scholarly journals A Comparison of Oral Gabapentin and Oral Pregabalin as Preemptive Analgesia for Orthopedic Surgery Under Spinal Anaesthesia

2021 ◽  
Vol 9 (1) ◽  
pp. 74-78
Author(s):  
Neena Jain ◽  
Rahul Bankapur ◽  
Preeti Lamba ◽  
saurav Singh
Keyword(s):  
Side Effects ◽  
Postoperative Pain ◽  
Spinal Anesthesia ◽  
Spinal Anaesthesia ◽  
Orthopedic Surgery ◽  
Lower Limb ◽  
Analgesic Efficacy ◽  
Double Blind Study ◽  
Group A ◽  
Group B

Background and Aims: Gabapentin and pregabalin, by decreasing noxious stimulus induced excitatory neurotransmitter release at central nervous system, may attenuate central sensitization and eventually decrease development of postoperative pain. We evaluated preemptive analgesic efficacy of single dose of oral gabapentin 600 mg and pregabalin 75mg for postoperative pain in patients undergoing lower limb orthopedic surgery under spinal anesthesia. Material and methods: A prospective, randomized, double blind study was conducted on 70 patients aged between 18 to 60 years with ASA grade 1 and 2 posted for lower limb surgeries under spinal anaesthesia. Patients were allocated into Group A and Group B receiving oral gabapentin(600mg) and oral pregabalin (75mg) respectively 1.5 hours before surgery. Primary objective was assessing duration and quality of analgesia by Visual Analogue Scale (VAS) score at 2,4,6,8,10,12,16,20 and 24 hours.Secondary objective was to assess total dose of rescue analgesic in first 24 hours, perioperative hemodynamic change and various side effects. Statistical Analysis used: Categorical data was compared using Chi- square test. Quantitative parametric data was analysed using unpaired student t-test. P value < 0.05 was considered statistically significant. Results: Mean duration of analgesia in Group A (10.53 ± 2.686 hours) was longer than Group B (7.943±3.199hr) (P = 0.0006).Mean number of analgesic dosesrequired in first 24 hourswere less in Group A (1.429 ± 0.5021) ascompared to Group B (1.771±0.6897) (P = 0.0202).All patients remained hemodynamically stable with no significant side effects noted in either group. Conclusion: We conclude that preemptive analgesic efficacy of oral gabapentin 600mg is better in comparison to oral pregabalin 75 mg for patients posted for lower limb orthopedic surgeries under spinal anesthesia.

scholarly journals Isobaric levobupivacaine a better and safer substitute for spinal anaesthesia in patients undergoing prolonged lower abdominal and lower limb surgeries

2018 ◽  
Vol 6 (9) ◽  
pp. 3111
Author(s):  
Wasimul Hoda ◽  
Abhishek Kumar ◽  
Priodarshi Roychoudhury
Keyword(s):  
Spinal Anesthesia ◽  
Spinal Anaesthesia ◽  
Lower Limb ◽  
Motor Block ◽  
Sensory Block ◽  
Double Blind Study ◽  
Double Blind ◽  
Sensory Blockade ◽  
Group A ◽  
Group B

Background: Bupivacaine being the drug of choice for spinal anaesthesia is associated with serious cardiac toxicity. Levobupivacaine and ropivacaine, both being the two S enantiomers of bupivacaine can be a safer alternatives with better cardiovascular safety. Hence, the clinical efficacy of both were assessed and compared in patients undergoing spinal anesthesia.Methods: A prospective randomized controlled double blind study was done in 68 adult posted for elective lower abdominal and lower limb surgeries under spinal anesthesia. They were randomized into 2 groups. About 3ml isobaric levobupivacaine 0.5% (15mg) was given in group A and 3ml isobaric ropivacaine 0.5% (15mg) was given in group B. Onset, duration of sensory and motor blocks, time for maximum sensory and motor block, time for 2 segment sensory regression and haemodynamic parameters were recorded and analyzed.Results: All patients achieved a sensory block of T10 dermatome. Onset of sensory blockade at T10 was similar in both groups, group A (5.71±1.31min) and group B (5.94±1.72min). Time from injection to two dermatomal regression was 129.68±15.54min in group A and 111.38±22.35min in group B. Onset of Bromage score of 1 in group A was 4.68±1.27min and in group B was 6.44±1.64min. The mean duration of motor and complete motor block was prolonged in group A patients (197.74±18.51min, 168.82±17.90 min) as compared to group B (131.88±20.41min, 106.71±10.85min).Conclusions: Isobaric levobupivacaine was found to be a better and safer substitute for spinal anesthesia in patients undergoing prolonged lower abdominal and lower limb surgeries.

scholarly journals Comparing the Analgesic Efficacy of Intrathecal Bupivacaine Alone with Intrathecal Bupivacaine Midazolam or Magnesium Sulphate Combination in Patients Undergoing Elective Infraumbilical Surgery

2016 ◽  
Vol 2016 ◽  
pp. 1-6 ◽  
Author(s):  
Josef Attia ◽  
Amany Abo Elhussien ◽  
Mostafa Zaki
Keyword(s):  
Side Effects ◽  
Magnesium Sulphate ◽  
Lower Limb ◽  
Analgesic Efficacy ◽  
Motor Blockade ◽  
Sensory Blockade ◽  
Lower Limb Surgery ◽  
Group A ◽  
Group B ◽  
Limited Duration

Background. Spinal anaesthesia, which is one of the techniques for infraumbilical surgeries, is most commonly criticized for limited duration of postoperative analgesia. Aim of the Work. The aim of this study was to decrease bupivacaine dose used in spinal anesthesia in patients undergoing orthopedic lower limb surgery and reduce its possible side effects. Patient and Methods. Sixty adult patients of both sexes, divided into three. Group C received 2.5 mL bupivacaine and 0.5 mL saline 0.9%. Group A received 2.5 mL bupivacaine and 0.5 mL midazolam. Group B received 2.5 mL bupivacaine and 0.5 mL magnesium sulphate. Results. As regards onset of both motor and sensory blockade, there are a significant decrease in group A and a significant increase in group B as compared to group C, with a significant decrease in duration of motor blockade and significant increase in duration of sensory blockade in both group A and group B, respectively, as compared to group C, with a significant decrease in the duration of sensory blockade in group B as compared to group C. Conclusions. These results suggested that intrathecal midazolam as an adjuvant for bupivacaine increases the duration of both sensory and motor blockade more than that of magnesium sulphate.

scholarly journals Haemodynamic Effects and Complications of Unilateral Spinal versus Standard Spinal Anesthesia in Elderly with Low Ejection Fraction Undergone Lower-Limb Surgery

2017 ◽  
Vol 5 (1) ◽  
pp. 20-24
Author(s):  
Md Mushfiqur Rahman ◽  
Md Mahbubul Hasan Munir ◽  
Raihanuddin ◽  
Shafiul Alam Shaheen ◽  
Md Abdus Salam Khan ◽  
...  
Keyword(s):  
Spinal Anesthesia ◽  
Spinal Anaesthesia ◽  
Lower Limb ◽  
Motor Block ◽  
Sympathetic Block ◽  
Hyperbaric Bupivacaine ◽  
Unilateral Spinal Anesthesia ◽  
Lower Limb Surgery ◽  
Group A ◽  
Group B

Background: Cardiovascular system may be profoundly affected by spinal anaesthesia due to unavoidable sympathetic blockade which is more prominent in elderly.A restricted sympathetic block during spinal anesthesia may minimize hemodynamic changes.Objective: To assess whether a unilateral spinal anaesthesia using 0.5% hyperbaric bupivacaine will restrict the sympathetic block to avoid the undesired cardio vascular effects.Materials and method: In this prospective study 60 ASA Ill and IV patients aged between 60-90 years undergoing unilateral lower limb surgery were included. Patients were divided into two groups. In group-A, dural puncture was performed with the patient in the lateral decubitus position with 1.5 mL of hyperbaric bupivacaine. In group-B, it was performed with the patient in a seated position using 1.5 mL hyperbaric bupivacaine. Each patient was then placed in supine position. The speed of injection was 1 mL/30s. Patients were placed in the lateral position with operated side down and kept in this position for 10 minutes. Motor and sensory levels were assessed, and haemodynamic alterations were monitored just after block, 5, 10, 15 and 30 minutes of spinal anaesthesia.Results: The demographic data were found similar in both groups. The time to the onset of the sensory and motor block was significantly shorter in group-B. The duration of motor and sensory block was significantly shorter in group-A. Haemodynamically all the parameters revealed better out come in unilateral spinal anesthesia. The incidence of complications (nausea, headache, and hypotension) was also lower in group A.Conclusion: When unilateral spinal anesthesia was performed using a low-dose, low-volume and low-flow injection technique, it provides adequate sensory-motor block and helps to achieve stable hemodynamic parameters during surgery on a lower limb. Furthermore, this technique avoids unnecessary paralysis on the non-operated side.Delta Med Col J. Jan 2017 5(1): 20-24

scholarly journals Epidural butorphanol for post operative analgesia in lower limb surgeries: A comparative study with epidural tramadol

2017 ◽  
Vol 6 (3) ◽  
pp. 26-32
Author(s):  
G P Deo ◽  
S K Shrestha ◽  
I N Shrestha
Keyword(s):  
Patient Satisfaction ◽  
Side Effects ◽  
Lower Limb ◽  
Analgesic Efficacy ◽  
Epidural Injection ◽  
Double Blind ◽  
Duration Of Action ◽  
Number Of Patients ◽  
Group B

To compare the efficacy of epidural butorphanol and tramadol for post operative analgesia in lower limb surgeries. Randomized, controlled, double blind, prospective study conducted at Department of Anaesthesia and Critical Care, Chitwan Medical College from September 1st 2015 to August 31st 2016. 60 patients of ASA Grade I and II of either sex, aged between 18-65 years willing for epidural analgesia for post operative analgesia were included in the study. They were divided into two groups: Group B- Butorphanol group and Group T- Tramadol group. Subjects of Group B received 2mg of Butorphanol and 0.25% Bupivacaine making a total volume of 10 ml and that of Group T received 100mg of Tramadol and 0.25% Bupivacaine also making a total volume of 10 ml. Analgesic efficacy was assessed by Visual Analogue Scale (VAS). The onset and duration of analgesia along with side effects were also assessed. The quality of analgesia was studied using time to independent mobilization and overall patient satisfaction. Total number of patients was 60, of ASA Grade I and II, aged between 18-65 years. The mean age of patients in Group B was 42.6±11.7 years and 46.1±11.2 years in Group T. Time of onset of analgesia after epidural injection was 7.4±0.9 minutes in Group B and 12.7±1.5 minutes in Group T and the difference was found to be statistically significant. Duration of analgesia was 317.1±99.1 minutes and 438.8±136.6 minutes in Butorphanol and Tramadol groups respectively which was also statistically significant. Sedation was significantly higher in butorphanol group whereas nausea and vomiting was higher in tramadol group. Quality of analgesia in terms of patient satisfaction was better with epidural butorphanol. Both epidural tramadol and butorphanol were effective in relieving post operative pain however butorphanol had lesser side effects and greater patient satisfaction compared to tramadol but the duration of action was relatively short.

scholarly journals Postoperative analgesia after lumbar disc surgery: A comparison between ketorolac and opioid

2014 ◽  
Vol 23 (2) ◽  
pp. 56-61
Author(s):  
Md Mustafa Kamal ◽  
Abdullah Al Maruf ◽  
Sabina Yeasmeen ◽  
Abdul Hye
Keyword(s):  
Side Effects ◽  
Postoperative Pain ◽  
Urinary Retention ◽  
Postoperative Analgesia ◽  
Lumbar Spine Surgery ◽  
Surgical Closure ◽  
Group A ◽  
The Mean ◽  
Group B ◽  
Post Operative Nausea

Background Most spinal surgery is painful and good postoperative analgesia is important. Opioids are the traditional first-line treatment. Ketorolac has been used for postoperative pain relief. However, there is no data available about controlling postoperative pain with ketorolac after open lumbar discectomy or laminectomy in Bangladesah. Objective To compare the efficacy of a Parentral ketorolac with conventional opioid for management of postoperative pain after lumbar disectomy or laminectomy. Methods Sixty patients who underwent lumbar disectomy or laminectomy were randomly allocated into two groups. Group A (n = 30) patients received 30 mg intramuscular ketorolac upon surgical closure and every 6 hours for 24 hours and intramuscular pethidine 1.5 mg/kg/b.w. as needed (PRN). Group B (n = 30) patients received only intramuscular pethidine 1.5 mgkg-1/b.w. every 6 hours for 24 hours and as needed (PRN). Postoperative analgesia was assessed in both groups by Visual Analogue Scale at arrival in postoperative ward and at 6, 12 and 24 hours for 24 hours. Total postoperative narcotic consumption and side effects like post operative nausea and vomiting (PONV), dizziness, urinary retention and pruritus were also recorded. Results Baseline data were comparable between the two groups. The mean VAS almost similar and less than 3 at different reading in both groups which indicate adequate postoperative analgesia and the differences were statistically not significant. The mean total cumulative amount of pethidine administered over 24 hrs period was less in group A it was 64.31+19.13 mg where as in group B was 161.23+21.25 mg. and the difference was statistically significant (p<0.01). Incidences of side effects like PONV, urinary retention and pruritus were more in group B than group A and differences were statistically significant (p<0.01). Conclusion For postoperative pain management after lumbar spine surgery both ketorolac and traditional parental opioid found effective. Total opioid consumption is significantly less with ketorolac and side effects like PONV, dizziness, urinary retention and pruritus were more with opioid alone. DOI: http://dx.doi.org/10.3329/jbsa.v23i2.18175 Journal of BSA, 2009; 23(2): 56-61

scholarly journals Comparison of Intrathecal Fentanyl and Butorphanol as an Adjuvant to Intrathecal Bupivacaine 0.5% in Infraumbilical Surgeries- A Randomised Double Blind Study

2020 ◽  
Author(s):  
Sandip Roy Basunia ◽  
Prosenjit Mukherjee ◽  
Md Bakir Hossain Munshi
Keyword(s):  
Spinal Anaesthesia ◽  
Motor Block ◽  
Controlled Trial ◽  
Sensory Block ◽  
P Value ◽  
Double Blind Study ◽  
Hyperbaric Bupivacaine ◽  
Double Blind ◽  
Group A ◽  
Group B

Introduction: Neuraxial opioids are widely used as adjuvants to local anaesthetic as they improve quality and duration of block. Neuraxial opioids like Butorphanol and Fentanyl allow prolonged analgesia in the postoperative period and faster recovery from spinal anaesthesia. Aim: To compare the safety and efficacy of Butorphanol and Fentanyl combined with bupivacaine for spinal anaesthesia in infraumbilical surgeries. Materials and Methods: The present study was a randomised controlled trial in which 110, ASA I and II patients of either sex who underwent elective infraumbilical surgeries under spinal anaesthesia were selected. Patients were allocated randomly into two groups A (n=55) and B (n=55). Group A (F) received intrathecal 0.5% hyperbaric bupivacaine 12.5 mg (3 mL) with fentanyl 25 microgram (0.5 mL) to make it total 3.5 mL. Group B (B) received intrathecal 0.5% hyperbaric bupivacaine 12.5 mg (3 mL) with butorphanol 250 microgram (0.25 mL) and Normal Saline (NS) 0.25 mL to make it total 3.5 mL. Heart Rate (HR), Systolic and Diastolic Blood Pressure (SBP, DBP), two segment regression time of sensory block, motor block were assessed at preset intervals. Chi-square test or Fischer’s-exact test were used and a p-value ≤0.05 was considered as statistically significant. Results: Mean of two segment sensory regression time of Group A was 41.94±1.73 minutes and Group B was 50.56±4.43 minutes (p<0.0001). Time to onset of motor block in Group A was 5.28±.32 minutes and Group B was 5.27±.32 minutes (p=0.96). Mean duration of motor block in Group A was 81.23±4.87 minutes and Group B was 109.83±2.61 minutes (p<0.0001). Time to rescue analgesic was 289.27±7.37 minutes in Group A and 378.41±10.25 minutes in Group B (p<0.0001). HR, SBP and DBP were comparable among the groups. Conclusion: Intrathecal bupivacaine-butorphanol mixture was clinically better as it provided longer duration of analgesia with lesser incidences of pruritus and nausea/vomiting compared to intrathecal fentanyl-bupivacaine mixture.

Compare the Analgesic Efficacy of Dexmedetomidineand Fentanyl as an Adjuvant to Bupivacaine for Lower Limb Surgery

2021 ◽  
Vol 15 (6) ◽  
pp. 2153-2155
Author(s):  
Arshi Naz ◽  
Mirza Shahzad Baig ◽  
Vijai Kumar ◽  
Samita S Khan ◽  
Sidra Javed ◽  
...  
Keyword(s):  
Spinal Anaesthesia ◽  
Lower Limb ◽  
P Value ◽  
Hyperbaric Bupivacaine ◽  
Rescue Analgesia ◽  
Sensory Blockade ◽  
Significant Difference ◽  
Lower Limb Surgery ◽  
Group A ◽  
Group B

Objective: To compare the analgesic effectiveness of Dexmedetomidine and Fentanyl as an adjuvant to 0.5% Bupivacaine in spinal anaesthesia for patients undergoing lower limb surgery. Study Design: Randomized controlled trial. Place & Duration:The study was conducted at department of Anesthesia, Shaheed Mohtarma Benazir Bhutto Institute of Trauma, Karachi for duration from 15thJuly2020 to 15thFebruary 2021. Methods: In this study 52 patients of both genders undergoing lower limb surgeries were included. Patient’s ages were ranging from 20 to 70 years. All the patients were divided into two Groups. Group A included 26 patients and received Inj. Dexmedetomidine 10 μg in 0.5ml normal saline with 12.5mg of 0.5% hyperbaric bupivacaine, Group B had 26 patients and received 25mg fentanyl with 12.5mg of 0.5% hyperbaric bupivacaine. Time to achieve T10 blockade, time to first rescue analgesia were examined and compare between both groups. All the statistical data was analyzed by SPSS 24.0. P-Value <0.05 was significantly considered. Results: Mean age of group A was 40.52±12.28 years and in group B it was 40.14±13.34 years. There were 18 (69.23%) male patients and 8 (30.77%) females in group A while in Group B 19 (73.08%) patients were male and 7 (26.92%) were females. No significant difference was observed between both groups regarding time to T10 blockade with p-value >0.05. A significant difference was found regarding time to rescue analgesia, in Group A it was 426.58±92.44 minutes and in Group B, it was 206.44±48.47 minutes (p-value <0.0001). Patients’ satisfaction was high in dexemedetomidine group as compared to fentanyl group. Conclusion: Dexmedetomidine 10 μg with 0.5% bupvicaine showed better effectiveness regarding time to first rescue analgesia as compared to fentanyl. No significant difference was observed regarding time to sensory blockade between both medications. Keywords: Dexmedetomidine, Fentanyl, Spinal Anaesthesia, Lower Limb Surgery, Sensory Block, Analgesia

scholarly journals Comparison of Pre-emptive Use of Diclofenac, Ketorolac and Tramadol for Post-operative Pain in Laparoscopic Cholecystectomy

2009 ◽  
Vol 20 (1) ◽  
pp. 24-29 ◽  
Author(s):  
Md Rafiqul Hasan Khan ◽  
Md Zohirul Islam ◽  
Md Sazzad Hossain ◽  
Lutful Aziz ◽  
SN Samad Choudhury
Keyword(s):  
Blood Pressure ◽  
Laparoscopic Cholecystectomy ◽  
Postoperative Pain ◽  
Analgesic Efficacy ◽  
Prospective Clinical Study ◽  
The Poor ◽  
Post Operative Pain ◽  
Group A ◽  
Group B ◽  
Better Than

Under treatment of postoperative pain has been the topic of several recent editorials. The prevention, recognition, and management of postoperative pain in adults, as well as in children, have been receiving a great deal of interest. The poor outcome obtained with current regimens is primarily due to the inadequacies of drug administration techniques rather than the qualities of opioids themselves. In this prospective study comparison of preemptive use of diclofenac, ketorolac and tramadol was done for postoperative pain in laparoscopic cholecystectomy. 60 patients were divided into three groups. Group A received injection Diclofenac (3mg/kg) 75mg maximum at a time. Group B received injection Ketorolac (30 mg). And group C patients received injection Tramadol (100 mg). All drugs were given intravenous half an hour before induction. Analgesic efficacy was measured in VAS scale. In addition pulse, systolic blood pressure, diastolic blood pressure, mean blood pressure, total pethidine requirement and time of first pethidine requirement were recorded Patients received an increment of 10-20 mg of pethidine when pain score was 3-4. In this study, total pethidine consumption in group A is 56.5±5.14, in group B is 46.75±4.65 and in group C is 49±5.42. It shows that group B and group C have same analgesic effectiveness and which is better than group A. On the basis of present prospective clinical study postoperative pain can be managed by preemptive use of diclofenac, ketorolac and tramadol. The analgesic efficacy of ketorolac and tramadol is same and better than diclofenac. Key Words: Pre-emptive analgesia, Laparoscopic cholecystectomy. Journal of BSA, Vol. 20, No. 1, January 2007 p.24-29

scholarly journals COMPARATIVE STUDY OF HAEMODYNAMIC CHANGES BETWEEN 6% HYDROXYETHYLSTARCH 130/0.4 AND RINGER LACTATE COLOADING IN ELDERLY PATIENTS UNDERGOING LOWER LIMB ORTHOPAEDIC SURGERY UNDER SPINAL ANAESTHESIA

2019 ◽  
Vol 3 (6) ◽  
Author(s):  
Jayanta Chakraborty ◽  
Uma Mandal
Keyword(s):  
Elderly Patients ◽  
Spinal Anaesthesia ◽  
Lower Limb ◽  
Orthopaedic Surgery ◽  
P Value ◽  
Ringer Lactate ◽  
Lower Limb Surgery ◽  
Group A ◽  
Group B ◽  
Lactate Solution

Background: Anaesthesia for the lower limb surgeries could be either general or regional. Studies had shown that regional anaesthesia for lower limb surgery results in better postoperative outcomes, including improved respiratory function, less nausea vomiting, less pain and lower incidence of deep vein thrombosis. Among all the regional anaesthetic techniques spinal anesthesia remained most preferred technique for its fast, predictable, profound, high quality sensory and motor block. However some complications like hypotension, bradycardia, post dural puncture headache, urinary retention were unavoidable and hypotension remained the most common one and found to be more in the elderly population with incidence of 25–82%. Treating spinal anaesthesia-induced hypotension included intravenous (IV) volume administration. IV Fluid infused before and at the time of spinal anaesthesia was referred to as preloading and coloading respectively. Although merit of coloading and the choice of fluid to be infused had remained  a matter of debate, till today no definitive study had indicated any superiority of colloids over crystalloids decisively  moreover large amount crystalloids to counter hypotensin  remained a threat to the cardiovascular overload for  elderly patients. Role of vasopressors in elderly remained controversial too. So this observational prospective study was  undertaken to compare  the effiicacy of coloading of infusion 6%HES 130/0.4 (colloid) and Ringer Lactate solution (crystalloid)  to maintain the intra operative haemodynamics in elderly patients undergoing lower limb orthopaedic surgery under spinal anaesthesia. Objectives: To assess and to compare the efficacy of infusion 6%HES 130/0.4 and infusion Ringer lactate solution coloading in preventing the intra-operative hypotension. Materials and method: On  approval of the Ethics Committee of Burdwan Medical College (BMC&H), 80 patients were included and equally divided into two groups group A and group B where groupp A received 6% HES  as coloading fluid and groupp B received RL as coloading fluid at the start of spinal anaesthesia. On entering Operation Theatre baseline parameters were noted for each patient and lumbar puncture for spinal anaesthesia was performed following strict aseptic precautions, in sitting position. Upon achieving adequate block episodes of hypotension were noted and treated according to the study protocol. Results: Statistical analysis for Continuous and categorical variables were done using Mann-Whitney U test and Pearson’s Chi Square test accordingly and p values less than 0.05 were considered significant. In group A, 17.5 % patients developed one episodes of hypotension whereas in group B, 37.5% patients developed one episodes of hypotension which was statistically significant with p value 0.0465.  In group A none of the patients developed further episodes of hypotension but in group B 5% affected patients developed one more episodes of hypotension and 2.5% affected patients developed two more episodes of hypotension. Average intravenous dose of mephentermine required to treat hypotension was 1.05 mg for group A and 2.70 mg for group B and found to be statistically significant with p value 0.039. Total fluid consumption In group A was 654.95 ml whereas in group B  was 976.73 ml and also  found to be statistically significant with p value <0.001. Conclusion:  The study found that coloading with 6% HES was significantly effective than Ringer Lactate solution in preventing episodes of hypotension in spinal anaesthesia induced elderly patients undergoing lower limb surgery without any noticeable adverse effect. Key Words: Spinal anaesthesia, lower limb surgery, elderly patients, coloading

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