CME 15/07/2022 Summary
PRESENTER
MODERATOR Dr. Abhay Kulkarni,
Dr. Mohit Shete, MBBS, DNB (Ortho), Fellowship in Sports Medicine, Fellowship in Arthroscopy & Arthroplasty, (Germany)
Professor, Head of Department, Rajiv Gandhi Medical College, Kalwa, Thane, Mumbai, Maharashtra, India.
Commonest Post-arthroplasty Complications Include: = Infection – surgical wound/deep infection = Wound healing problems = Thromboembolic disease = Neurological injury = Restriction of movements = Persistent pain and dissatisfaction = Stiffness, malalignment, instability
Impact of inflammation & edema on healing Excessive swelling would lead to: = Restricted movements ⇒ delayed rehabilitation = Increased chances of infection
Trypsin, Bromelain, Rutoside plays important role in = Pain management = Promote healing = Prevent swelling = Prevent infections
Limitations with use of NSAIDs Efficacy limitations: = Effect limited to COX inhibition = Negative impact on wound healing Safety concerns: = Gastro-intestinal irritation = Renal disturbances = Cardiovascular events = Potential hepatotoxicity
Enhanced antibiotic penetration with Trypsin, Bromelain, & Rutoside = Trypsin, Bromelain, Rutoside combination has been shown to increase the absorption of antibiotics = The ↑ absorption - primarily driven by the Bromelain component = This action has been reported with multiple antibiotics and with different routes of application including subcutaneous and intramuscular routes
Most perceived clinical benefit with Trypsin, Bromelain, & Rutoside = Reduction of edema Þ promote healing = Pain management = Enhanced perfusion Þ better healing = Help in penetration of antibiotics Þ infection prevention
CME 15/07/2022 Summary
Tissue injury Vascular response Initial vasoconstriction Secondary vasodilation vascular permeability (plasma leakage)
Coagulation
Inflammatory infiltrate Growth factors, Inflammatory cytokines, polyphosphates
Platelet activation Platelet aggregation
Coagulation cascade initiation
Leucocyte activation & migration T cells
M1 macrophage
Phagocytosis
Cytokines+GFs
Neutrophil
M2 macrophage
Clot Prosta glandins
Proteases
Thromboxanes
Kininogen
Lysis Plasminogen
Tissue repair
activation threshold
Arachidonic acid Bradykinin
ROS, RNS
Plasmin
Limited action of Trypsin - Chymotrypsin than TBR combination availability
1
Potentiation2
Daftary GV, Shah AP, Divekar GH, John J, Patil NN, Khemnar BM. Systemic therapy with bromelain -trypsin-rutoside combination in inflammation: A narrative review of the pharmacodynamics. Natl J Physiol Pharm Pharmacol. Online First: 09 Mar, 2022
Trypsin/ Chymotrypsin
-
1 – by displacing “bound” plasmin from plasma proteins 2 – by the activation of PAR1 and PAR2 receptors on macrophages
Link to CME on Post Operative Management of Pain/inflammation in Arthroplasty
To access the CME Post Operative management of pain/inflammation in Arthroplasty: The role of NSAIDs vs Anti- Inflammatory enzyme please click on the youtube link. https://youtu.be/3j3WT-FjnCM.