Effects of Intrathecal Morphine Administration in Patients Undergoing Primary Total Hip Arthroplasty Under Spinal Anesthesia With Quadratus Lumborum Block for Postoperative Analgesia

Introduction Quadratus lumborum (QL) block has previously been shown to provide improved analgesia in patients undergoing primary total hip arthroplasty (THA) under spinal anesthesia when compared to spinal anesthesia alone. Additionally, recent studies have shown the addition of intrathecal morphine (ITM) to provide superior postoperative analgesia in patients undergoing various surgical interventions including total knee arthroplasty under spinal anesthesia with peripheral nerve blockade. At this time, however, there has not been a study evaluating the effects of intrathecal morphine in patients undergoing THA under spinal anesthesia with QL block. This study aims to assess if the addition of intrathecal morphine can provide adequate or even superior postoperative analgesia in patients undergoing primary THA. Methods This retrospective study included 26 patients in the spinal/QL block/intrathecal morphine (SA+QLB+ITM) group, 31 patients in the spinal/QL block group (SA+QLB), and 28 patients in the spinal only (SA or control) group. Twenty-six patients undergoing primary THA under a combination of spinal anesthesia and peripheral nerve blockade (quadratus lumborum block) were given a dose of 100 mcg of intrathecal morphine. Various parameters were evaluated including Post-Anesthesia Care Unit (PACU) and 24-hour visual analog scale (VAS) scores, time to first opioid use, 24- and 48-hour total opioid use as oral morphine equivalents (OME), 24-hour ambulation distance, and time from block placement to hospital discharge. The results were analyzed and compared to patients undergoing primary THA under spinal anesthesia with QL block (no intrathecal morphine) and compared to a control group of patients undergoing primary THA under spinal anesthesia only. Results The study analysis included 26 patients in the SA+QLB+ITM group, 31 patients in the SA+QLB group, and 28 patients in the SA (control) group. When compared with the control group, the SA+QLB+ITM had lower 24-hour total opioid usage (mean difference 20.80 OME, CI 6.454 to 35.15, p-value 0.0025), longer time to 1st opioid use (mean difference -20.51 hours later, p-value .0052), lower 24-hr VAS (difference 2.421, p-value 0.0012, CI 0.8559 to 3.987), and faster time to discharge (16.00 hr earlier, p-value 0.0459). When compared to the SA+QLB group, the SA+QLB+ITM group only showed a statistically significant difference in faster time to discharge (19.46 hr earlier, p-value 0.0068). However, while there was no statistically significant difference in time to 1st opioid use between the control and SA+QLB group, the difference did become significant when comparing the control to the SA+QLB+ITM group (mean difference -20.51 hours later (p-value .0052). There was no significant difference in either of the three groups in ambulation distance at 24 hours, PACU VAS, or 48-hour total opioid use. Conclusion Our study concludes that the addition of 100 mcg ITM for total hip arthroplasty under spinal anesthesia improved postoperative analgesia compared to the control group. Also, the ITM group did better with respect to delay in first opioid use and decreased hospital stay compared to the control and block-only groups. Our study warrants no more concerns of PONV, pruritus, or respiratory depression with this dose of ITM and requires standard postoperative care.

Comparison of Pericapsular Nerve Group (PENG) Block Versus Quadratus Lumborum (QL) Block for Analgesia After Primary Total Hip Arthroplasty Under Spinal Anesthesia: A Retrospective Study

BACKGROUND

Total hip arthroplasty (THA) is one of the most common operative procedures performed. Controlling postoperative pain following THA remains a challenge due to the complex innervation of the hip joint and the recent desire to preserve motor function following nerve blockade. Several nerve block techniques have been used for THA in the past, but the quadratus lumborum (QL) block and the blockade of the pericapsular nerve group (PENG) have emerged as opiate-sparing regional anesthesia techniques that preserve motor function. To date, little data comparing the two block techniques exists. The purpose of our study was to compare outcomes following these techniques in patients undergoing primary THA.

MATERIALS AND METHODS

This retrospective analysis utilized data from three distinct groups who underwent primary THA at our institution: 45 patients who received PENG block, 38 patients who received QL block, and 77 control patients. Chart review analysis was performed by authorized personnel to obtain cumulative oral morphine equivalent (OME) data at 24 and 48 hours postoperatively (primary outcomes). In addition, visual analog pain scale (VAS) scores in the post-anesthesia care unit (PACU) and at 12, 24, and 48 hours, ambulation distance, and length of hospital stay data were obtained (secondary outcomes). Group comparisons were conducted using either analysis of variance (ANOVA) with Tukey's multiple comparison test for parametric data or Krustal-Wallis with Dunn's multiple comparison tests for nonparametric endpoints.

RESULTS

This study found a statistically significant difference in cumulative OME usage across all groups at 24 and 48 hours. Significant difference in OMEs was found between QL and control and PENG and control; however, no difference was found in OMEs between PENG and QL groups at either time point. There was a statistically significant difference in VAS scores in the PACU across all groups; QL showed significantly lower VAS scores in the PACU compared to PENG and control, while PENG only showed significantly lower VAS scores compared to control. There was a statistically significant difference in VAS scores at 24 hours across all groups; however, only QL showed significantly lower VAS scores compared to control at 24 hours. QL was associated with a statistically significant increase in the length of hospital stay compared to PENG.

CONCLUSION

This study showed no difference between OME usage in patients who received PENG or QL nerve blocks for primary THA. VAS scores were similar between groups with the exception of QL outperforming PENG in the PACU. Optimizing postoperative pain via multi-approach strategies should remain a priority for patients undergoing THA. Future research is warranted in order to provide guidance on best practice for these patients.

The Dose Comparison of Intrathecal Morphine for Postoperative Analgesia in Total Knee Arthroplasty Under Spinal Anesthesia: A Single Institute Retrospective Study

Background and purpose of the study Intrathecal morphine (ITM) provides effective postoperative analgesia in patients undergoing total knee arthroplasty (TKA) under spinal anesthesia. However, the ideal dose at which maximal analgesic effects can be delivered with minimal side effects is not clearly known. This retrospective study is aimed to compare two different doses of ITM with respect to analgesia benefits and side effects. Methods This is a retrospective, descriptive, single-center study approved by the Institutional Review Board (IRB) at the University of Alabama at Birmingham. Three patient groups were selected: a control group receiving continuous adductor canal block (CCACB) under spinal anesthesia, and two experimental groups receiving single-dose adductor canal block (SSACB) under spinal anesthesia with either 100 mcg or 150 mcg of ITM. The sample size included 75 patients (25 per group) who were 18 years and older, American Society of Anesthesiology (ASA) class 1-3 who were undergoing primary TKA. Patients with chronic pain or opioid use exceeding 30 days and those undergoing surgeries other than primary TKA were excluded. Outcome data, including opioid use (from which post-operative oral morphine equivalents (OME) were calculated), antiemetic use, visual analog pain scale (VAS) scores, distance ambulated at 24 hours, and length of hospital stay, were extracted by chart review. Results In the post-anesthesia care unit (PACU), patients in both ITM groups experienced significantly lower opioid consumption and pain scores compared to the control group (p<.001). Furthermore, cumulative OME at 24 hours was significantly less in the ITM groups compared to the control, but there was no difference between ITM doses (p=0.004; mean cumulative OME for control was 77.2 OME vs 43.4 OME for 100 mcg ITM vs 42.6 OME for 150 mcg ITM). Antiemetic usage did not increase in the ITM groups. Although there was no statistically significant difference in ambulation at 24 hours, both ITM groups exhibited a trend toward greater average ambulation distance compared to the control group (p=0.095; mean distance walked for control was 67.6 feet, 76.6 feet for 100 mcg ITM vs 98.8 feet for 150 mcg ITM). Hospital length of stay did not significantly differ between the groups. Conclusion ITM doses of 100 mcg and 150 mcg provide effective analgesia for patients undergoing lower extremity total knee arthroplasty under spinal anesthesia. Patients receiving ITM had better pain scores in the immediate post-operative period and had overall less oral morphine equivalent consumption when compared to control. In addition, the safety and side effect profile for ITM is similar for both doses as there was no incidence of respiratory depression and antiemetic usage did not differ between all study arms. Future studies should explore the use of higher ITM doses and consider a broader patient population to further understand the advantages and potential drawbacks of ITM in TKA surgery.

Systemic Complications of Obesity in Operative Acetabular Fractures

OBJECTIVE

To determine the effect of obesity on rates of systemic complications in operatively treated acetabular fractures.

DESIGN

Retrospective Case-Control study.

SETTING

Level 1 Trauma Center.

PATIENTS/PARTICIPANTS

All patients with acetabular fractures managed operatively from January 2015 to December 2019. Patients were divided into groups based on their body mass index (BMI) (normal weight = BMI <25 kg/m2, overweight = BMI 25-30, obese = BMI 30-40, and morbidly obese = BMI >40).

INTERVENTION

Operative management of an acetabular fracture.

MAIN OUTCOME MEASUREMENT

Systemic complications, including mortality, sepsis, pneumonia, acute respiratory distress syndrome, deep vein thrombosis, pulmonary embolism, or venous thrombotic event.

RESULTS

A total of 428 patients were identified. One hundred nine patients (25.4%) were in normal weight, 133 (31.1%) were overweight, 133 (31.1%) were obese, and 53 (12.4%) were morbidly obese. The rate of systemic complications was 17.5%, and overall mortality rate was 0.005%. There were no significant differences between the different BMI groups in all-cause complications or any individual complications. When the morbidly obese group was compared with all other patients, there were also no significant differences in all-cause complications or any individual complications.

CONCLUSION

In conclusion, in this study, there was no association with increasing BMI and inpatient systemic complications after operative management of acetabular fractures. As we continue to refine our understanding of how obesity affects outcomes after acetabular fracture surgery, other indices of obesity might prove more useful in predicting complications. In the obese population, there are well-documented risks of postoperative infections and challenges in obtaining an anatomic reduction, but the fear of postoperative systemic complications should not deter surgeons from undertaking operative management of acetabular fractures in the obese population. Because the prevalence of obesity in trauma patients continues to increase, it is incumbent on us to continue to improve our understanding of optimal treatment for our patients.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Calcium pyrophosphate deposition disease of the cervical and thoracolumbar spine: A report of two cases

Background

Spinal calcium pyrophosphate deposition disease (CPPD) is uncommon, and often resembles more common spine pathologies causing pain and neural compression. Here, we present two unusual cases of CPPD of the cervical and thoracolumbar spines.

Case description

Case 1: A 71-year old female smoker presented with a large epidural mass causing rapidly progressive cervical myelopathy with weakness in the upper and lower extremities.

Case 2: A 66-year-old morbidly obese male presented with chronic back pain for several years associated with progressively worsening radicular pain in his left lower extremity.

Outcome

The first case is an example of tumoral CPPD involving the facet joint and expanding into the epidural space. The second case was an example of CPPD involving a thoracolumbar facet cyst, resulting in unilateral radiculopathy. Both patients were treated surgically and had significant improvement in symptoms post-operatively.

Conclusions

CPPD in the spine is an uncommon diagnosis but should be considered in the differential diagnosis of patients presenting with back pain and associated neurological symptoms. Accurate diagnosis of spinal CPPD is important in that it will guide postoperative management with anti-inflammatory medications and reduce risk of recurrence.

Chronic modifications of lung and heart development in glucocorticoid-treated newborn rats exposed to hyperoxia or room air

We assessed the mechanics and morphology of the lung in 165 rats treated neonatally with either room air (RA), O2, RA + steroids, or O2 + steroids. Newborn Sprague-Dawley male rats were randomly assigned to these groups. O2-exposure (0.96-1.0 FiO2) lasted 5 days, and dexamethasone treatment consisted of eight daily S.C. injections of drug or buffer in successive doses of 0.5, 0.4, 0.3, 0.2, 0.1, 0.1, 0.1, and 0.1 mg/kg. At 58 days, right ventricular systolic pressure (RVP) was measured. At 60 days, all rats were sacrificed for obtaining lung weight and DNA, saline pressure-volume (P-V) curves, and morphometry. We weighted right ventricles (RV) and left ventricles + septa (LV). Hyperoxia alone did not, but steroid decreased survival rate to 79.4% (95.3% in RA rats, P < 0.02). Only 21 of 40 (52%) O2 + steroids rats survived, less than in both RA groups (P < 0.001). RV weight, RVP and muscularization of alveolar duct arteries were significantly increased in O2 vs. RA rats. In RA + steroids rats, weight of the LV was decreased but RV, RVP, and lung vasculature were not affected. These effects were additive in the O2 + steroid group. Wet lung weights and DNA were increased for RA + steroid rats over all others. O2 and steroids shifted the P-V curve to the left and O2 + steroids still further. Maximal lung volume increased significantly with RA + steroids and still further in O2 + steroids but not in O2 alone. O2 and steroids significantly increased the mean linear intercept and O2 + steroids even more so.(ABSTRACT TRUNCATED AT 250 WORDS)

Lung antioxidant enzymes and cardiopulmonary responses in young rats exposed to hyperoxia and treated intratracheally with PEG catalase and superoxide dismutase

The 27-day-old rat exposed to 100% oxygen (O2) for 8 days will have predictable lung vascular and parenchymal changes at 60 days of age. Using this model, the goals of this study are (1) to measure the lung antioxidant enzyme activities serially following intratracheal PEG antioxidant therapy during the 8-day O2 exposure; and (2) to assess chronic cardiopulmonary changes in the O2-exposed rats treated with PEG-CAT and/or PEG-CuZn SOD given intraperitoneally (IP) and/or intratracheally (IT). The study encompassed 202 male rats exposed to room air or oxygen. CuZn SOD doses were 300 U IT and 2000 U IP. The CAT dose was 500 or 4000 U IT and 10,000 U IP. At 60 days of age, the right ventricular systolic pressure (RVP), RV weight, % acinar wall arterial thickness, and parenchymal air space were significantly increased in O2-exposed rats compared to RA rats. The RVP, RV weight, and parenchymal changes were prevented by daily IT PEG-CAT 4000 U + CuZn SOD 300 U but the increased small artery muscularization was not. Three hours after the initial dose of IT PEG-CAT 4000 U, lung CAT activity was more than doubled and remained constant throughout the 8-day daily treatment course. This dose of CAT depressed the induction response to O2 of CuZn and MnSOD. It is concluded that daily intratracheal administration of PEG-CAT 4000 U + CuZn SOD 300 U can significantly ameliorate some of the chronic parenchymal and vascular lung O2 toxic changes. However, it appears that high-dose exogenous PEG-CAT suppresses the endogenous enzyme induction to hyperoxia of both CuZn and Mn-SOD.

Prevention of chronic pulmonary oxygen toxicity in young rats with liposome-encapsulated catalase administered intratracheally

The lungs and hearts of young rats exposed to 100% oxygen (O2) for 8 days (27 to 35 days of age) were studied following recovery in room air at 60 days of age using morphometric, biochemical, and physiological techniques. In an attempt to prevent chronic oxygen toxicity 153 rats had transtracheal catheters surgically implanted and were treated during the O2 exposure with daily intratracheal injections of liposome-encapsulated superoxide dismutase (SOD) and/or catalase (CAT). Oxygen exposure in this model results in chronic cardiopulmonary alterations which include pulmonary hypertension, right ventricular hypertrophy, and a decrease in number of pulmonary arterioles 25 to 50 microns in diameter with increased muscularization of their walls. The volume densities of the parenchyma, parenchymal air space, and the alveolar space are increased, while that of the combined alveolar ductal and respiratory bronchiolar space is decreased. Daily intratracheal administration of liposome-encapsulated CAT (160 U) during the O2 exposure prevented these chronic changes. Liposome-encapsulated SOD (110 U) or SOD (50 U) + CAT (70 U) did not appear to have a preventive effect. During the first 3 to 5 days following oxygen exposure the lung tissue enzymes SOD, CAT, and glutathione peroxidase markedly increased. We conclude that in the young rat animal model liposome-encapsulated CAT (160 U) given intratracheally during the period of O2 exposure is safe and will prevent the chronic vascular and parenchymal damage due to oxygen toxicity.

Neonatal pulmonary oxygen toxicity in the rat and lung changes with aging

The aims of this study were to determine if neonatal hyperoxia exposure causes permanent lung damage and to define the relationship between neonatal lung oxygen toxicity and aging. Sprague-Dawley newborn rats (n = 85) breathed 100% oxygen (O2) or room air (RA) during the first 8 days of life, and then RA. At 2 and 22 months of age we assessed right ventricular (RV) systolic pressure (RVSP), RV weight, saline and air pressure-volume curves, volume density of lung parenchyma and nonparenchyma, parenchymal air space (PAS), mean linear intercept (Lm), number of small arteries/mm2 and the extent of their medial muscularization. Aging in RA did not affect the RVSP, RV weight, the number of small arteries/mm2, or their muscularization. The maximal lung volume/g of dry lung and the elastic recoil pressure between 40 and 90% maximal lung volume decreased. The volume density of lung parenchyma increased but the fraction of the lung parenchyma that was PAS decreased and that of the alveolar septa and Lm increased. The O2-treated rats at 60 days of age had increased RVSP and RV weights with a decrease in the small arteries/mm2. The lung parenchymal volume density and PAS increased and the density of alveolar septa decreased. The Lm increased and the alveoli/mm2 and elastic recoil pressure decreased. The lung damage seen in the O2-treated rats at 60 days persisted and in addition underwent the changes seen in the aging controls. However, the extent of muscularization of the arteries decreased. We conclude that neonatal hyperoxia causes permanent functional and structural changes of the lung but these do not interact with aging; that is, the effects of O2 toxicity and aging are additive but not synergistic.