Gabapentin does not improve multimodal analgesia outcomes for total knee arthroplasty: a randomized controlled trial

Purpose

This study assessed whether gabapentin given preoperatively and for two days postoperatively (in addition to patient-controlled analgesia [PCA] morphine, acetaminophen, and ketorolac) is effective in reducing morphine requirements and moderating pain scores when compared with placebo for primary total knee arthroplasty.

Methods

This single-centre double-blind randomized controlled trial was undertaken in patients who underwent primary total knee arthroplasty. All subjects received acetaminophen 1,000 mg and ketorolac 15 mg po preoperatively. Postoperatively, subjects received PCA morphine, acetaminophen 1,000 mg every six hours, and ketorolac 15 mg po every six hours. Subjects received either gabapentin 600 mg po preoperatively followed by 200 mg po every eight hours for two days or matching placebo. The primary outcome was cumulative morphine consumption at 72 hr following surgery. Secondary outcome measures included pain scores and patient satisfaction.

Results

There were 52 subjects in the gabapentin group and 49 subjects in the placebo group. The average cumulative morphine consumption at 72 hr postoperatively was 66.3 mg in the gabapentin group and 72.5 mg in the placebo group (difference ?6.2 mg; 95% confidence interval ?29.1 to 16.8 mg; P = 0.59). Mean pain scores at rest, with passive movement, or with weight bearing were similar in both groups at corresponding time periods for the first three days following surgery. In addition, mean patient satisfaction scores and hospital length of stay were similar in the two groups.

Conclusion

Gabapentin 600 mg po given preoperatively followed by 200 mg po every eight hours for two days has no effect on postoperative morphine consumption, pain scores, patient satisfaction, or length of hospital stay. This trial is registered at ClinicalTrials.gov NCT01307202.     

Long-term follow-up after mesh removal and selective neurectomy for persistent inguinal postherniorrhaphy pain

Purpose

Persistent inguinal pain, influencing daily activities, is seen in about 5 % of patients following inguinal herniorrhaphy. Surgical treatment of patients with persistent postherniorrhaphy pain has been associated with pain relief and improvement in functional status. However, the detailed long-term outcome effects remain to be clarified. The aim of this study was to determine the long-term effects of mesh removal and selective neurectomy in patients with persistent postherniorrhaphy pain after previous open repair.

Methods

The study consecutively included 54 inguinal postherniorrhaphy pain patients treated with mesh removal and aimed neurectomy. Patients completed questionnaires evaluating pain intensity with a numerical rating scale (NRS) and pain-related functional impairment preoperatively, and, 3, 6, 12, 24, and 36 months postoperatively. Endpoints were changes in pain intensity and functional ability when comparing preoperative and postoperative assessments.

Results

Pain intensities (average, maximum, and during activity) were significantly lower at all time points during follow-up compared to preoperative values (p < 0.01 for all) with a reduction in median (IQR) average pain intensity from 6.0 (5.0–7.0) preoperatively to 3.0 (1.0–5.5) at 36-month follow-up. There was no association between positive pain outcome and intraoperative nerve identification (p = 0.47). The number of patients who reported a long-term negative effect of the operation (≥25 % increase in average pain intensity at 36-month follow-up) was 1 of 8. The functional ability was improved at 3 months after the operation (p < 0.01), but the improvement was not statistically significant in the follow-up period. Preoperative signs of depression, anxiety, and catastrophizing had no influence on outcome.

Conclusions

Mesh removal and attempted neurectomy may provide long-lasting analgesic effects in most patients and with a small proportion being worse, without relation to pain history and operative findings. Detailed multicenter collaboration is required to define preoperative diagnostics and the indication for mesh removal and neurectomy, the exact surgical procedure (type of neurectomy) and with detailed follow-up.     

Cardiopulmonary bypass does not affect plasma concentration of preoperatively administered gabapentin

Purpose

Drug effects can be unpredictable during cardiac surgery due to factors that may influence drug concentration, such as extracorporeal oxygenation and hemodilution. The primary aim of the current investigation was to determine whether plasma gabapentin concentration is altered by cardiopulmonary bypass (CPB).

Methods

Following approval from the Research Ethics Board and written informed consent, we conducted this open-label prospective cohort investigation. A convenience sample of 16 patients, who were scheduled for coronary bypass surgery, received oral gabapentin 600 mg as follows: 90 min prior to induction of anesthesia, following tracheal extubation, and then every eight hours for a total of four doses. Plasma gabapentin concentration, as well as pain and sedation scores, were documented.

Results

Plasma gabapentin concentrations were unaltered during CPB (31.9 ± 12.7 μmol·L^?1 prior to CPB, 35.6 ± 12.9 to 37.2 ± 9.6 μmol·L^?1 during CPB). However, using the current protocol, drug accumulation (reflected by increased drug concentrations) was observed following the third (58.2 ± 19.5 μmol·L^?1) and the fourth (71.9 ± 34.3 μmol·L^?1) doses. Pain and sedation scores and opioid requirements were comparable with those found in other studies.

Conclusion

Plasma gabapentin concentration is unaltered during CPB following preoperative administration. Drug accumulation following third and fourth postoperative doses suggests the need for therapeutic drug monitoring in future trials. Gabapentin is well established as an effective adjunct analgesic in a number of surgical settings. Randomized controlled trials are necessary to evaluate analgesic efficacy, optimal dosing, and adverse effects in the setting of cardiac surgery. (ClinicalTrials.gov number, NCT01022736).     

Effects of a single 1200-mg preoperative dose of gabapentin on anxiety and memory

Background

Gabapentin has antihyperalgesic and potential anxiolytic effects. We therefore evaluated the effects of gabapentin premedication on anxiety, amnesia, and sedation. We tested the primary hypothesis that 1200 mg of oral gabapentin 2 to 3 h before surgery reduces preoperative anxiety. Our secondary hypothesis was that gabapentin administration is sedative without causing preoperative amnesia.

Study design

Prospective, randomized and placebo-controlled study.

Methods

Surgical patients having general anaesthesia were randomly assigned to either 1200 mg oral gabapentin (n = 32) or an identical-looking placebo (n = 32) 2 to 3 h before anaesthesia. Anxiety, sedation, and amnesia were quantified before premedication, 2 h thereafter, and postoperatively. Preoperative anxiety was measured using the Spielberger state trait anxiety inventory (STAI state) and the visual analogue scale anxiety (VAS). Memory was assessed with the picture recall test of Snodgrass and Vanderwart. Results were compared with t, Mann-Whitney U, or Chi² tests as appropriate, P < 0.05 was considered statistically significant.

Results

STAI state, our primary outcome, decreased significantly in the gabapentin group, from 37.2 to 30.8, and remained unchanged in the placebo group, from 39.3 to 37.9 (P = 0.003). The VAS score for anxiety also decreased, but not significantly, from 28.2 to 19.2 in the gabapentin group and from 28.7 to 24.7 in the placebo group (P = 0.065). No difference was observed in the amnesic effect; nor did the groups differ in terms of recovery times or sedation scores.

Conclusion

Gabapentin premedication, 1200 mg, provided preoperative anxiolysis without causing sedation or impairing preoperative memory.     

The patient’s perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study

Background

The purpose of this study was to provide prospective independently analyzed evidence on how patients feel about a carpal tunnel release (CTR) performed under local anesthesia only (no sedation or tourniquet) versus with local anesthesia, intravenous (IV) sedation, and a tourniquet.

Methods

This prospective cohort study compared 100 consecutive CTRs done with only lidocaine and epinephrine in Saint John, New Brunswick to 100 consecutive CTRs done with IV sedation in Davenport, Iowa. Patient perspectives on the anesthesia were captured in a blinded questionnaire 1 week postoperatively.

Results

For subsequent surgery, 93 % of wide awake patients would choose local anesthesia only and 93 % of sedated patients would choose sedation. Wide awake patients spent less time at the hospital (M?=?2.6 h) than sedated patients (M?=?4.0 h; p?<?.001). Preoperative blood work, electrocardiograms, and/or chest radiographs were done for 3 % of wide awake patients and 48 % of sedated patients (p?<?0.001). Preoperative anxiety levels for wide awake patients were lower than for sedated patients (p?=?0.007); postoperative anxiety was similar. There were no anesthesia complications in either group. Narcotics were used by 5 % of unsedated patients and 67 % of sedated patients (p?<?0.001). Adequate pain control was reported by 89 % and 90 % of patients, respectively.

Conclusions

The majority of patients from both cohorts liked whichever method of anesthesia they received and would choose it again. However, sedated patients spent more time at the hospital, required more preoperative testing, and reported greater preoperative anxiety.     

Ultrasound-guided adductor canal block for arthroscopic medial meniscectomy: a randomized, double-blind trial

Purpose

The saphenous nerve block using a landmark-based approach has shown promise in reducing postoperative pain in patients undergoing arthroscopic medial meniscectomy. We hypothesized that performing an ultrasound-guided adductor canal saphenous block as part of a multimodal analgesic regimen would result in improved analgesia after arthroscopic medial meniscectomy.

Methods

Fifty patients presenting for ambulatory arthroscopic medial meniscectomy under general anesthesia were prospectively randomized to receive an ultrasound-guided adductor canal block with 0.5% ropivacaine or a sham subcutaneous injection of sterile saline. Our primary outcome was resting pain scores (numerical rating scale; NRS) upon arrival to the postanesthesia care unit (PACU). Secondary outcomes included NRS at six hours, 12 hr, 18 hr, and 24 hr; postoperative nausea; and postoperative opioid consumption.

Results

There was a statistically significant difference in mean NRS pain scores upon arrival to the PACU (P = 0.03): block group NRS = 1.71 (95% confidence interval [CI] 0.73 to 2.68) vs sham group NRS = 3.25 (95% CI 2.27 to 4.23). Cumulative opioid consumption (represented in oral morphine equivalents) over 24 hr was 71.8 mg (95% CI 56.5 to 87.2) in the sham group vs 44.9 mg (95% CI 29.5 to 60.2) in the block group (P = 0.016).

Conclusions

An ultrasound-guided block at the adductor canal as part of a combined multimodal analgesic regimen significantly reduces resting pain scores in the PACU following arthroscopic medial meniscectomy. Furthermore, 24-hr postoperative opioid consumption and pain scores were also reduced.     

Prospective,randomized-controlled trial comparing postoperative pain after plug and patch open repair with totally extraperitoneal inguinal hernia repair

Purpose

The aim of this study was to compare postoperative pain between the open tension-free plug and patch (PP) technique and the totally extraperitoneal patch (TEP) hernioplasty.

Methods

One hundred and fifty-four male patients with unilateral inguinal hernia were randomized to undergo PP and TEP from 2005 to 2009. Pain assessment was conducted using the numerical rating scale (NRS) and the McGill Pain Questionnaire preoperatively, 6, 12 and 24 months postoperatively. All patients received the same analgesic regimen and documented pain in a NRS-based 4-week diary.

Results

Of the 154 patients 77 underwent TEP and 77 PP. Median follow-up was 3.8 years. One recurrent hernia was observed in the TEP and two in the PP group (p = 0.56). Median preoperative NRS scores were 2 and 2, 0.3 and 0.4 at 6 months, 0.1 and 0.3 at 12 months, 0.2 and 0.1 at 24 months postoperatively in the PP and TEP groups, respectively (p > 0.05). Data from the 4-week pain diaries revealed significant differences in pain intensity between the two different techniques from the second postoperative week (p < 0.05). Patients in the PP group required more additional analgesics on day four and five postoperatively (p = 0.037 and 0.015, respectively).

Conclusions

Our data favor the TEP technique concerning postoperative pain as primary endpoint between tension-free PP and TEP hernia repair.     

Predictors of postoperative pain and analgesic requirements following abdominal hysterectomy: an observational study

Purpose

A prospective observational study is conducted to identify independent predictors of pain and morphine consumption following abdominal hysterectomy.

Methods

Preoperative State Trait Anxiety Inventory (STAI), Numerical Rating Scales (NRS) for anxiety and pain expectations, thermal pain thresholds and pain scores at forearm and incision site, and pain scores generated from the insertion of an intravenous catheter were measured in female patients undergoing abdominal hysterectomy. Pearson correlations between the predictors and the two outcome measures postoperative pain scores and morphine consumption were studied and multiple regression analysis was conducted to identify independent predictors (primary outcome). Secondary outcomes included cut-off values of predictive tools for morphine consumption.

Results

Data from 60 patients were analyzed. STAI state anxiety, NRS pain expectations, and NRS anxiety scores were identified as independent predictors of postoperative morphine consumption. We identified a cut-off value of 4.5 (sensitivity 90 %, specificity of 60 %) for the NRS anxiety and a cut-off of 42.5 (sensitivity 70 %, specificity 70 %) for the state anxiety STAI score for increased postoperative morphine consumption.

Conclusions

Preoperative STAI state anxiety scores and NRS pain expectations are independent predictors for increased morphine consumption following hysterectomy. The STAI state anxiety tool and NRS 0-10 anxiety tool can be used interchangeably. The NRS 0-10 anxiety is a much simpler tool than STAI state anxiety and is associated with a higher sensitivity for high morphine consumption. Thermal pain thresholds and IV pain scores were not predictive of postoperative morphine consumption.

     

A 2-year follow-up of quality of life, pain, and psychosocial factors in patients with chronic prostatitis/chronic pelvic pain syndrome and their spouses

Objectives

There are two objectives: (1) Examine quality of life (QoL) and mood between chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) patients and spouses over a 2-year period; (2) Longitudinally assess CP/CPPS patient pain, disability, and pain catastrophizing over a 2-year period.

Methods

Forty-four CP/CPPS diagnosed men and their spouses participated. Patients completed demographics, QoL, depression, anxiety, pain, disability, and catastrophizing across the study. Spouses completed QoL, depression, and anxiety. Patients/spouses were not different in education, but patients were older (49 years; SD = 9.56). The average symptom duration was 8.68 (SD = 7.61). Couples were married or common law, and majority of patients were employed. Due to attrition, approximately 21 couples provided analyzable data.

Results

Patients and spouses physical QoL did not statistically differ over time from one another, and both increased over the study period. Mental QoL increased over time, but patients reported lower QoL. Patients reported more depression and anxiety, but both measures remained stable over time for spouses and patients. Finally, patient only analyses showed that disability did decrease over time from a high at 6 months, but pain and catastrophizing showed stability over the 2 years.

Conclusions

Patients reported worse mental QoL, depression, and anxiety compared to spouses, and spouses reported significant stable levels of depression and anxiety similar to patients. Further, patient catastrophizing, pain, and disability did not reduce over the 2-year assessment period. These results provide further impetus for the development and implementation of mental health strategies alongside continued medical efforts in couples suffering from CP/CPPS.     

A comprehensive multimodal pain treatment reduces opioid consumption after multilevel spine surgery

Purpose

Major spine surgery with multilevel instrumentation is followed by large amount of opioid consumption, significant pain and difficult mobilization in a population of predominantly chronic pain patients. This case–control study investigated if a standardized comprehensive pain and postoperative nausea and vomiting (PONV) treatment protocol would improve pain treatment in this population.

Methods

A new regimen with acetaminophen, NSAIDs, gabapentin, S-ketamine, dexamethasone, ondansetron and epidural local anesthetic infusion or patient controlled analgesia with morphine, was introduced in a post-intervention group of 41 consecutive patients undergoing multilevel (median 10) instrumented spinal fusions and compared with 44 patients in a pre-intervention group.

Results

Compared to patients in the pre-intervention group, patients treated according to the new protocol consumed less opioid on postoperative day (POD) 1 (P = 0.024) and 2 (P = 0.048), they were mobilized earlier from bed (P = 0.003) and ambulation was earlier both with and without a walking frame (P = 0.027 and P = 0.027, respectively). Finally, patients following the new protocol experienced low intensities of nausea, sedation and dizziness on POD 1–6.

Conclusions

In this study of patients scheduled for multilevel spine surgery, it was demonstrated that compared to a historic group of patients receiving usual care, a comprehensive and standardized multimodal pain and PONV protocol significantly reduced opioid consumption, improved postoperative mobilization and presented concomitant low levels of nausea, sedation and dizziness.     

Quality of lidocaine analgesia with and without midazolam for intravenous regional anesthesia

Purpose

Midazolam has analgesic effects mediated by gamma aminobutyric acid-A receptors. This study was designed to evaluate the effect of midazolam on anesthesia and analgesia quality when added to lidocaine for intravenous regional anesthesia (IVRA).

Methods

Forty patients undergoing hand surgery were randomly assigned to two groups to receive IVRA. The control group received 3 mg/kg lidocaine 2% w/v diluted with saline to a total volume of 40 ml, and the midazolam group received an additional 50 μg/kg midazolam. Sensory and motor block onset and recovery times, tourniquet pain, intraoperative analgesic requirements, sedation, and anesthesia quality were recorded. Postoperative pain and sedation scores, time to first analgesic requirements, analgesic use in the first 24 h, and side effects were noted.

Results

Sensory and motor block onset and recovery times did not differ significantly between groups. Tourniquet pain scores were lower at 10, 15, 20, and 30 min (P < 0.0001) in the midazolam group. Three (15%) patients in the midazolam group required fentanyl for tourniquet pain compared with thirteen (65%) patients in the control group (P = 0.02). Patients in both groups received fentanyl once. Midazolam group showed that significantly less patients required diclofenac for postoperative analgesia (P < 0.01) and analgesic-free period during first postoperative 24 h was significantly longer (726.8 ± 662.8 min vs. 91.0 ± 35.9 min, P < 0.0001). Postoperative pain scores were lower (P < 0.0001) and sedation scores higher (P < 0.05) for the first 2 h in the midazolam group.

Conclusion

Addition of midazolam to lidocaine for IVRA improves anesthesia quality and enhances intraoperative and postoperative analgesia without causing side effects.     

Effect of pre-emptive pregabalin on pain intensity and postoperative morphine consumption after laparoscopic cholecystectomy

Background

Postoperative pain is the dominant complaint and the most common cause of delayed discharge after laparoscopic cholecystectomy. The aim of this study is to evaluate the potential of preoperative administration of pregabalin to reduce postoperative pain and opioid consumption.

Methods

Fifty American Society of Anesthesiologists (ASA) I and II adult patients with symptomatic gallstone disease scheduled for elective laparoscopic cholecystectomy were randomized into two groups: group I patients (n = 25) were given 600 mg pregabalin per os divided in two doses, the night before surgery and 1 h preoperatively, respectively, while group II patients (n = 25) received a matching to pregabalin placebo at the same scheme. Postoperative pain, morphine consumption, and complications were compared between the two groups.

Results

Postoperative pain (static and dynamic assessment) was significantly less at 0, 1, 8, 16, and 24 h (p < 0.001) after the procedure for group I (pregabalin) compared with the placebo group. Postoperative patient-controlled morphine consumption during hospital stay was also significantly less in the pregabalin group compared with the placebo group. Side-effects were similar in both groups expect for dizziness, which was significantly higher (p < 0.0001) in the pregabalin group.

Conclusions

Administration of 600 mg pregabalin per os, divided in two preoperative doses, significantly reduces postoperative pain as well as opioid consumption in patients undergoing laparoscopic cholecystectomy, at the cost of increased incidence of dizziness.     

Successful management of postoperative pain with pregabalin after thoracotomy

Purpose

There is no established treatment for intercostal neuralgia associated with thoracotomy. We investigated the administration of pregabalin as a new perioperative treatment, assessing its safety and efficacy for intercostal neuralgia after thoracotomy.

Methods

Thirty patients suffering pain after thoracotomy severe enough to cause insomnia were prospectively enrolled and treated with 150 mg of pregabalin. We evaluated pain scores (Numeric Rating Scale, NRS), severity of nocturnal insomnia, and adverse effects before and after pregabalin administration.

Results

We noted significant decreases in pain scores, before vs. after pregabalin administration, from 8.2 ± 1.3 to 3.4 ± 1.3 (p < 0.0001), with improvement in nocturnal insomnia in 29 out of 30 patients. Eight patients reported adverse effects, including dizziness and daytime drowsiness; however, by reducing the dose of pregabalin, these effects were minimized while pain was controlled well.

Conclusion

Pregabalin was highly effective for neuralgia associated with intercostal damage after thoracotomy.     

Clinical assessment of a CMC/PEO gel to inhibit postoperative epidural adhesion formation after lumbar discectomy: a randomized, control study

Purpose

To evaluate effectiveness of carboxymethylcellulose/polyethylene oxide (CMC/PEO) gel in improving clinical outcomes after the first-time lumbar discectomy.

Method

Ninety-three patients with herniated lumbar disc at L4–L5 or L5–S1 were enrolled and randomized into two groups: CMC/PEO gel treatment group and control group. All the patients underwent laminotomy and discectomy by posterior approach. The preoperative and postoperative Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) scores for lower-back pain and leg pain were analyzed and compared between two groups at 30- and 60-day time points.

Results

No patient presented with any clinically measurable adverse event during surgery. There were no significant differences between the treated group and the control group on the preoperative ODI and VAS scores. In general, the ODI and VAS scores decreased in both groups at all the time points. At the 30-day time point, the VAS scores for back pain and leg pain and the ODI scores in treatment group were lower by 9.9 % (P = 0.0302), 27.0 % (P = 0.0002) and 16.3 % (P = 0.0007) than those in control group. And at the 60-day time point, the ODI and VAS scores further decreased in both groups. The VAS scores for leg pain in treatment group were lower by 4.5 % than that in the control group (P = 0.0149). However, no significant difference was detected between two groups on the ODI and VAS scores for back pain.

Conclusions

The results demonstrated that CMC/PEO gel is effective in reducing posterior dural adhesions in the spine with no apparent safety issues. It can improve patients’ postoperative clinical outcome.     

Comparison of the effects of intranasal midazolam versus different doses of intranasal ketamine on reducing preoperative pediatric anxiety: a prospective randomized clinical trial

Purpose

To compare the effects of intranasal midazolam versus different doses of intranasal ketamine on reducing preoperative pediatric anxiety.

Methods

The participants of this double-blinded clinical trial study consisted of 120 children aged between 2 and 8 years. They were chosen for elective surgery and randomly assigned to four equal groups. For reducing preoperative anxiety, in the first group midazolam 0.2 mg/kg, in the second group (K1) ketamine 0.5 mg/kg, in the third group (K2) ketamine 3 mg/kg, and in the fourth group normal saline 1 drop/5 kg were administered intranasally. After 15 min, severity of anxiety was assessed with the modified Yale preoperative anxiety score (m-Yale PAS), and level of sedation was evaluated by the Ramsay Sedation Scale before intravenous catheterization. All data were transferred to SPSS-10 software and analyzed statistically with ANOVA, Kruskal–Wallis, and Mann–Whitney tests. A p value < 0.05 was considered meaningful.

Results

The mean of m-Yale PAS in midazolam group was significantly lower than the other three groups (p < 0.05). Regarding this score, there was no significant statistical difference between K2 and normal saline groups (p = 0.944), but the differences between K1 and K2 (p = 0.034) and also between K1 and normal saline (p = 0.049) groups were significant statistically. The Ramsay Sedation Scale in the midazolam group was significantly higher than the other three groups (p < 0.05). By this scale, there was no significant statistical difference between (K2) and normal saline groups (p = 0.940). The differences between (K1) and normal saline (p = 0.045) and also between (K1) and (K2) groups (p = 0.009) were significant statistically.

Conclusion

Intranasal midazolam was more effective than low- or high-dose intranasal ketamine in reducing preoperative pediatric anxiety. The lower dose of ketamine reduced preoperative anxiety more than a higher dose of ketamine, which may be clinically insignificant.     

Low-dose gabapentin as useful adjuvant to opioids for neuropathic cancer pain when combined with low-dose imipramine

Purpose

Painful neuropathic conditions of cancer pain often show little response to nonopioid and opioid analgesics but may be eased by antidepressants and anticonvulsants. Although gabapentin is effective in the treatment of neuropathic pain in patients with cancer, some patients experience intolerable side effects sufficient to warrant discontinuation. The aim of this study was to see whether low-dose gabapentin is effective in treating cancer-related neuropathic pain when combined with low-dose imipramine.

Methods

Fifty-two cancer patients diagnosed as having neuropathic pain were allocated into four groups: G400-I group took gabapentin 200 mg and imipramine 10 mg every 12 h orally; G400 group took gabapentin 200 mg every 12 h orally; G800 group took gabapentin 400 mg every 12 h orally; I group took imipramine 10 mg every 12 h orally.

Results

Low-dose gabapentin–imipramine significantly decreased the total pain score and daily paroxysmal pain episodes. Several patients developed mild adverse symptoms in the four groups, and three patients discontinued treatment due to severe adverse events in the G800 group.

Conclusion

Low-dose gabapentin–antidepressant combination with opioids was effective in managing neuropathic cancer pain without severe adverse effects.     

Female gender is a risk factor for pain, discomfort, and fatigue after laparoscopic groin hernia repair

Purpose

Female gender is a risk factor for early pain after several specific surgical procedures but has not been studied in detail after laparoscopic groin hernia repair. The aim of this study was to compare early postoperative pain, discomfort, fatigue, and nausea and vomiting between genders undergoing laparoscopic groin hernia repair.

Methods

Prospective consecutive enrollment of women and age-matched (±1 year) and uni-/bilateral hernia-matched male patients undergoing elective transabdominal preperitoneal hernia repair (TAPP). Patients in the two groups received a similar anesthetic, surgical, and analgesic treatment protocol.

Results

Between August 2009 and August 2010, 25 women and 25 men undergoing elective TAPP were prospectively included in the analysis (n = 50) with no significant difference between groups in psychological status regarding anxiety, depression, and catastrophizing. On day 0, women had significantly more pain during rest (p = 0.015) and coughing (p = 0.012), discomfort (p = 0.001), and fatigue (0.020) compared with men. Additionally, cumulative overall postoperative pain during coughing, discomfort, and fatigue on day 0–3 was significantly higher in women compared with men (all p values < 0.05). Women required significantly more opioids (p = 0.015) and had a significantly higher incidence of vomiting on days 0 and 1 (p = 0.002).

Conclusions

Women experienced more pain, discomfort, and fatigue compared with men after laparoscopic groin hernia repair.

Trial registration

Registration number NCT00962338 (www.clinicaltrials.gov).     

Multimodal analgesic approach incorporating paravertebral blocks for open radical retropubic prostatectomy: a randomized double-blind placebo-controlled study

Introduction

Perioperative pain management influences both the quality as well as the speed of recovery following surgery.

Methods

This was a randomized double-blind placebo-controlled study designed to assess the effectiveness of a multimodal analgesic approach (MMA) vs patient-controlled analgesia (PCA) alone in patients undergoing open prostatectomy. Prior to surgery, paravertebral blocks (PVBs) were performed with either 0.5% ropivacaine in the MMA group or saline in the PCA group. Patients in the MMA group also received celecoxib (400 mg po prior to surgery and 200 mg po bid for seven days following surgery) and ketamine 10 mg iv. Following surgery, every patient had free access to morphine PCA. A pain numerical rating scale (NRS) at 24 hr was chosen as the primary endpoint. Secondary endpoints included morphine consumption at 24 hr and SF-36 (36-Item Short-Form Health Survey) scores from two weeks to 24 weeks following surgery.

Results

The primary endpoint, average pain NRS at 24 hr, was 2.6 in the MMA group compared with 3.9 in the PCA group (difference = ?1.6, 95% confidence interval [CI]: ?2.3 to ?0.4; P = 0.01). The average morphine consumption at 24 hr was 4.8 mg in the MMA group compared with 10.5 mg in the PCA group (difference = ?5.7, 95% CI: ?13.0 to 0.5; P = 0.01). Higher SF-36 scores at two, four, eight, and 12 weeks were observed in the MMA group compared with the PCA group, but no statistically significant (P < 0.05) between-group difference was found after Bonferroni correction of comparisons conducted repeatedly over time. Postoperative adverse effects included low episodes of postoperative nausea and vomiting, bladder spasms, constipation, and pruritus.

Conclusion

This study demonstrates that PVBs combined with celecoxib and ketamine provide better immediate postoperative pain control and facilitate earlier functional recovery in patients undergoing an open radical prostatectomy when compared with PCA alone.