Orthopedics
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Aprotinin is a potent pharmacological agent that reduces bleeding. In current surgical practices, the rate of blood transfusions has decreased with the use of aprotinin. Recently, studies using aprotinin have been conducted in orthopedic surgery. ⋯ One adverse effect was the potential occurrence of an anaphylactoid reaction. Prophylactic administration of aprotinin should be considered in extensive spine surgery and in high-risk orthopedic operations. The decision to use aprotinin can be guided by a risk/benefit analysis.
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Based on a literature review, this article evaluates the efficacy of aprotinin to limit blood transfusion during spine surgery. Most prospective studies confirm this effect. However, broader studies are required to evaluate adverse effects. ⋯ The cost of the medication has to be balanced with the cost of blood transfusion. A careful use of aprotinin allows a surgeon dealing with high-risk patients to avoid or limit the use of transfusions. For patients who are not high-risk, aprotinin should be avoided until other questions are answered.
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The demand for increased efficiency and decreased hospital stay has magnified the role of anesthesia and acute postoperative pain management in orthopedics. Orthopedic anesthesia and acute postoperative pain management, which are subspecialties of anesthesiology, are increasingly recognized for their positive effect on the length of hospital stay, functional recovery, and patient satisfaction. ⋯ The use of peripheral nerve blocks for anesthesia has been associated with earlier discharge when compared with general anesthesia and neuraxial blocks in patients undergoing ambulatory orthopedic surgery. Regional techniques are usually part of a multimodal strategy that includes both pharmacological and nonpharmacological approaches to pain management.
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Spinal hematoma is a rare and potentially catastrophic complication of spinal or epidural anesthesia. Risk factors include traumatic needle/catheter placement, sustained anticoagulation in an indwelling neuraxial catheter, and catheter removal during therapeutic levels of anticoagulation. ⋯ Signs of cord compression, such as severe back pain, progression of numbness or weakness, and bowel and bladder dysfunction, warrant immediate radiographic evaluation. A delay in diagnosis and intervention of spinal hematoma may lead to irreversible cord ischemia.
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Deep vein thrombosis and pulmonary embolism are major causes of morbidity and mortality after knee and hip arthroplasty in the United States. Although patients frequently receive prophylaxis for thromboembolism postarthroplasty, surgeons vary in their choice of modality and often use suboptimal strategies due to the possibility of provoking postoperative bleeding. ⋯ Supporting medical evidence for these recommendations is described. A summary of current prophylactic regimens and discussion of duration of therapy are also presented.