الفهرس 
Pain in patient with total knee arthroplasty
Anatomy of the lumbar spineOnly 14 pages are availabe for public view
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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.