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Anesthésie par infiltration locale (LIA) et nouvelle technique pour un soulagement efficace de la douleur après un remplacement primaire électif de la hanche et du genou - Étude innovante

Mohammed Salhab

Arrière-plan : 

Le contrôle de la douleur aiguë après des remplacements électifs du genou (TKR) et des remplacements électifs de la hanche (PTH) est souvent médiocre et est associé à un syndrome de douleur chronique à long terme. Une douleur modérée à sévère est souvent observée dans les 48 heures suivant l'intervention, nécessitant différentes méthodes de traitement de la douleur, telles que l'anesthésie locale contrôlée et l'anesthésie multimodale. L'anesthésie locale par infiltration (LIA) est actuellement une méthode établie pour traiter la douleur périopératoire ; cependant, des études ont montré des preuves contradictoires jusqu'à présent. Dans une étude en cours de 29 études explorant l'utilisation de LIA dans la TKR, LIA s'est développé comme une procédure sûre avec un meilleur contrôle de la douleur (Gibbs DMR 2012). Nous avons développé la méthode LIA pour inclure un cathéter intra-articulaire permettant de mélanger en permanence un nouveau composé (NM) après l'opération. L'insensibilité préventive à la douleur, un traitement antinociceptif, est le traitement qui est commencé avant l'intervention chirurgicale dans le but de prévenir l'aggravation de la douleur provoquée par les blessures liées aux coupures et aux brûlures survenant pendant l'intervention. En plus d'être administré avant l'intervention chirurgicale, l'insensibilité préventive à la douleur peut être utilisée dans la période postopératoire précoce. Cet effet défensif est donné par l'insensibilité préventive à la douleur sur le système nociceptif. Afin de prévenir la sensation de douleur, la littérature a répertorié plusieurs méthodes, notamment des médicaments et des traitements.

Joint substitution medical procedures are considered as one of the most excruciating orthopedic techniques. This excruciating method is the aftereffect of lacking and inadequately rewarded postoperative torment after significant joint substitution medical procedure. This agony scene must be ideal tended to in light of the fact that not exclusively does this fundamentally drag out the restoration procedure, yet in addition purposes the expanded danger of different inconveniences. If not tended to inside time or without legitimate methodology, these postoperative excruciating scenes can advance into constant torment, which in the long run drags out the general length of hospitalization and cost. The excursion to accomplish the total and long haul help with discomfort starts before the medical procedure is performed. A significant premise to accomplish long haul help with discomfort and practical recuperation after the joint medical procedure includes adequate peri-employable absense of pain. One of the significant angles to accomplish effective result after joint medical procedure is the early joint preparation with the commencement of non-intrusive treatment. A few new medications and novel procedures to enhance the post-employable agony post-medical procedure are being presented each year, yet the greater part of the patients despite everything wind up experiencing extraordinary torment following medical procedure which frequently advances into constant torment.

Arthroscopic knee medical procedure has gotten progressively well known in present day orthopedics. In any case, the post-employable knee torment the board including early help and agony free postoperative consideration to the patient stays a test to a few clinicians. Now and again, torment the board in itself has become a need for the board as a childcare methodology. Tenacious agony after knee arthoplasty stays an uncertain issue for some patients. Torment is considered as an exceptionally emotional occasion since everybody has an alternate recognition and edge of agony. What's more, hence, it turns out to be hard to normalize any agony system for a specific medical procedure. A few factors that cause knee torment, which incorporate aggravation of free sensitive spots of the joint case, synovial tissue, front fat cushion.

The point of neighborhood penetration is to anesthetize sensitive spots in a limited territory of tissue by the infusion of neighborhood sedatives close by. This stands as opposed to fringe nerve obstructs, in which nerve axons are the objective and the infusion may occur in a region expelled from the careful site (eg, brachial plexus hinder for hand medical procedure). The profundity of the region to be worked on commonly decides the necessary degree of invasion. For shallow skin methods, for example, stitching of slashes and skin biopsies, subcutaneous or intradermal penetration is adequate. Increasingly broad tasks may request invasion into muscle, belt, and other profound tissues. Two general methodologies exist for anesthetizing skin and subcutaneous tissue. The first includes infusing neighborhood sedative legitimately into the line of cut and close by tissues, successfully flooding the individual nearby sensitive spots to deliver sedation. This can be exceptionally successful, yet may require huge volumes of neighborhood sedative to accomplish total inclusion.

Aims and Objectives:

In this study we find out the results on our experience using LIA in addition to the Novel Techniques and Proprietary NM developed in Leeds-Bradford and infiltrated at 4-5 mls/hour for 48 hours post surgery.

Materials and Methods:

Between October 2013 and October 2015, 62 patients undergoing primary TKR were prospectively followed up. Three groups of patients were studied. All patients studied had spinal anaesthesia (SA) with 300-400mcg diamorphine.

Group 1.  GA. No LIA and no NM. 20 patients.

Group 2.   SA plus NM for 48 hours post operatively with catheter placed anteriorly under the patella.  21 patients.

Group 3.  SA plus LIA plus NM for 48 hours post operatively with catheter placed posteriorly in the knee joint.  21 patients.

Between June 2011 and July 2014, 173 consecutive patients undergoing primary THR using the posterior approach were also prospectively followed up.

Results and complications: 

The patients without LIA or NM required more morphine in the initial 12 hours postoperative period than different gatherings. 70% (n=14) of these gathering 1 patients required 10mg morphine following TKR contrasted with just 2% (n=1) of patients requiring 10mg of morphine when LIA and NM were utilized. The expanded morphine necessity proceeded for 48 hours postoperatively in bunch 1, while none of the patients in bunches 2 or 3 required morphine following 36 hours. Factual investigation uncovered no distinction of morphine necessities with various catheter situation. Less patients experienced sickness and heaving or urinary maintenance in the gathering with LIA and NM (p-esteem <0.05, Mann-Whitney test). There were no contaminations DVT or different difficulties in any of the gatherings.

Conclusion:

Français Cette étude montre que les patients suivant une arthroplastie totale du genou récompensés par LIA et NM pendant 48 heures après l'intervention ont eu besoin de beaucoup moins de morphine pendant cette période. Cet avantage a généralement été observé dans les 24 premières heures après l'intervention et l'avantage a été maintenu pendant 48 heures. Moins de patients ont eu besoin d'une absence de sédatif pour soulager la douleur lorsque LIA en plus de NM a été utilisé par rapport aux autres groupes. La centralité la plus importante était de 0 à 12 heures pour les patients nécessitant jusqu'à 20 mg de morphine (χ2(2) = 46,713, p = 0,000) ; et de 0 à 12 heures pour les patients nécessitant 30 mg de morphine (χ2(2) = 46 310, p = 0,000).