The scientific work presents a new solution to the current problem of modern anaesthesiology and intensive care – the increase of effectiveness and safety of regional anaesthesia for hip arthroplasty with development of algorithm for the choice of optimal option on the basis of anatomical and clinical studies.
The experimental part of the study included modelling of caudal, lumbar paravertebral, and psoas compartment blockades in 44 fresh unembalmed adult cadavers with either aqueous solution of methylene blue or suspension of red lead in glycerol. The clinical part of the study included 398 adult patients who underwent hip arthroplasty with one of six anaesthetic and analgesic options. In group I (n=78), intraoperative spinal anaesthesia and postoperative systemic opioid analgesia; in group II (n=69), intraoperative spinal anaesthesia and postoperative prolonged lumbar paravertebral analgesia; in group III (n=68), intraoperative spinal anaesthesia and postoperative lumbar epidural analgesia; in group IV (n=69), intraoperative psoas compartment block with sciatic nerve block and postoperative systemic opioid analgesia; in group V (n=63), intraoperative lumbar paravertebral block with caudal epidural block and postoperative prolonged lumbar paravertebral analgesia; in group VI (n=51), intraoperative general anaesthesia and postoperative systemic opioid analgesia were used.
The results of both experimental and clinical parts of the study showed the possibility of anaesthesia of lumbar and sacral plexuses branches with 20 or 40 mL of anaesthetic solution.
In studies of circulation, significant changes were observed during central neuraxial (especially spinal) blocks, with significant reduction in blood pressure and a tendency for bradycardia. General anaesthesia was accompanied by rather stable circulatory parameters, but with a tendency to their growth at the traumatic stage, which can be explained by insufficient anti-nociceptive protection. Intra-operatively, circulation was the most stable during paravertebral block combined with caudal epidural anaesthesia or peripheral nerve blocks (lumbar plexus plus sciatic nerve). Post-operatively, circulation was the most stable during prolonged regional analgesia methods, the paravertebral block being the best option for hemodynamic stability.
Glycaemia during surgery was the highest with general anaesthesia, after surgery it was the highest with systemic opioid analgesia. Insulin levels were lowest even at the most traumatic stage of surgery with spinal anaesthesia; at all other stages of the study, the level of insulin between the groups did not differ significantly. Plasma levels of cortisol did not change significantly at all stages in all six groups.
C-reactive protein, both intra- and postoperatively was less increased in venous and drainage blood of patients with regional anaesthesia and analgesia, than with general anaesthesia and systemic opioid analgesia.
The platelet count, fibrinogen, and D-dimer levels depend more on the method of postoperative analgesia than on the method of intraoperative anaesthesia. Higher levels of D-dimer were observed in patients who received systemic opioid analgesia after surgery than those receiving regional analgesia.
The intensity of pain rest and movement during the first postoperative hours was statistically significantly and clinically essentially higher in patients operated under spinal and general anaesthesia, which is explained by the rapid recovery of nociceptive impulses. In the next three days, the intensity of pain was also the highest in patients of groups I and VI and tended to increase in the evening. During the first postoperative days at all stages, the best analgesia was observed with prolonged epidural block, somewhat inferior was the blockade of the nerves: paravertebral and psoas compartment.
As a result of our research, algorithms for the selection of optimal methods for intra-operative and post-operative regional anaesthesia/analgesia and their combinations for hip arthroplasty have been developed.
