Orthopedics
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Multimodal pain management has become an important part of the perioperative care of patients undergoing total joint replacement. The principle of multimodal therapy is to use interventions that target several different steps of the pain pathway, allowing more effective pain control with fewer side effects. Many different protocols have shown clinical benefit. The goal of this review is to provide a concise overview of the principles and results of multimodal pain management regimens as a practical guide for the management of joint arthroplasty patients.
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Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) has been recognized as a public health concern since the mid-1990s. Because of the increase in reports of this pathogen, it has become increasingly tempting for clinicians to provide prophylaxis against this entity using antibiotics known to be effective against MRSA. The goal of this study was to assess the use of MRSA prophylaxis to determine whether it is safe and effective. ⋯ However, local administration appears to be safe and effective. The data are most compelling in orthopedic spine surgery in which a patient without prophylaxis is more than 4 times as likely to have a deep postoperative wound infection compared with a patient who received local vancomycin. The authors recommend the use of local antibiotics when possible in clean orthopedic surgery.
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Multimodal pain management should be considered for all perioperative orthopedic patients. The goal of reducing the amount of perioperative opioid medication given may be achieved by using nonopioid medications, including intravenous acetaminophen. ⋯ The safety profile and relative lack of systemic adverse reactions make this an attractive analgesic for a wide variety of orthopedic surgical patients. Clinical studies have demonstrated the efficacy and safety of intravenous acetaminophen in elective total hip and knee arthroplasty, knee arthroscopy, lumbar spine surgery, and for acute traumatic limb pain.
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Comparative Study
Comparative study of the prevalence of venous thromboembolism after elective spinal surgery.
To the authors' knowledge, no comparative studies exist of venous thromboembolism (VTE) based on different pathologies, surgical procedures, or spinal levels after spinal surgery. The authors prospectively investigated VTE after elective spinal surgery. The study comprised 4 patient groups. ⋯ Spinal tumor surgery carries a high risk of critical VTE, whereas cervical spine surgery carries a low risk. No DVT occurred in 60% of PTE-positive patients. This result indicates that screening for PTE is also needed in patients who are at high risk for VTE.
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Pain due to intra- and extracapsular hip fractures is usually treated with opioid medication. Paracetamol (acetaminophen in North America) has better bioavailability when given intravenously than orally and has been successfully used in the postoperative care of orthopedic patients. However, no study has evaluated its use in the preoperative trauma patient. ⋯ There was a significant reduction (P<.005) in the mean total intravenous morphine with intravenous paracetamol (6.5 mg) compared with oral paracetamol (21.8 mg). There was no difference in the mean pain score between the groups, 2.1 vs 1.8 (P=.3). Intravenous paracetamol had a significant opioid-sparing effect and satisfactory pain relief in preoperative hip fracture patients.