Diz Atroplastilerinde Postoperatif Analjezi Prof. Dr. Ercan KURT GATA Anesteziyoloji ve Reanimasyon AD

Multimodal (Dengeli) Analjezi Farklı mekanizma ile veya farklı yerlere etki eden analjeziklerin kombine edilmesidir Daha iyi analjezik etki sağlanır Postoperatif üriner retansiyon ve ileus azalır Opioid yan etkileri azalır Hastanede kalma süresi kısalır Hasta memnuniyeti artar

Dorsal Boynuz Hücreleri Dorsal Boynuz Hücreleri Korteks 6) Opioid Supraspinal Nosiseptif Sistem Supraspinal Nosiseptif Sistem Supraspinal Antinosiseptif Sistem Supraspinal Antinosiseptif Sistem 5) HKA Dorsolateral Fasikulus Anterolateral yol Anterolateral yol 4) Santral bloklar Dorsal Boynuz Hücreleri Lamina I, II ve V Dorsal Boynuz Hücreleri Lamina I, II ve V 3) Periferik Sinir C C A A A A 2) Periartiküler Enjeksiyon Nosiseptör ve çevresi Nosiseptör ve çevresi 1) NSAİD Ağrı Yolları Üzerinde Multimodal Analjezinin Rolü

Korteks Supraspinal Nosiseptif Sistem Dorsal Boynuz Hücreleri 6) Opioid Supraspinal Nosiseptif Sistem Supraspinal Antinosiseptif Sistem 5) HKA Dorsolateral Fasikulus Anterolateral yol 4) Santral bloklar Dorsal Boynuz Hücreleri Lamina I, II ve V 3) Periferik Sinir C A A 2) Periartiküler Enjeksiyon Ağrı Yolları Üzerinde Multimodal Analjezinin Rolü Nosiseptör ve çevresi 1) NSAİD

Multimodal Analjezi Preoperatif: İntraoperatif Postoperatif: Analjezi Preemtif analjezi (lokal infiltrasyon, İV analjezik, Parasetamol) İntraoperatif Periartiküler enjeksiyon Spinal - Epidural Genel + Epidural Postoperatif: Analjezi (Epidural, Periferik sinir blokları, İV, HKA)

Atroplastilerde Postoperatif Ağrı Tedavisinde Amaç Analjezi (VAS < 3 olmalı) Erken ambulasyon Erken mobilizasyon Erken oral alım Motivasyonu yükseltmek

Preemptif Analjezi Cerrahiye stres yanıtı azaltmada çok etkili ACTH - Kortizon ADH - Aldestoren GH TSH Sempatik aktivasyonu azaltır Adrenalin Noradrenalin

Preemptif Analjezi SSS’de oluşan ağrı hafızasını azaltır Santral sensitizasyonu engeller Postoperatif ağrıyı azaltır Stress yanıtı azaltır Opioidler, lokal anestezikler, NSAI, Kortikosteroidler Periferik sinir blokları, lokal anestezik infiltrasyonları Rejyonal anestezi yöntemleri spinal, epidural

İntraoperatif Uygulamalar (Periartiküler, İntraartiküler enjeksiyon) Basit ve etkili Yara iyileşmesini etkilemez Enfeksiyon riski yok Lokal infiltrasyon ve/veya yara yerine kateter yerleştirilerek yapılır Opioid tüketimini Hastanede kalış süresini Andersen KV et al. Acta Orthop, 2007

Periartiküler Enjeksiyon % 0.5 Bupivakain 200-400 mg Morfin sülfat 4-10 mg Epinefrin 300 µg Metilprednizolon asetat 40 mg Cefuroxime 750 mg Serum Fizyolojik (60 ml volüm) Andersen KV et al. Acta Orthop, 2007

Periartiküler Enjeksiyon Toplam hacim 60 ml. %0.5 Şirokain 40 ml Depomedrol 40 mg Morfin 0.4 ml Epinefrin 0.6 ml Zinnat 750 mg

Diz Artroplastisinde Periartiküler Enjeksiyon Yerleri İnsert yerleştirme öncesi: Posterior kapsül Posteromedial ve posterolateral yapılar Redüksiyon sonrası: Ekstensör mekanizma Snovia, kapsül, iliotibial bant, periost Pes anserinus, anteromedial kapsül Kollateral ligamentler ve orjinleri

Periartiküler Enjeksiyon J Bone Joint Surg Am 2006 May;88(5):959-63 Basit bir uygulamadır Opioid gereksinimi azaltır Hasta konforunu artırır

Periartiküler Enjeksiyon J Bone Joint Surg Am 2006 Feb;88(2):282-9 Protokol olmalıdır İlaçlara bağlı yan etkiler azaltılır

Periartiküler Analjezi Comparison of peri-and intraarticular analgesia with femoral nerve block after total knee arthroplasty: a randomized clinical trial Acta Orthopaedica 78(2):172-9, 2007 Toftdahl K. Nikolajsen L. Haraldsted V. Madsen F. Tonnesen EK. Soballe K. BACKGROUND: Postoperative pain after total knee arthroplasty (TKA) can be difficult to manage and may delay recovery. Recent studies have suggested that periarticular infiltration with local anesthetics may improve outcome. METHODS: 80 patients undergoing TKA under spinal anesthesia were randomized to receive continuous femoral nerve block (group F) or peri- and intraarticular infiltration and injection (group I). Group I received a solution of 300 mg ropivacaine, 30 mg ketorolac, and 0.5 mg epinephrine by infiltration of the knee at the end of surgery, and 2 postoperative injections of these substances through an intraarticular catheter. RESULTS: More patients in group I than in group F could walk < 3 m on the first postoperative day (29/39 vs. 7/37, p < 0.001). Group I also had significantly lower pain scores during activity and lower consumption of opioids opinefrinn the first postoperative day. No differences between groups were seen regarding side effects or length of stay. INTERPRETATION: Peri- and intraarticular application of analgesics by infiltration and bolus injections can improve early analgesia and mobilization for patients undergoing TKA. Further studies of optimal drugs, dosage, and duration of this treatment are warranted Ropivakain 300 mg Ketorolac 30 mg Epinefrin 0,5 mg

Periartiküler Analjezi High-dose local infiltration analgesia after hip and knee replacement--what is it, why does it work, and what are the future challenges? Bupivakain 2-3 mg/kg Prilokain 5-6 mg/kg Rostlund T. Kehlet H Acta Orthopaedica 78(2):159-61, 2007

Periartiküler Enjeksiyon The use of local periarticular injections in the management of postoperative pain after total hip and knee replacement: a multimodal approach Parvataneni HK Instr Course Lect 2007;56:125-31

Periferik Sinir Bloğu Lomber Pleksus Sakral Pleksus Posterior lumbar Pleksus bloğu Tek doz Devamlı Femoral sinir bloğu Sakral Pleksus Siyatik sinir bloğu

Periferik Sinir Bloğu Analgesia for total hip and knee arthroplasty: a multimodal pathway featuring peripheral nerve block Horlocker TT J Am Acad Orthop Surg 2006 Mar;14(3):126-35

Psoas kompartman bloğu CI CI Girişim noktası SİPS L4 L4 L4 L5 CI Girişim noktası CI

Psoas kompartman bloğu Winnie tekniği

Femoral sinir bloğu İnguinal ligament FV FA Girişim noktası

Devamlı Epidural ve Femoral Blok Postoperative pain management following total knee arthroplasty: a randomized comparison of continuous epidural versus femoral nerve infusion Long T J Knee Surg 2006 Apr;19(2):137-43 Femoral blok; Quadriceps femoriste zayıflık Epidural blok; yan etkiler sık (hipotansiyon,motor blok, kaşıntı, yamalı blok)

Femoral ve Siyatik Blok Analgesia After Total Knee Arthroplasty: Is Continuous Sciatic Blockade Needed in Addition to Continuous Femoral Blockade? Ben-David, Bruce. Volume 98(3), March 2004, 747-749 Continuous femoral “3-in-1” nerve blocks are commonly used for analgesia after total knee arthroplasty (TKA). There are conflicting data as to whether additional sciatic blockade is needed. Our routine use of both continuous femoral (CFI) and sciatic (CSI) peripheral nerve blocks was changed because of concerns that sciatic blockade, and its motor consequences in particular, might obscure diagnosis of perioperative sciatic nerve injury. The revised protocol includes placing single-shot blocks and perineural catheters at both sites, but infusing local anesthetic postoperatively only in the CFI. CSI is reserved for patients having poorly controlled posterior knee or calf pain. Our APS protocol for TKA remains as described in this report and ongoing audit continues to show roughly an 85% rate of use of the CSI after TKA. We perform both femoral and sciatic blocks preoperatively and place the corresponding perineural catheters. The CFI is systematically started in the PACU and the sciatic catheter is connected but the infusion not commenced unless the patient complains of pain in the “sciatic territory” (posterior aspect of the knee or calf). Pain experienced in the anterior knee in the presence of a demonstrable femoral block that fails to respond to further femoral catheter bolus of local anesthetic may on occasion, as seen in one case here, respond to CSI. Although we have not been able to eliminate the CSI, given our analgesic approach and its focus on limiting opiate consumption, we remain cognizant of the surgeons’ concerns. It is therefore important to stress the need for constant vigilance as to developing motor blockade in either the tibial (plantar flexion) or common peroneal (dorsiflexion) distribution that would require at least temporary cessation of CSI. We acknowledge that as our analgesic techniques develop their success will be measured not only by analgesic response, but also by how well they incorporate and respect the goals and concerns of our surgical colleagues. Diz arkası ve baldırda yetersiz analjezi

Posterior Lumbar Pleksus bloğu ve Femoral Blok Posterior lumbar pleksus (PLP) bloğunun etkinliği femoral bloktan üstündür PLP daha proksimal bir blok olduğu için tüm lomber pleksus bloke olur Our protocol was written before the modification for posterior lumbar plexus block by using the peripheral nerve stimulator became popular, and we totally agree that the posterior lumbar plexus block is superior to the femoral three-in-one block. We also agree with regard to the need for patient-controlled analgesia morphine in this subset of patients with the femoral block. In our study, we used the patient-controlled analgesia to allow patients to dose themselves to achieve similar analgesic endpoints, and morphine consumption was used as an indicator of the severity of the pain. Thus, our pain scores are similar, but the morphine consumption is not. Evaluation of the femoral catheter location was done entirely for experimental purposes and is not routinely done for this block in our institution. The investigation, however, teaches a good point that not all catheters reach where you aim to put them. Although there is no doubt about the presence of opiate receptors in the spinal cord and peripheral nerve nociceptive terminals, their presence in the peripheral axons has not been proven, to our knowledge. Systemic absorption of opiates delivered in the periaxonal area could per se provide some analgesia. We did not use opiates in our infusion to keep the study as clean as possible. S. Ganapathy FRCA FRCPC J. Watson FRCPC R. Wasserman FRCPC

3-1 Femoral + Siyatik Blok Combined continuous "3-in-1" and sciatic nerve blocks provide improved postoperative analgesia with no correlation to catheter tip location after unilateral total knee arthroplasty. Randomized Controlled Trial Journal of Arthroplasty. 22(8):1181-6, 2007 Rajeev S. Batra YK. Panda NB. Kumar M. Nagi ON. UI: 18078888 Authors Full Name Rajeev, Subramanyam. Batra, Yatindra Kumar. Panda, Nidhi Bidyut. Kumar, Mukesh. Nagi, Onkar Nath. This study assessed the efficacy and duration of postoperative analgesia after continuous sciatic nerve block with and without continuous "3-in-1" block with bupivacaine after unilateral total knee arthroplasty and determined catheter tip correlation with analgesia. Thirty patients were randomized into 2 groups. Results suggested significantly reduced pain and rescue analgesic requirement in combined sciatic and 3-in-1 (group TS) compared to 3-in-1 group alone (group T). The postoperative pain-free interval and satisfaction score was significantly higher in the combined group (P < .05). The percentage of catheters in the ideal position was 53.3% for 3-in-1 and 93.3% for sciatic nerve. In conclusion, continuous sciatic nerve block when added to continuous 3-in-1 block provides a better quality of analgesia with lesser requirements of rescue analgesics without the need for routine radiographic conformation. İki sinir birlikte bloke edilmelidir

Femoral Kateter ve Düşük Doz Ketamin İnfüzyonu Small-Dose Ketamine Infusion Improves Postoperative Analgesia and Rehabilitation After Total Knee Arthroplasty Adam Frédéric Anesth Analg 2005 Feb;100(2):475-80 We designed this study to evaluate the effect of small-dose IV ketamine in combination with continuous femoral nerve block on postoperative pain and rehabilitation after total knee arthroplasty. Continuous femoral nerve block was started with 0.3 mL/kg of 0.75% ropivacaine before surgery and continued in the surgical ward for 48 h with 0.2% ropivacaine at a rate of 0.1 mL . kg(-1) . h(-1). Patients were randomly assigned to receive an initial bolus of 0.5 mg/kg ketamine followed by a continuous infusion of 3 mug . kg(-1) . min(-1) during surgery and 1.5 mug . kg(-1) . min(-1) for 48 h (ketamine group) or an equal volume of saline (control group). Additional postoperative analgesia was provided by patient-controlled IV morphine. Pain scores and morphine consumption were recorded over 48 h. The maximal degree of active knee flexion tolerated was recorded daily until hospital discharge. Follow-up was performed 6 wk and 3 mo after surgery. The ketamine group required significantly less morphine than the control group (45 +/- 20 mg versus 69 +/- 30 mg; P < 0.02). Patients in the ketamine group reached 90 degrees of active knee flexion more rapidly than those in the control group (at 7 [5-11] versus 12 [8-45] days, median [25%-75% interquartile range]; P < 0.03). Outcomes at 6 wk and 3 mo were similar in each group. These results confirm that ketamine is a useful analgesic adjuvant in perioperative multimodal analgesia with a positive impact on early knee mobilization. No patient in either group reported sedation, hallucinations, nightmares, or diplopia, and no differences were noted in the incidence of nausea and vomiting between the two groups. Devamlı femoral kateter 0.3 ml %0,5 ropivakain Ketamin infüzyonu 3µg/kg

Devamlı Femoral Blok ve İV Opioid A pilot study on continuous femoral perineural catheter for analgesia after total knee arthroplasty: the effect on physical rehabilitation and outcomes De Ruyter ML Journal of Arthroplasty 21(8):1111-7, 2006 Two techniques of postoperative analgesia for primary total knee arthroplasty were compared retrospectively. Twenty-four patients received a femoral nerve catheter with continuous infusion of ropivacaine (FNC group), whereas 26 patients received intravenous (IV) opioids (IV opioid group). Pain and rehabilitation scores and hospital length of stay (LOS) were compared. On the first postoperative day, both groups reported similar pain scores. After 4 sessions of twice-daily rehabilitation, the FNC group used less IV patient-controlled opioids (29.1% vs 84.5%, P = .0001) and demonstrated better performance with knee flexion and mobility. Hospital LOS was significantly less in the FNC group (3.6 vs 4.2 days, P = .034). Femoral nerve catheters with continuous infusion of ropivacaine provide satisfactory analgesia, improve rehabilitation, and shorten hospital LOS. Devamlı femoral blok Analjezi daha fazla Hastanede kısa kalış Rehabilitasyonda daha iyi

Hasta Kontrollü Analjezi (HKA/PCA) Hastanın bir infüzör pompa aracılığı ile kendine istediği zaman belirli bir kilitli kalma aralığında, önceden belirlenen miktarda analjezik enjekte etmesidir İntravenöz Periferik sinir kateteri Epidural Subkütan

Ağrı çemberi Ağrı Analjezi Sedasyon Hasta hemşireyi çağırır H.K.A. Hemşire yanıt verir Ağrı çemberi Doz emilir Değerlendirme yapılır Geleneksel İM narkotik analjezisini TERCİH ETMİYORUZ!!!!!...... Enjeksiyon yapılır İlaç belirlenir Enjeksiyon hazırlanır

Avantajları ve Yararları Hasta Kontrollü Analjezi (HKA) Avantajları ve Yararları Tedaviye aktif katılım Plazma ilaç düzeyi sabit, iyi analjezi Toplam dozda azalma Erken mobilizasyon Solunum problemlerinde azalma Daha kısa yatış süresi

Hasta Kontrollü Analjezi (HKA) Avantajları ve Yararları Sedasyon Analjezi Ağrı

Hasta Kontrollü Analjezi (HKA) Komplikasyonları 1. Teknik komplikasyonlar a) Cihaza ait b) Programa ait 2. Hastaya ait komplikasyonlar Ağrı skoru, bulantı, kusma, sedasyon

Opioid Tedavi; Tramadol+ Morfin The addition of tramadol to morphine via patient-controlled analgesia does not lead to better post-operative pain relief after total knee arthroplasty Stiller CO Acta Anaesthesiologica Scandinavica 51(3):322-30, 2007 BACKGROUND: Tramadol is used as an analgesic in post-operative pain treatment. Intravenous tramadol is often combined with morphine to achieve better pain relief and less side-effects after orthopaedic surgery. However, the available evidence is insufficient to support this combination. For this reason, we conducted the present non-commercial, randomized, double-blind clinical trial. METHOD: Sixty-three patients with osteoarthritis of the knee, selected for primary total knee arthroplasty (TKA), were randomized to receive saline or tramadol 100 mg/ml intravenously every 6 h during the first post-operative day (total, 400 mg/24 h). All patients had access to morphine via a patient-controlled analgesia (PCA) pump. RESULTS: Neither during the 6 h after the first dose nor during the first post-operative day could we detect any statistically significant difference with regard to pain intensity, sedation and nausea between patients treated with tramadol and the placebo group. However, the withdrawal rate caused by insufficient pain relief was greater in the tramadol group (7/31) than in the saline group (2/32). This difference did not reach statistical significance. In the group of patients who remained in the study for 24 h ('per protocol'), those randomized to receive tramadol had a significantly (P < 0.05) lower morphine consumption (20 mg or 31%) than the placebo group. CONCLUSION: Our study does not support the combination of tramadol and morphine via PCA for post-operative pain relief after primary TKA. In addition, our study indicates that morphine via PCA as the sole means of post-operative analgesia does not provide sufficient pain relief after TKA. Thus, other means of post-operative analgesia should be used following TKA.

Epidural Analjezi ve Tromboembolizm Thromboembolism in patients undergoing total knee arthroplasty with epidural analgesia Brooks PJ. Keramati M. Wickline A. UI: 17689769 Authors Full Name Brooks, Peter J. Keramati, Magid. Wickline, Andrew. We retrospectively reviewed the charts of 381 consecutive patients who underwent primary unilateral or bilateral total knee arthroplasty with regional anesthesia between 1995 and 2002. All operations in this study were performed at the Cleveland Clinic Foundation by the senior author. Calf-high intermittent pneumatic compression stockings were used in all patients, and routine ultrasound examinations were performed at an average of 3 days after surgery. We compared the early postoperative rates of venous thromboembolism between patients with indwelling epidural catheters and no chemoprophylaxis and those with spinal anesthesia combined with low-molecular-weight heparin. We found no significant difference between the 2 groups. Journal of Arthroplasty 22(5):641-3, 2007 Aug

GATA Anestezi Kliniğinin Protokolü - 1 İntraoperatif dönem Kombine spinal-epidural blok Periartiküler enjeksiyon Bupivacain 20 ml %0.5 Epinefrin 300 mcg Metilprednizolon asetat 40 mg Toplam volüm 60 ml Postoperatif Epidural HKA

GATA Anestezi Kliniğinin Protokolü - 2 İntraoperatif dönem Kombine spinal-epidural blok Periartiküler enjeksiyon Bupivacain 20 ml %0.5 + Epinefrin 300 mcg Metilprednizolon asetat 40 mg Toplam volüm 60 ml Postoperatif Epidural HKA

Epidural HKA Protokolü - 2 Konsantrasyon: %0.125 mg/ml bupivakain 2 µg/ml fentanyl Saatlik infüzyon: 4 ml/saat HKA dozu: 5 ml Kilitli Kalma süresi: 30 dakika 4 Saatlik Limit: 30 dakika Toplam mayi: 100 ml

GATA Anestezi Kliniğinin Protokolü - 3 İntraoperatif dönem Kombine spinal-epidural blok Postoperatif Epidural kateter başarısız olursa İV HKA ile Tramadol

GATA Anestezi Kliniğinin Protokolü - 4 İ.V. Tramadol HKA Protokolü Konsantrasyon: 5 mg/ml Saatlik infüzyon: 5 mg/saat HKA dozu: 20 mg HKA kilitli kalma süresi: 30 dakika 4 Saatlik limit:150 mg Toplam: 500 mg/100 ml

Sonuç Ortopedi ve Anestezi uzmanları işbirliği yapmalıdır Bir çok yöntem içinden o hastaya uygun yöntem ve ajanın ameliyat öncesi belirlenmesi gerekmektedir Her kurum kendi protokollerini geliştirmelidir Akut ağrı ekibi kurulmalıdır

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