الفهرس | Only 14 pages are availabe for public view |
Abstract Total knee arthroplasty (TKA) was and continues to be a major advancement in the treatment of chronic refractory joint pain. Currently, TKA is a safe and highly effective procedure to improve mobility and patient quality of life for those suffering from end-stage osteoarthritis, surgical and anesthetic techniques for TKAs have progressed over time. Regional anesthesia has been shown to have several advantages over general anesthesia as decrease pain, nausea and vomiting, and time to discharge, as well as reducing cardiovascular and pulmonary complications. Epidural anesthesia is a technique for perioperative pain management with multiple applications in anesthesiology. It is useful as a primary anesthetic, but most commonly it is used as pain management adjuvant. It can be a single shot or a continuous infusion for long term pain relief. The dural puncture epidural (DPE) technique is a modification of the combined spinal epidural (CSE) technique, where a dural perforation is created from a spinal needle but intrathecal medication administration is withheld. The DPE technique has been shown to improve caudal spread of analgesia. This study aimed to evaluate the efficacy of dural puncture epidural technique versus epidural technique as an anesthetic method in patients undergoing total knee arthroplasty.This randomized single blinded study was carried out in Tanta University Hospital at orthopedic surgery department, seventy patients aged more than 45 years of both sex, ASA physical activity I, II and III were enrolled in this study. Patients were randomly classified into two equal groups; 35 patients were enrolled in each group using closed sealed, opaque, sequentially numbered envelopes. ❖ group I: Epidural anesthesia (EP) (n=35) Patients of this group received 15 mL mixture of (0.25% plain bupivacaine and 50 μg fentanyl) over 5 minutes, injected in the epidural space by epidural catheter at L3-L4 interspace; there is no dural puncture in this group. ❖ group II: Dural puncture epidural Anesthesia (DPE) (n=35) Patients of this group received 15 mL mixture of (0.25% plain bupivacaine and 50 μg fentanyl) over 5 minutes, injected in the epidural space by epidural catheter at L3-L4 interspace, a dural puncture is created by the spinal needle of combined spinal epidural kit before insertion of epidural catheter (needle-through-needle technique) but intrathecal medication administration is withheld. Anesthesiologist who was blinded about the study groups recorded the following data: 1) Demographic data (age, gender, BMI, Duration of surgery). 2) Hemodynamic Parameters (HR, MABP) was monitored at the following time points: baseline before performance of the techniques, 5,10,15 min after end of injection of the drug, thenevery 15 min for one hour then every 30 min till the end of the surgery 3) Time till Sensory block occur (onset of anesthesia): Assessment of the onset by test sensory loss at T10 by pin prick using sterile needle with blunt edge ( was defined as time from end of injection of bolus dose to 1st sign of sensory block at T10). Sensory loss assessed at 2 min then every 3 min after end of injection of bolus dose of the drug till 30 min then every 15 min till the end of the surgery 4) Time of onset of motor block (time from end of drug injection to time of achieving BMBS grade 1) in the lower extremities was assessed by using a Breen Modified Bromage scale which was assessed at 2 min then every 3 min after injection of the drug till 30 min then every 15 min till the end of the surgery 5) Duration which was defined as time from administration of the drug to time of regression of sensory level and demand of first top-up dose 6) Number of top-up doses for 24 hours postoperative:. - Top-up dose was given postoperative when VAS >3; VAS will be measured after the end of surgery at PACU every 2hours for the first 24 hours.7) Averse events as bradycardia, hypotension, urine retention, PDPH, backache local anesthetic systemic toxicity (LAST) and failed blockade). Our results demonstrated insignificant difference between epidural technique and dural puncture epidural technique regarding patient ar surgical characteristics. Also, changes in mean value of heart rate and mean arterial blood pressure were comparable between the two techniques. Moreover, onset of sensory loss and motor block were faster in patients who received dural puncture epidural technique when compared to traditional epidural technique. In addition, no major complication or side effects were encountered with either epidural or dural puncture epidural technique, Also, the incidence of complication as as bradycardia, hypotension, urine retention, PDPH, backache local anesthetic systemic toxicity (LAST) and failed blockade) were comparable. |