary risk factor on first year mortality in patients older than 75 years old with hip fractures. Addition to older age, more need to blood transfusions, and arthroplasty are other risk factors for first year mortality. It should be kept in mind that after 75 years old first year mortality may be higher if the patient is treated with arthroplasty.

The efficacy of cell saver method in the surgical treatment of adolescent idiopathic scoliosis.

OBJECTIVE The aim of the study was to evaluate the efficacy of the intraoperative blood salvage cell saver method for allogeneic blood transfusion in the surgical treatment of adolescent idiopathic scoliosis with pedicle screw and rod combination. METHODS The study included 33 patients (5 males and 28 females) who underwent surgery due to adolescent idiopathic scoliosis. Patients were divided into 2 groups; 16 patients (mean age: 17.1±3.9 years) in Group A were operated using the cell saver (Medtronic Autolog; autologous cell saver machine) method and the 17 patients (mean age 18.7±6.8 years) in Group B (control group) were treated without cell saver. The Cobb angle, levels of pedicle fixation, operation time, postoperative bleeding, hemoglobin change, allogeneic blood replacement and the amount of autologous erythrocytes were recorded. RESULTS Mean level of pedicle fixation was 12.9±1.54 vertebra using a mean of 21.1±3.21 screws in Group A and 12.8±1.47 vertebra using 18.7±3.59 screws in Group B (p>005). The mean operation time was 224 (Group A: 228±58; Group B: 221±60) minutes. There were no statistically significant differences in the demographic characteristics of both groups (p>0.05). The preoperative mean hemoglobin levels were 12.2±1.47 mg/dl in Group A and 13.1±1.56 mg/dl in Group B. Postoperative mean hemoglobin level was 11.3±1.62 mg/dl in Group A and 9.86±0.93 mg/dl in Group B (p=0.004). The mean amount of autologous erythrocyte replacement was 284±139 ml. The mean postoperative bleeding was 834±253 ml in Group A and 759±380 ml in Group B (p>0.05). The mean allogeneic blood replacement was 1.88±0.88 units in Group A and 1.94±1.34 in Group B (p>0.05). CONCLUSION Autologous erythrocyte replacement was possible using the cell saver method. However, there was no decrement in allogeneic blood replacement using cell saver in the surgical treatment of adolescent idiopathic scoliosis.

Efficacy of preoperative administration of single high dose intravenous tranexamic acid in reducing blood loss in total knee arthroplasty: A prospective clinical study

Objective The aim of this study was to analyse the effectiveness of single dose of 20 mg/kg intravenous tranexamic acid (TXA), in reducing the blood loss in patients undergoing total knee arthroplasty (TKA). Material and method 70 patients (65.5 ± 8.1 years old) that have undergone TKA were divided in two groups. The 20 mg/kg IV TXA was given before the skin incision to one group (study group). On the control group, TKA was performed without TXA. The demographic data, body mass index, amount of bleeding and erythrocyte infusion during the operation, hemoglobin and hematocrit values (preoperative and 48th hour), the amount of drainage after the operation were compared between the groups. Results The total amount of bleeding in the study group was 634.03 ± 182.88 ml and 1166.42 ± 295.92 ml in the control group (p < 0.001). Perioperative bleeding was 252.01 ± 144.13 ml in the study group and 431.33 ± 209.10 ml in the control group (p = 0.018). The drainage after the operation was 311.11 ± 141.64 ml at the 24th hour in the study group, 640.74 ± 279.43 ml at the 24th hour in the control group (p < 0.001). The drainage after 24th hour was 97.96 ± 115.86 ml in the study group and 112.96 ± 64.43 ml in the control group (p = 0.584). Conclusion A high, single dose of TXA intravenously given to the patient prior to the TKA significantly reduces the bleeding during the operation and within the postoperative 24 h. There is no significant change in the bleeding amount after the 24th hour following the operation.

Two-year experience with cell salvage in total hip arthroplasty

BACKGROUND AND OBJECTIVE The aim of this study was to determine the efficacy of the cell salvage system in total hip arthroplasty surgeries and whether the cell salvage system can reduce the allogeneic blood transfusion requirement in total hip arthroplasty patients. METHODS We reviewed retrospectively the medical records of patients who underwent hip arthroplasty surgeries between 2010 and 2012 in a university hospital. A total of 181 arthroplasty patients were enrolled in our study. RESULTS In the cell salvage group, the mean perioperative rate of allogeneic blood transfusion was significantly lower (92.53±111.88mL) than that in the control group (170.14±116.79mL; p<0.001). When the mean postoperative transfusion rates were compared, the cell salvage group had lower values (125.37±193.33mL) than the control group (152.22±208.37mL), although the difference was not statistically significant. The number of patients receiving allogeneic blood transfusion in the CS group (n=29; 43.2%) was also significantly lower than control group (n=56; 73.6%; p<0.05). In the logistic regression analysis, perioperative amount of transfusion, odds ratio (OR) -4.257 (95% CI -0.502 to 0.184) and operation time, OR: 2.720 (95% CI 0.001-0.004) were independent risk factors for the usage of cell salvage system. CONCLUSION Cell salvage is an effective strategy for reducing the need for allogeneic blood transfusion in the perioperative setting; it provides support to patient blood management interventions. Thus, we recommend the cell salvage system for use in total hip arthroplasty surgeries to reduce the need for allogeneic blood transfusion, if possible.

Perioperative dexketoprofen or lornoxicam administration for pain management after major orthopedic surgery: a randomized, controlled study.

OBJECTIVE Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended for multimodal postoperative pain management. The purpose of this study was to evaluate the postoperative pain relief and opioid-sparing effects of dexketoprofen and lornoxicam after major orthopedic surgery. METHODS After obtaining ethical committee approval and informed consent, 120 patients undergoing elective hip or knee replacement under general anesthesia were randomized to receive two intravenous injections of 50 mg dexketoprofen (GD), 8 mg lornoxicam (GL) or saline as placebo (GP) intravenously. Postoperatively, patient-controlled analgesia (PCA) morphine was started as a 0.01 mg.kg-1 bolus dose, with lockout time of 10 minutes without continuous infusion. Pain assessment was made using the Visual Analogue Scale (VAS) at rest or during movement at postoperative 1, 2, 4, 6, 8, 12, and 24 hours. RESULTS The three groups were similar in terms of age, gender, American Society of Anesthesiologists (ASA) class, number of patients who underwent hip or knee surgery, weight, height, and operation duration. Patients in GD and GL demonstrated significantly reduced pain scores at rest and active motion compared to GP, with lower scores in the dexketoprofen group. Patients in GD and GL used significantly less morphine in the postoperative period compared to GP. The total morphine consumption of patients in GD was lower than in GL. CONCLUSION Intravenous application of 50 mg dexketoprofen twice a day and 8 mg lornoxicam twice a day improved analgesia and decreased morphine consumption following major orthopedic surgery. When the two active drugs were compared, it was found that dexketoprofen was superior to lornoxicam in terms of analgesic efficacy and opioid consumption.

Dois anos de experiência com recuperação intraoperatória de sangue em artroplastia total do quadril

BACKGROUND AND OBJECTIVE The aim of this study was to determine the efficacy of the cell salvage system in total hip arthroplasty surgeries and whether the cell salvage system can reduce the allogeneic blood transfusion requirement in total hip arthroplasty patients. METHODS We reviewed retrospectively the medical records of patients who underwent hip arthroplasty surgeries between 2010 and 2012 in a university hospital. A total of 181 arthroplasty patients were enrolled in our study. RESULTS In the cell salvage group, the mean perioperative rate of allogeneic blood transfusion was significantly lower (92.53±111.88mL) than that in the control group (170.14±116.79mL; p<0.001). When the mean postoperative transfusion rates were compared, the cell salvage group had lower values (125.37±193.33mL) than the control group (152.22±208.37mL), although the difference was not statistically significant. The number of patients receiving allogeneic blood transfusion in the CS group (n=29; 43.2%) was also significantly lower than control group (n=56; 73.6%; p<0.05). In the logistic regression analysis, perioperative amount of transfusion, odds ratio (OR) -4.257 (95% CI -0.502 to 0.184) and operation time, OR: 2.720 (95% CI 0.001-0.004) were independent risk factors for the usage of cell salvage system. CONCLUSION Cell salvage is an effective strategy for reducing the need for allogeneic blood transfusion in the perioperative setting; it provides support to patient blood management interventions. Thus, we recommend the cell salvage system for use in total hip arthroplasty surgeries to reduce the need for allogeneic blood transfusion, if possible.

Anesthetic Approach for a Patient with Jeune Syndrome.

Jeune syndrome (JS) is an autosomal recessive disease also known as asphyxiating thoracic dystrophy. A narrow bell-shaped thoracic wall and short extremities are the most typical features of the syndrome. Prognosis in JS depends on the severity of the pulmonary hypoplasia caused by the chest wall deformity. Most patient deaths are due to respiratory problems at early ages. Herein, we report a case of JS patient, who was scheduled for femoral extension under general anesthesia. The severity of respiratory problems in JS patients is thought to diminish with age. Our case supported this theory, and we managed the anesthetic process uneventfully.

Regional anaesthesia in a Duchenne muscular dystrophy patient for upper extremity amputation.

Duchenne muscular dystrophy (DMD) is the most common of the neuromuscular disorders. DMD is usually a challenge for the anaesthesiologist, with poor cardiac function, a high risk of developing rhabdomyolysis, and the probable life-threatening complications of general anaesthesia. To avoid possible morbidity associated with general anaesthesia, we applied a supraclavicular blockade. In this report, we present a 17-year-old DMD patient with a massive rhabdomyosarcoma, for whom a left arm amputation was indicated. In the post-operative period, a malignant hyperthermia-like reaction occurred, which resolved in a short time. We suggest a regional blockade as a safer alternative to general anaesthesia for the management of high risk DMD patients during orthopedic procedures.

Analgesia for Arthroscopic Shoulder Surgery: A Comparison of Interscalene and Subacromial Levobupivacaine with IV Morphine Patient Controlled Analgesia

Backgorund and Aim : Arthroscopic shoulder surgery (ASS) may result in severe postoperative pain. We compared a continuous subacromial infusion of levobupivacaine after single shot interscalene block (ISB), a continuous ISB with levobupivacaine and intravenous morphine PCA with preoperative ISB for patients undergoing arthroscopic shoulder surgery. Methods : After obtaining ethics committee approval and informed consent 120 patients were randomized to three groups, Group 1 (G1) ISB with 0.5% levobupivacaine (l-bupi) (30 mL) followed by a postoperative subacromial infusion: 0.125% l-bupi 5 mL/h basal infusion, 5mL bolus dose and a 20 min lockout time or; Group 2 (G2) ISB with 0.5% l-bupi (30 mL) followed by a postoperative interscalene infusion: 0.125% l-bupi 5 mL/h basal infusion, 5mL bolus dose and a 20 min lockout time; or Group 3 (G3) ISB with 0.5% l-bupi (30 mL) followed by a postoperative morphine PCA 0.3 mg/h basal infusion, 1mg bolus dose and a 20 min lockout time. Infusions were maintained for 24 hours. Results : The median VAS scores in the postanesthesia care unit and at 4 h were not different. The median VAS scores at 8, 12, and 24 hours were ≤ 4 in all groups; but they were significantly lower in G2. There were no differences in VAS values of G1 and G3 patients. Additional analgesic requirements were lower in G2 (60% vs 7.5% vs 50% respectively for G1, G2 and G3). Nausea and vomiting were more common in G3. Patients’ satisfaction scores of groups were 8 ± 0.7 in G1, 9 ± 0.8 in G2 and 7.1 ± 0.9 in G3 (G1 vs G3, p< 0,001). Conclusions : Subacromial infusion provided good postoperative analgesia for ASS, but it’s less effective than ISB, but is superior to intravenous PCA because it causes less nausea and vomiting with higher patient satisfactions. Subacromial infusions can be considered as an alternative for postoperative pain treatment after ASS when ISB is contrainticated.

Pulse Pressure Variation and Weight-Loss Percentage Predict Hypotension After Anesthesia Induction in Neurosurgery Patients: A Prospective, Observational, Blinded Study.

Background: Hypotension after anesthesia induction is a common problem and is partly related to patient volume status. The present study aimed to investigate the correlation between blood pressure change and pulse pressure variation (PPV), and percentage of weight loss while determining threshold for hypotension by receiver operating characteristic analysis. Methods: We analyzed 231 neurosurgery patients. In all patients, propofol was used for standard anesthesia induction. Patient demographics, medical histories, fasting duration, percentage weight loss, baseline blood pressure, and PPV during normal tidal volume breathing and that during forced inspiratory breathing (PPVfi) were recorded. Hemodynamic changes within 10 minutes of intubation were observed. Patients developing hypotension and severe hypotension were determined; lowest mean arterial pressure (MAP) and systolic arterial pressure (SAP) values were recorded, and their differences relative to baseline values were calculated. Results: The incidence of hypotension was 18.6%. Both percentage weight loss and PPVfi were correlated with the changes in MAP and SAP. A PPVfi>14 identified all observed hypotensive episodes with 86% sensitivity and 86.2% specificity, whereas percentage weight loss >1.75% identified all observed hypotensive episodes with 81.4% sensitivity and 70.7% specificity. Furthermore, PPVfi>16.5 identified severe hypotension with 85% sensitivity and 90.5% specificity, whereas percentage weight loss >1.95% identified severe hypotension with 85% sensitivity and 73% specificity. Conclusions: Percentage weight loss and PPVfi are good predictors of hypotension after anesthesia induction and, thus, may allow anesthesiologists to adopt preventative measures and ensure safer anesthesia induction.