Thirty percent of patients have moderate to severe pain 24 hr after ambulatory surgery: A survey of 5,703 patients

PURPOSE: Postoperative pain is the commonest reason for delayed discharge and unanticipated hospital admission after ambulatory surgery. We investigated the severity of pain at 24 hr postoperatively and determined the most painful procedures. The need for further medical advice and clarity of postoperative analgesia instructions were also studied. METHODS: Five thousand seven hundred and three ambulatory surgical patients were telephoned 24 hr postoperatively. Patients graded their pain using the ten-point self-assessing verbal scale (0 = no pain, 10 = worst pain). Data were analyzed in two groups, those with moderate to severe pain (pain score 4-10) and those with no or mild pain (0-3). RESULTS: Thirty percent of patients (1,495/5,703) had moderate to severe pain. Microdiscectomy, laparoscopic cholecystectomy, shoulder surgery, elbow/hand surgery, ankle surgery, inguinal hernia repair, and knee surgery were identified as the procedures causing most pain at 24 hr. 13.2% of patients needed medical advice by telephone, 1.4% made an unplanned visit to a doctor while the rate of readmission to the hospital was 0.08%. Ninety-eight percent found postoperative instruction sheets and advice helpful. Eighty-eight percent of patients indicated that analgesic instructions were absolutely clear. CONCLUSION: This study has identified the more painful common ambulatory surgical procedures which will allow take home analgesia to be tailored according to individual procedures. Further improvement in analgesic instructions may help in better pain management of ambulatory surgery patients.     

Preoperative administration of controlled-release oxycodone for the management of pain after ambulatory laparoscopic tubal ligation surgery

STUDY OBJECTIVE: To examine the analgesic efficacy of administering controlled-release (CR) oxycodone 10 mg before elective ambulatory laparoscopic tubal ligation surgery. DESIGN: Randomized, double-blind study. PATIENTS: 50 healthy women presenting for elective ambulatory laparoscopic tubal ligation surgery. SETTING: Ambulatory surgery center of a university hospital. INTERVENTIONS: Fifty patients were administered either placebo (n = 25) or CR oxycodone 10 mg (n = 25) 1 hour before surgery. All patients were administered a similar general anesthetic. In the postanesthesia care unit (PACU), fentanyl 25 microg was administered for a verbal analog scale (VAS) pain score >or=3. Patients were discharged home when they were awake and alert, had stable vital signs, were able to void, tolerated oral fluids, experienced no side effects, had a VAS or=3. MEASUREMENTS: VAS pain scores and the frequency of postoperative nausea and vomiting were recorded in the PACU. While at home, patients were contacted by telephone after surgery and asked about their pain score, time to first analgesic use, frequency of postoperative nausea and vomiting, and total acetaminophen/oxycodone use in the 24 hours following surgery. MAIN RESULTS: Patients in the CR oxycodone group had a shorter time to discharge (p < 0.001), reported lower postoperative pain scores (p < 0.001), lower frequency of postoperative nausea and vomiting (p < 0.05), longer time to first analgesic use (p < 0.0,001), and required less fentanyl in the PACU (p < 0.01) and fewer acetaminophen/oxycodone tablets in the 24 hours following surgery. CONCLUSION: The preoperative administration of CR oxycodone 10 mg is an effective analgesic technique in the management of pain following ambulatory laparoscopic tubal ligation surgery, and may facilitate earlier postoperative discharge.     

Postoperative pain management in a tertiary care hospital: initial situation prior to starting a quality assurance program

OBJECTIVE: To characterize the initial situation in postoperative pain management among the services General and Vascular surgery as the first step in developing a program to improve postoperative analgesia. METHODS: An anonymous questionnaire with 14 items covered the characteristics of postoperative pain, information received about analgesic treatments and requesting medication, and degree of satisfaction. The questionnaire was filled in during an early postoperative interview with all patients undergoing surgery in the aforementioned departments. RESULTS: A total of 158 patients were interviewed; 89% were from the general surgery department and 11% from vascular surgery. At 24 hours after surgery, 18% were free of pain, 35% had mild pain, and 47% had moderate or intense pain. Nonsteroidal anti-inflammatory drugs were the most frequently used postoperative analgesics, in 94% of patients, and the dosage and timing had been prescribed for 74%. Thirty-six percent of the patients asked for an analgesic to be administered. The correlation between degree of greatest pain and request for an analgesic was statistically significant (P < 0.001). CONCLUSIONS: Postoperative pain is an area in which improvements can be implemented to provide better care and treatment of surgical patients, particularly since there are efficacious analgesic treatments for pain control that are presently not being used. The custom of prescribing pain medication on demand should be avoided in all surgical procedures that are known to produce postoperative pain.     

Postoperative pain treatment for ambulatory surgery

One of the most significant changes in surgical practice during the last two decades has been the growth of ambulatory surgery. Adequate postoperative analgesia is a prerequisite for successful ambulatory surgery. Recent studies have shown that large numbers of patients suffer from moderate to severe pain during the first 24-48 hr. The success of fast-tracking depends to a considerable extent on effective postoperative pain management routines and the cost saving of outpatient surgery may be negated by unanticipated hospital admission for poorly treated pain. Depending on the intensity of postoperative pain current management includes the use of analgesics such as paracetamol, NSAIDs including coxibs and tramadol as single drugs or in combination as part of balanced (multimodal) analgesia. However, in the ambulatory setting many patients suffer from pain at home in spite of multimodal analgesic regimens. Sending patients home with perineural, incisional, and intra-articular catheters is a new and evolving area of postoperative pain management. Current evidence suggests that these techniques are effective, feasible and safe in the home environment if appropriate patient selection routines and organization for follow-up are in place.     

A survey of pain and other symptoms that affect the recovery process after discharge from an ambulatory surgery unit

STUDY OBJECTIVE: To determine the significance of pain and other symptoms on the recovery process after ambulatory surgery, by surveying pain, analgesic use, and related aspects of recovery in the first 48 hours after discharge from an ambulatory surgery unit. DESIGN: Prospective, observational, surveillance survey. PATIENTS: A total of 175 patients were studied, 25 in each of 6 surgical groups including knee arthroscopy, hernia repair, pelvic laparoscopy, transvaginal surgery, surgery for breast disease, and plastic surgery. INTERVENTIONS: Patients were treated in a manner considered normal or "usual" for the surgeon and the institution. MEASUREMENTS: Pain scores (0 to 10), analgesic use, symptom frequency, symptom distress scores, activity level (% of normal), and satisfaction scores were obtained by telephone interview 24 and 48 hours after discharge. Group means (+/-SE), proportions and correlations between predictor variables were determined in relevant groups. MAIN RESULTS: The response rate to postoperative telephone calls was 89% at 24 hours, and 82% at 48 hours. At 24 hours, maximum pain was >3/10 in 60%, or >7/10 in 20% of patients. Pain prevented or disrupted sleep in 46% of patients. Activity level was reduced to 33% of normal at 24 hours; pain was reported as the primary or secondary reason for limiting activity by 54% of patients. At 24 hours, average pain scores correlated inversely with activity (r = -0.49, p = or < 0.0001); least pain score correlated best with satisfaction (r = 0.03, p = 0.0005). CONCLUSIONS: Improvements in pain therapy after discharge appear warranted to provide more consistent pain relief, and hasten return to normal activity.     

Randomized clinical trial of postoperative subfascial infusion with bupivacaine following ambulatory open mesh repair of inguinal hernia

BACKGROUND: Wound pain remains the commonest problem after ambulatory open repair of inguinal hernia. Postoperative subfascial infusion of the wound with bupivacaine extends local analgesia at home and may achieve superior analgesia compared with oral analgesics alone. The objective of the present trial was to evaluate the efficacy of postoperative subfascial infusion of the wound with 0.5% bupicavaine at 2 ml per hour for 48 h after operation. METHODS: Forty-four patients who underwent ambulatory open tension-free mesh hernioplasties were randomized to two arms of treatment. The pump group had an infusion pump containing 100 ml 0.5% bupivacaine being placed between the external oblique aponeurosis and the Prolene mesh, whereas the nonpump group was treated with oral analgesics alone. Assuming that an observed difference of 2.0 existed between the mean pain scores of the two groups, the estimated sample size would be at least 20 patients in each group. RESULTS: Postoperative pain scores at rest and on coughing were significantly lower in the pump group than in the nonpump group on days 0 and 1 after surgery (p < 0.01). Before being discharged, none of the pump group patients requested analgesics, but 6 patients of the nonpump group required analgesic supplement (p = 0.025). Ten patients (50%) of the pump group experienced no pain during the period of bupivacaine infusion. Recovery variables, including time taken to resume ambulation and micturition, were comparable between the two groups. The pump and nonpump group patients returned to their normal activities after a median of 3 and 4 days, respectively (p = 0.217). The postoperative morbidity rates of the two groups were similar. CONCLUSION: Postoperative subfascial infusion of the wound with 0.5% bupivacaine achieved superior analgesia compared with oral analgesics alone. Portable infusion pump is a safe technique to continue local analgesia at home after ambulatory open repair of inguinal hernia. The drawbacks of the ON-Q Pain Management System included its high cost and frequent seepage of blood-stained anesthetic fluid into the wound dressing.     

Chronic post-sternotomy pain

BACKGROUND: Chronic postoperative pain is a well-recognised problem. The incidence of severe incapacitating pain is about 3-5% after various types of surgery such as thoracotomy, repair of inguinal hernias and mastectomy. Sternotomy causes considerable postoperative pain and patients with chronic post-sternotomy pain are often referred to pain clinics. Epidemiological studies on chronic post-sternotomy pain are scarce, however. The aim of this paper was to study the incidence and possible risk factors of chronic pain following sternotomy operations performed for coronary bypass grafting or thymectomy. METHODS: Two groups of patients were studied for persistent pain following sternotomy operations. A questionnaire was sent in January 1997 to 71 patients with myasthenia gravis (MG) who had undergone a thymectomy during 1985-1996 and 720 patients who had had coronary bypass grafting (CABG) in 1994 were interviewed by letter. The patients were asked about the presence of pain and other symptoms in the chest, shoulders, arms or legs that they thought were connected to surgery. They were also asked about the quality of the pain and its evolvement with time. The patients' records were checked for details about surgery, anaesthesia and the state of the coronary disease. RESULTS: The response rate was 87%. The interval between the interview and surgery varied from 6 months to 12 years in the MG group and it was 2-3 years in the CABG group. In the MG group, 27% of the patients reported chronic post-sternotomy pain, which was moderate to severe in 48% of the patients. In the CABG group, 28% of the patients still had post-sternotomy pain, which was moderate to severe in 38% of patients. Of the patients who had post-sternotomy pain, one-third reported sleep disturbances due to the pain. CONCLUSION: Chronic post-sternotomy pain is an important complication that may have a significant impact on the patient's everyday life. Future studies will show whether minimising complications, improving postoperative care and starting early adequate pain management will reduce the incidence of this problem.     

Pain relief following breast augmentation surgery: a comparison between incisional patient-controlled regional analgesia and traditional oral analgesia

BACKGROUND AND OBJECTIVES: Postoperative pain is a common problem following ambulatory breast augmentation surgery. This study was performed to compare standard of care (oral analgesics) with patient-controlled incisional regional analgesia (PCRA) for postoperative pain management at home for 48 h. A second aim was to compare the analgesic efficacy of ropivacaine 0.25% vs. 0.5%. METHODS: Surgery was performed under local anaesthesia and monitored anesthesia care. Sixty adults (ASA 1-2) were randomized to one of two groups. Patients in Group PCRA could self-administer ropivacaine 0.25% 10 mL in the left breast and ropivacaine 0.5% in the right breast. Patients in Group T (tablets) received our standard of care treatment, i.e. oral paracetamol 1 g four times a day and oral ibuprofen 500 mg three times a day. Parameters measured included: analgesic requirements (in post-anesthesia care unit, PACU and post-discharge), pain intensity (visual analogue scale), patient satisfaction, global analgesia, side-effects, and quality of recovery. RESULTS: Pain scores were significantly lower in Group PCRA compared to Group T at all time periods (P < 0.05). No differences were found in pain scores between the right and left breasts. Significantly more patients in Group T requested analgesics in the recovery unit (27 vs. 7; P = 0.001) and also at home (20 vs. 11; P < 0.02). More patients in the tablet group had nausea and vomiting (10 vs. 3; P < 0.05). Global analgesia on day 2 was significantly better in PCRA group; however, patient satisfaction was similar in both groups. More patients in the tablet group had sleep disturbance and woke up at night due to pain. CONCLUSIONS: Pain relief after ambulatory breast augmentation is superior with incisional PCRA when compared to oral analgesic combination of paracetamol and ibuprofen. Incisional PCRA was associated with minimal side-effects and less sleep disturbance. There was no difference in the analgesic efficacy between ropivacaine 0.25% and 0.5%.     

Efficacy of intra-articular bupivacaine, ropivacaine, or a combination of ropivacaine, morphine, and ketorolac on postoperative pain relief after ambulatory arthroscopic knee surgery: a randomized double-blind study

BACKGROUND: Effective pain relief is important after diagnostic and therapeutic arthroscopic knee surgery to permit early discharge and improve comfort and mobility at home. The aim of this study was to assess the efficacy of bupivacaine, ropivacaine, or a combination of ropivacaine, morphine, and ketorolac injected intra-articularly for postoperative pain relief after arthroscopic knee surgery. METHODS: Sixty-three healthy patients undergoing knee arthroscopy under local anesthesia (LA) were randomized to receive 1 of the following substances intra-articularly postoperatively: group B: 30 mL of bupivacaine (150 mg); group R: 30 mL of ropivacaine (150 mg); and group RMK: ropivacaine 150 mg, morphine 4 mg, and ketorolac 30 mg in normal saline (total volume 30 mL). Oral paracetamol 1g and tramadol 50 mg were used as rescue drugs. Postoperatively, pain was assessed at rest and movement, and side effects were recorded. The patients were asked to self-assess pain for 7 days and record analgesic consumption as well as activities of daily living (ADLs). Plasma concentration of LA was measured in another 8 patients. RESULTS: All groups had excellent analgesia at 0 and 4 hours postoperatively. Group RMK had significantly lower visual analog pain score at rest at 8 hours and during movement at 8 and 24 hours compared with the other groups (P<.05). Group RMK required less paracetamol and tramadol on day 1 (P<.05), had less sleep disturbances because of pain, more patients were ready to work on days 1 and 2 (P<.05), and were more satisfied on days 1 and 4 to 7. Postoperatively, plasma concentrations of ropivacaine and lidocaine were far below known systemic toxic concentrations in all patients. CONCLUSION: Addition of morphine and ketolorac to ropivacaine intra-articularly enhances analgesic efficacy of LA, reduces postdischarge analgesic consumption, and improves ADLs without increasing side effects after ambulatory arthroscopic knee surgery.     

Postoperative analgesia with controlled-release oxycodone for outpatient anterior cruciate ligament surgery.

Reconstruction of the anterior cruciate ligament (ACL) of the knee is associated with a considerable degree of postoperative pain. Although immediate-release oral opioids are usually effective in relieving moderate to severe pain, they must be given every 4-6 h. A controlled-release (CR) formulation of oxycodone maintains therapeutic opioid concentrations for a more prolonged period, thus providing sustained pain relief. We designed this study to determine whether CR oxycodone is more effective and clinically acceptable than immediate-release oxycodone for managing pain after ambulatory ACL repair surgery. All patients received a standard general anesthetic and postoperative analgesic regimen with one of three oxycodone dosing regimens: oxycodone 10 mg every 4 h as needed, oxycodone 10 mg every 4 h, and CR oxycodone 20 mg every 12 h. Rescue analgesic consisted of oxycodone 5 mg every 6 h as needed. At 24, 36, 48, 60, and 72 h, there was a difference in pain scores among the groups (P < 0.0001); there was less pain in the CR oxycodone group. At most times, the fixed-dose group had lower pain scores than the as-needed group. The sedation scores were significantly different at 12 h (P < 0.02) and at 24, 36, 48, 60, and 72 h (P < 0.0001); the patients were more alert in the CR oxycodone group. The 72-h consumption of oxycodone was less in the CR oxycodone group (P < 0.0001). The patients had less sleep disturbance (P < 0.0001), were more satisfied (P < 0.0001), and experienced less vomiting (P < 0.02) in the CR oxycodone group compared with the other two groups. In conclusion, using CR oxycodone in the immediate 72 h after ambulatory ACL surgery provides more effective analgesia with less sedation, sleep disturbance, and postoperative vomiting compared with oxycodone prescribed on either a fixed dose or as-needed schedule. IMPLICATIONS: A controlled-release formulation of oxycodone in patients undergoing anterior cruciate ligament repair on an ambulatory basis provides significant analgesic benefit and a lowering of side effects compared with either fixed-dose or as-needed oxycodone regimens.     

Safety of laryngeal mask airway and short-stay practice in office-based adenotonsillectomy

Background: It is still disputed whether laryngeal mask airway (LMA) is safe and convenient for adenotonsillectomy, and whether these procedures can be safely undertaken in an office-based short-stay ambulatory setting. We report the result of this practice in 1126 consecutive children <16 years of age.
Methods: The patients received general anaesthesia with propofol and remifentanil. For analgesic prophylaxis, they received paracetamol, fentanyl and local anaesthetic administration. NSAIDs were given to patients weighing above 15 kgs. A surgical technique with elevation, scissors and electrocoagulation was used. Post-operatively, the tonsillectomies were observed in the unit for at least 1.5 h and the adenoidectomies for at least 15–20 min.
Results: Conversion from LMA to an endotracheal tube was carried out in six patients (0.5%), mostly due to airway leakage during ventilation. One patient had a pulmonary atelectasis and was re-intubated. No re-operation was needed in the clinic after surgery, and all patients, except for the one with atelectasis (0.1%), were discharged home as planned. In 122 patients answering a questionnaire, after discharge, two patients (1.6%) were admitted to hospital and re-operated due to bleeding; a further six patients (4.9%) were admitted for observation. In 25% of the patients, nausea and vomiting occurred after discharge, including 21% vomiting of swallowed blood during home travel. Only 5.6% reported significant post-discharge pain.
Conclusion: With a well-trained team, adenotonsillectomy on children can be carried out safely in an office-based setting with LMA and a short post-operative stay.     

Use of elastomeric pumps for continuous intravenous analgesia administration in ambulatory surgery pain management

Aim: To evaluate the feasibility and security of the use of elastomeric infusion pumps for the administration of continuous intravenous analgesia during the post-operative period of potentially painful surgical operations performed in the context of ambulatory surgery. Material and methods: Prospective study with 40 patients scheduled for inguinal hernia repair, haemorrhoidectomy, knee arthroscopy and foot orthopedic surgery. At the end of surgery a LV-5 of 5 ml/h Baxter^® elastomeric infusor was connected. Intravenous ketorolac, tramadol and ondansetron were supplied for 55 h. Daily out-patient controls were performed by the nurses of the post-operative out-patient care unit. Pain intensity by means of a plain oral scale, the need for supplemental oral analgesics and the level of patient satisfaction were evaluated daily. Results: 92.5% of the patients reported absence or slight pain 48 h after the surgical operation, and 7.5% referred to moderate pain. No severe pain was reported by the patients in the first 72 h of the post-operative period. 7.5% of the patients felt nauseated, 15% vomited and 10% had discomfort at the venous puncture point. No patient required re-admission after discharge. 87.5% of the patients revealed satisfaction with the analgesic treatment. Conclusion: The use of invasive out-patient analgesic techniques could have viability in some procedures in which oral analgesics are unable to control the post-operative pain. Comparative studies would be needed in order to elucidate the procedures that could benefit from these techniques in our context.     

Severity and impact of pain after day-surgery

Purpose

To assess the intensity, duration and impact of pain after day-surgery interventions. Predictors of pain severity were also evaluated along with the quality of analgesic practices and patient satisfaction.

Methods

Eighty-nine consecutive day-surgery patients completed self-administered questionnaires before leaving the hospital and at 24, 48 hr and seven days after discharge. The survey instrument was composed of 0–10 pain intensity scales, selected items of the Brief Pain Inventory, of the Patient Outcome Questionnaire and of the Barriers Questionnaire. Analgesic intake in hospital and at home was recorded along with the use of other pain control methods.

Results

Forty percent of the patients reported moderate to severe pain during the first 24 hr after hospital discharge. The pain decreased with time but it was severe enough to interfere with daily activities in a substantial number of patients. The best predictor of severe pain at home was inadequate pain control during the first few hours following the surgery. More than 80% of the participants were satisfied with their pain treatment. However, one patient in four (25%) needed contact with a health care provider because of pain at home. Many patients (33% to 51 %) reported that instructions about pan control were either unclear or non-existent on several aspects. Medication use was low overall. Thirty-two percent of the patients did not take any pain medication during the first 24 hr after discharge although almost half of them (46%) rated their pain ≥4. The most common concerns patients had about using pain medication were fear of drug addiction and side effects.

Conclusion

The severity and duration of pain after day-surgery should not be underestimated. Aggressive analgesic treatment during the hospital stay should be provided along with take-home analgesia protocols and comprehensive patient education programs.     

Postoperative pain relief using intermittent injections of 0.5% ropivacaine through a catheter after laparoscopic cholecystectomy

Postoperative pain has been an important limiting factor for ambulatory laparoscopic cholecystectomy. We anesthetized 40 ASA physical status I-II patients using propofol for the induction and sevoflurane in oxygen and air for the maintenance of anesthesia. At the end of the anesthesia, the patients were randomized into one of two groups: Group P (Placebo) and Group R (0.5% Ropivacaine). Twenty milliliters of normal saline or ropivacaine, respectively, were injected intraperitoneally at the end of surgery via a catheter placed in the bed of the gall bladder. Postoperatively, intermittent injections (10 mL) of the study solution were given when required for pain. Ketobemidone 1-2 mg was given IV as rescue medication. Pain was assessed using a visual analog scale at 1, 2, 3, 4, 8, 12, 16, and 20 h after surgery and once each day for 1 wk at rest (deep pain), shoulder and incision sites, and pain during coughing. Recovery was assessed by the time to transfer from Phase 1 to 2, the ability to walk, drink, and eat, and the ability to void. Plasma concentrations of ropivacaine were measured in eight patients. Time to ability to walk, defecation, driving a car, and return to normal activities were also recorded through a questionnaire sent home with the patient. During the first 4 postoperative h, patients in Group R had lower scores for deep pain and during coughing compared with Group P (P < 0.05). No differences were found in the postoperative consumption of ketobemidone. Median times to recovery at home were similar between the groups. By the seventh day, 93% of the patients had returned to normal activities of daily living. We conclude that the early postoperative pain after ambulatory laparoscopic cholecystectomy could be relieved using intermittent injections of ropivacaine 0.5% into the bed of the gall bladder. IMPLICATIONS: Early postoperative pain can be relieved by intermittent injections of ropivacaine 0.5% through a catheter placed in the bed of the gall bladder after ambulatory laparoscopic cholecystectomy.     

Patients' assessment of 4-week recovery after ambulatory surgery

Background: Patients' own assessment of recovery after ambulatory surgery has not been well studied. The aim was to study patients' self‐assessed recovery, the occurrence and time course of post‐operative problems in relation to the type of ambulatory surgery. Methods: A questionnaire was filled in by 355 patients at five time points: pre‐operative, first day at home, 1, 2 and 4 weeks post‐operatively. Consecutive patients who underwent either inguinal hernia repair (IHR), arthroscopic procedures (AS) or cosmetic breast augmentation (CBA) were included. Results: Unplanned return to hospital was rare (3/355). Health care contacts were noted for 9% of the patients during the first week; a total of 70 contacts occurred during the entire period. Pain was the most frequently reported symptom; 40% of the patients reported pain or mobility problems at 1 week, 28% after 2 weeks and 20% after 4 weeks. Pre‐operative pain was associated with an increased level of pain during the early post‐operative course, in the recovery room and at 1 week post‐operatively. IHR was associated with an overall rapid recovery, while AS patients experienced a slower restitution. All AS patients who reported pain after 4 weeks had reported pain problems already pre‐operatively. Pain was not present pre‐operatively in the CBA group, but was common at 1 and 2 post‐operative weeks and was still reported by 11% at 4 weeks. Conclusion: Self‐assessed recovery was found to cover several weeks with procedure‐specific recovery patterns. Pain and mobility impairment were still frequently reported 4 weeks post‐operatively.     

Patient-controlled regional analgesia (PCRA) at home: controlled comparison between bupivacaine and ropivacaine brachial plexus analgesia

BACKGROUND: The aim of this randomized, double-blinded study was to compare the analgesic efficacy of bupivacaine versus ropivacaine brachial plexus analgesia after ambulatory hand surgery. An additional aim was to study the feasibility and safety of patient-controlled regional analgesia (PCRA) outside the hospital. METHODS: Sixty patients scheduled for ambulatory hand surgery underwent surgery with axillary plexus blockade. After surgery, the plexus catheter was connected to an elastomeric, disposable "homepump," containing 100 ml of either 0.125% bupivacaine or 0.125% ropivacaine. When patients experienced pain, they self-administered 10 ml of the study drug. Analgesic efficacy of PCRA was evaluated by self-assessment of pain intensity by visual analog scale (VAS) and verbal scale. Patients recorded adverse effects, technical problems, use of rescue analgesic tablets, and overall satisfaction. A follow-up telephone call was made the day after surgery. RESULTS: Visual analog scale scores decreased after each treatment in both groups, but there were no significant differences between the two drugs. One patient in each group took rescue dextropropoxyphene tablets. In both groups, 87% patients expressed their desire to have the same treatment again. On the day of surgery, significantly more patients were satisfied with ropivacaine PCRA. None of the patients had any signs or symptoms of local anesthetic toxicity or catheter infection. CONCLUSIONS: This double-blinded study has demonstrated the feasibility of self-administration of local anesthetic to manage postoperative pain outside the hospital. Ropivacaine and bupivacaine provided effective analgesia, and patient satisfaction with PCRA was high. Patient selection, follow-up telephone call, and 24-h access to anesthesiology services are prerequisites for PCRA at home.     

Ambulatory surgery and sleep disorders

The aim of this study was to assess the impact of ambulatory surgery on sleep quality in patients undergoing ambulatory surgery and to identify those patients who are at an increased risk of preoperative anxiety and sleep disorders. A total of 220 patients were admitted for ambulatory surgery between October 1996 and April 1997. They were asked to assess their usual sleep patterns on a questionnaire. Patients were divided into three groups: good, intermediate and bad sleep quality. Of the 220 patients, 150 (68.1%) had severe disturbances in the quality of sleep the night before surgery. Of the patients with usually bad sleep quality, 100% had disturbances the night before surgery. In conclusion, these data show that many patients undergoing ambulatory surgery, experience disturbances in the quality of sleep the night before surgery. Premedication could help the group of patients with previous abnormal sleep patterns.     

Ondansetron disintegrating tablets of 8 mg twice a day for 3 days did not reduce the incidence of nausea or vomiting after laparoscopic surgery

BACKGROUND AND OBJECTIVE: Although many antiemetic drugs are available for intravenous use in the hospital setting, few are available after patient discharge. Consequently, nausea and vomiting are frequent complaints from patients at home after ambulatory surgery. We tested the hypothesis that the new 8 mg ondansetron disintegrating tablets will decrease the rate of nausea and vomiting at home after laparoscopic surgery. METHODS: Ninety-six patients were studied in a randomized double-blind study. Starting the first evening after operation and continuing every 12 h for 3 days, patients received either placebo or ondansetron 8 mg disintegrating tablets orally. The patients returned a questionnaire about postoperative nausea and vomiting, other side-effects, e.g. dizziness, headache, nightmare, anxiety and pain, as well as their overall satisfaction at 24 and 72 h after completion of surgery. RESULTS: The rates of nausea and vomiting were similar in the two groups, both during the first 24 h (28 versus 48%, placebo and ondansetron, respectively (ns) and during the 24-72 h (21 versus 35% (ns)). The incidence rate of vomiting was 8% (placebo) versus 12% (ondansetron) during the first 24 h (ns) and 9 versus 13% respectively in the 24-72 h (ns). No difference between groups was observed in overall satisfaction, incidence of postoperative pain or other side-effects. CONCLUSIONS: The use of ondansetron disintegrating tablets of 8 mg twice a day for 3 days did not reduce the incidence of nausea and vomiting in patients undergoing outpatient laparoscopic surgery.