Prophylactic antiemetic effect of midazolam after middle ear surgery.

OBJECTIVE: To investigate the prophylactic antiemetic effect of midazolam after middle ear surgery. STUDY DESIGN: A prospective, randomized, double-blind, placebo-controlled study. SUBJECTS AND METHODS: Ninety women patients undergoing middle ear surgery with general anesthesia received intravenously either midazolam 0.075 mg/kg or normal saline (n = 45 each) after induction of anesthesia. The incidence and severity of postoperative nausea and vomiting, rescue antiemetics, pain intensity, and side effects such as headache, dizziness, and drowsiness were assessed during the first 24 hours after anesthesia. RESULTS: Midazolam groups showed total incidence and severity of nausea and vomiting. Patients who required rescue antiemetics were significantly lower than in saline group (P < 0.05), but there were no significant differences in pain intensity and side effects such as headache, dizziness, and drowsiness between groups. CONCLUSIONS: Midazolam 0.075 mg/kg is effective for reducing nausea and vomiting after middle ear surgery.     

Supplemental oxygen does not prevent postoperative nausea and vomiting after gynecological laparoscopy

Purpose

Postoperative nausea and vomiting are among the most common and distressing side effects of general anesthesia. Supplemental intraoperative 80% oxygen reduces postoperative nausea and vomiting following open and laparoscopic abdominal surgery. However, this benefit has not been observed in other patient populations. We undertook this study to evaluate the effect of 80% supplemental intraoperative oxygen on the incidence of postoperative nausea and vomiting following ambulatory surgery for laparoscopic tubal ligation.

Methods

Following Research Ethics Board approval, 304 subjects were enrolled into one of two arms of a randomized prospective controlled study. The intervention group (n = 147) breathed 80% oxygen and the control group (n = 145) breathed routine 30% oxygen (balance medical air) while both groups were receiving a standardized general anesthetic. Nausea was assessed as: none, mild, moderate, or severe; vomiting was any emetic episode or retching. Any assessment either greater than none (nausea) or greater than zero (vomiting) was considered positive.

Results

The incidence of postoperative nausea and vomiting up to 24 hr following surgery was 69% in the 80% oxygen intervention group and 65% in the 30% oxygen control group (P = 0.62). There were no differences in nausea alone, vomiting, or antiemetic use in the postoperative anesthetic care unit or at any time (pre- or post-discharge) up to 24 hr after surgery.

Conclusions

This trial of 304 women did not demonstrate that administering intraoperative supplemental 80% oxygen during ambulatory surgery for laparoscopic tubal ligation prevented postoperative nausea or vomiting during the initial postoperative 24 hr compared with women who received routine 30% oxygen.     

Double-blind comparison of granisetron, promethazine, or a combination of both for the prevention of postoperative nausea and vomiting in females undergoing outpatient laparoscopies

Purpose

Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) are common problems after surgery. Prophylactic combination antiemetic therapy is recommended for patients at high risk for developing PONV and PDNV. Granisetron, a serotonin antagonist, is an effective antiemetic that is devoid of sedative side effect. Although promethazine is effective, commonly used doses are associated with sedation. This study investigates the combination of low doses of granisetron and promethazine for the prevention of PONV.

Methods

Women undergoing ambulatory gynecological laparoscopy were enrolled. A standard general anesthetic regimen was prescribed. Fifteen minutes before the expected end of surgery, the patients were randomly assigned to receive granisetron 0.1 mg iv, promethazine 6.25 mg iv, or a combination of the two drugs. Prophylaxis with oral promethazine 12.5 mg, granisetron 1 mg, or both was started in the respective groups 12 hr after the end of surgery and continued every 12 hr until postoperative day 3 (a total of five oral doses). The following outcomes were recorded: total response rate (defined as no vomiting, no more than mild nausea, and no use of rescue antiemetic); incidence of nausea, vomiting, and use of rescue antiemetics; severity of nausea; patient activity level; and patient satisfaction with PONV management.

Results

Patients in the combination group had a higher total response rate at 6, 24, 48, and 72 hr after surgery compared with those who received promethazine alone (at 24 hr, Combination 69.6%, Promethazine 36.2%, Granisetron 53.3%; P = 0.0079). The maximum nausea scores were also lower in the combination group at 6, 24, 48, and 72 hr (Combination 1.7 ± 2.2, Promethazine 4.0 ± 3.6, Granisetron 3.1 ± 3.2 at 24 hr; P < 0.05). There was no difference in the sedation scores, incidence of drowsiness, patient activity level, and satisfaction with PONV management.

Conclusions

Low-dose granisetron and promethazine combination was more effective in reducing PONV and PDNV than promethazine monotherapy. The combination also reduced the severity of nausea.     

Unanticipated admission after ambulatory surgery — a prospective study

Purpose

To determine the incidence, the reasons, and the predictive factors for unanticipated admission after ambulatory surgery.

Methods

Preoperative, intraoperative, and postoperative data were collected prospectively on 15,172 consecutive ambulatory surgical patients during a 32-month period. The data were built into a statistical model, and predictive factors were identified and classified.

Results

The overall incidence of unanticipated admission was 1.42%. Admitted patients were more likely to be older, male, and ASA status II or III. Duration of anaesthesia was longer, and surgery was more likely to be completed after 3 pm. Length of stay in the Postanaesthesia Care Unit and the Ambulatory Surgery Unit was longer. Surgical reasons were cited in 38.1% of admitted patients; anaesthesia-related reasons were cited in 25%; social reasons accounted for 19.5%, and medical reasons for 17.2%. Ear, nose and throat (ENT) patients had the highest unanticipated admission rate (18.2%), followed by urology (4.8%) and chronic pain block (3.9%). Gynaecological patients had the lowest rate (0.4%). Among the predictive factors found were male, ASA status II and III, long duration of surgery, surgery finishing after 3 pm, postoperative bleeding, excessive pain, nausea and vomiting, and excessive drowsiness or dizziness.

Conclusion

Earlier operating time for certain surgical procedures, screening for proper support at home, and implementation of clinical pathways to deal aggressively with problems such as pain, nausea and vomiting should decrease the incidence of unanticipated admission.     

Postoperative Beschwerden

Objective

Women report more severe postoperative complaints than men (e.g. nausea and pain) and expectations of complaints prior to surgery influence the postoperative complaints. Therefore, the aim of this study was to explore if gender differences in complaint expectation can account for differences in postoperative complaints. A further objective was to investigate the effective load of complaints and to look for gender differences.

Methods

In total 281 patients (128 men and 153 women) were included in the study and all patients underwent elective general surgery. Patients were asked for symptom expectations and symptom experiences prior to surgery. After surgery they answered the Anesthesiological Questionnaire (ANP) a validated self-rating method for the assessment of postoperative symptoms and complaints. The symptoms referred to in the questionnaire included sensation of cold, sensation of heat, nausea and vomiting, tickly throat, croakiness, dry mouth and thirst, difficulty in breathing, sore throat, pain in the area of surgery, pain in the area of infusion, muscle pain, back pain, headache, difficulties in urination, difficulty in awakening and feeling of somatic discomfort. In addition patients rated the affective load of the postoperative complaints.

Results

In previous surgery women reported experiencing more postoperative somatic complaints than men. Sex-related differences were significant (p?<?0.05) for sensation of cold, nausea and vomiting, tickly throat, croakiness, sore throat, pain and the feeling of somatic discomfort. Likewise, women expected more intensive postoperative complaints following the forthcoming operation. After surgery women reported significantly more severe complaints in negative symptoms of the ANP (e.g. nausea and vomiting, pain and somatic discomfort). Effect sizes of sex-related differences varied according to the symptom (e.g. for pain effect strength d?=?0.50, for nausea d?=?0.60 and for thirst d?=?0.13). Effect sizes decreased when the effect of expectation was statistically controlled. Logistic regression revealed that expectation was an independent predictor for the sensation of severe nausea (odds ratio OR 4.3] and intensive postoperative pain (OR 2.6). Regardless of gender, postoperative pain, nausea and dry mouth/thirst were symptoms with the highest affective load.

Conclusions

Preoperative expectations increase gender differences in somatic complaints following surgery. Anesthesiological education of patients should influence dysfunctional expectations. Postoperative pain, nausea and thirst should be the main targets of interventions to improve patient complaints.     

Transversus abdominis plane block does not improve early or late pain outcomes after Cesarean delivery: a randomized controlled trial

Objectives

Cesarean delivery is a common surgical procedure with anticipated substantial postoperative pain. The addition of a transversus abdominis plane block (TAPB) to a multimodal analgesic regimen that includes intrathecal morphine may provide improved early pain outcomes and decrease the risk of chronic post-surgical pain. The purpose of this research was to assess the ability of an ultrasound-guided TAPB with low-dose ropivacaine to decrease early postoperative pain, opioid consumption, and risk of developing persistent pain when compared with a placebo block.

Methods

Eighty-three women were randomly assigned to either a treatment (0.25% ropivacaine) or control group (0.9% saline) in this double-blind trial, and 74 women were included in the final analysis. Ultrasound-guided TAPBs were performed with an injection of 20 mL of study solution per side. The primary outcome measures of this study were: pain at rest and pain after movement measured with a numeric rating scale, results of the Quality of Recovery-40 (QoR-40) questionnaire, and opioid consumption at 24 hr. These were used with an a priori sample size calculation to detect a 30% reduction in pain scores, a 10% improvement in QoR-40 score, and a 50% reduction in opioid consumption. Health quality and physical functioning were assessed using the Short Form 36 (SF-36®) Health Survey at 30 days and six months.

Results

Assessment at 24 hr after Cesarean delivery revealed no clinically important differences between groups in postoperative pain, QoR-40, or opioid consumption. There were no clinically important differences between groups regarding measures of nausea, pruritus, vomiting, urine retention (2, 24, and 48 hr postoperatively), 24-hr QoR-40 sub-dimensions, or the SF-36 Health Survey (30 days and six months postoperatively).

Conclusions

Ultrasound-guided TAPB did not improve postoperative pain, quality of recovery, or opioid consumption 24 hr following surgery. Similar health and functioning (SF-36) at 30 days and six months were reported by both groups. This trial was registered at ClinicalTrials.gov number: NCT01261637.     

Oral clonidine reduces postoperative PCA morphine requirements

Purpose

The purpose of this study was to evaluate the effect of perioperative oral clonidine on postoperative analgesia and PCA morphine requirements in adult patients after major orthopaedic knee surgery.

Methods

In this prospective, double blind, placebo-controlled study 44 patients undergoing either total knee replacement or hemiarthroplasty of the knee were randomly assigned to receive oral placebo or clonidine (5 μg · kg^?1) 1.5 hr before surgery, and at 12 hr, and 24 hr after the initial dose. Five patients were subsequently withdrawn from study. No other preoperative drugs were given. Preoperative sedation score was recorded. A standardized general anaesthetic was administered to all patients. Postoperative blood pressure, heart rate, PCA morphine use, visual analogue score (VAS) for pain, sedation, nausea, and pruritus were recorded for 36 hr postoperatively.

Results

The cumulative PCA morphine used was 37% lower after clonidine 57.3 ± 26.8 mg (mean ± SD) compared with placebo 91 ± 31.6 mg (P = 0.031). There was no difference in pain or sedation scores postoperatively but patients who received clonidine were more sedated preoperatively (P < 0.001) and had a lower mean arterial blood pressure throughout the period of study by 10 to 26 mmHg (P < 0.0001). Clonidine reduced the incidence of postoperative nausea (25% vs 74%) (P < 0.01) and vomiting compared with placebo (10% vs 53%) (P < 0.01) and required less antiemetic (dimenhydrinate 37.5 ± 20.9 mg vs 82.1 ± 49.4 mg) but not statistically significant (P = 0.065).

Conclusions

Oral clonidine is a useful component to postoperative balanced analgesia as it decreases PCA morphine requirements and decreases the incidence of nausea and vomiting.     

Factors contributing to a prolonged stay after ambulatory surgery

We identified predictors for prolonged postoperative stay after ambulatory surgery using multiple logistic regression models. We collected perioperative data for 16,411 ambulatory surgical patients. A log-transformed time to discharge variable was modeled by multiple linear regression, including patient-, anesthesia-, and surgery-specific variables. The impact of hypothetical elimination of perioperative adverse events on mean length of stay was also estimated. Separate analyses were performed among patients who received general anesthesia (GA) and monitored anesthesia care (MAC). Patients receiving GA stayed 50 min longer than patients receiving MAC. Patients receiving GA and undergoing strabismus, transurethral, or otorhinolaryngological/dental procedures had the longest postoperative stay. Among patients receiving GA, smokers had a 4% shorter stay compared with nonsmokers; among patients receiving MAC, those with congestive heart failure (CHF) had a 11% longer stay compared with patients without CHF. Postoperative nausea and vomiting, dizziness, excessive pain, and cardiovascular events predicted 22%-79% increases in postoperative stay. The hypothetical elimination of all adverse events resulted in a 9.6% decrease in mean length of stay among patients receiving GA, but in only a 3.8% decrease among patients receiving MAC. The length of postoperative stay among ambulatory surgical patients is mainly determined by the type of surgery and by adverse events, such as excessive pain, postoperative nausea and vomiting, dizziness, drowsiness, and cardiovascular events. Patients with CHF and those who underwent long procedures had a higher risk of a prolonged stay. Appropriate prevention and management of postoperative symptoms could significantly decrease the length of stay among patients receiving GA. IMPLICATIONS: The length of postoperative stay among ambulatory surgical patients is mainly determined by the type of surgery and by adverse events, such as excessive pain, postoperative nausea and vomiting, dizziness, drowsiness, and untoward cardiovascular events. Patients with congestive heart failure and those who underwent long procedures had a higher risk of a prolonged stay. Appropriate prevention and management of postoperative symptoms could significantly decrease the length of stay among patients receiving general anesthesia.     

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.     

RETRACTED ARTICLE: Antiemetic effects of granisetron on postoperative nausea and vomiting in patients with and without motion sickness

Purpose

This randomized, placebo-controlled, double-blind study was to evaluate the effects of granisetron, a selective 5-hydroxytryptamine type 3 receptor antagonist, for preventing postoperative nausea and vomiting in 110 patients with (n = 50) and without (n = 60) a history of motion sickness undergoing general anaesthesia for major gynaecological surgery.

Methods

The patients received a single dose of either granisetron (40 μg · kg^?1) or placebo (saline) iv over 2–5 min immediately before induction of anaesthesia. Postoperatively, during the first 24 hr after anaesthesia, the frequencies of nausea and vomiting were recorded.

Results

Except for a positive history of motion sickness, the treatment groups were similar for patient characteristics, types of surgery, anaesthetics administered and opioids given. Postoperatively, the frequency of nausea was 44% and 16% after administration of placebo and granisetron in patients with motion sickness, and was 30% and 7% in patients without it, respectively; the corresponding frequencies of vomiting were 28%, 8%, 13% and 3%. The incidence of adverse events postoperatively were not different among the groups.

Conclusion

These results suggest that preoperative prophylactic administration of granisetron is effective and safe for preventing postoperative nausea and vomiting in patients with motion sickness as well as in patients without it.     

Pre-treatment with morphine does not prevent the development of remifentanil-induced hyperalgesia

Purpose: Remifentanil, an ultra short-acting opioid commonly used to supplement general anesthesia, is associated with the development of hyperalgesia that manifests clinically as an increase in postoperative analgesic requirement. This study involving adolescents undergoing scoliosis surgery evaluated whether pre-treatment with morphine prior to commencing remifentanil infusion would decrease the initial 24-hr morphine consumption and pain scores. Methods: Forty ASA 1–11 pediatric patients undergoing surgical correction of idiopathic scoliosis were recruited in a prospective, randomized, double-blind fashion to receive 150µg·kg^?1 morphine or an equal volume saline prior to commencing remifentanil by infusion. The primary outcome was the initial 24-hr postoperative morphine consumption. Numeric rating scale (NRS) pain scores at rest and on coughing were recorded, as were scores for nausea, vomiting, and sedation and incidences of pruritus. Results: The groups were demographically similar. No differences were observed between groups vis-à-vis the initial 24-hr morphine consumption, NRS pain scores, sedation, nausea, or vomiting. Conclusion: Pre-treatment with 150µg·kg^?1 morphine did not decrease the initial 24-hr morphine consumption in adolescents who received remifentanil by infusion for surgical correction of idiopathic scoliosis.     

A comparison of ondansetron and prochlorperazine for the prevention of nàusea and vomiting after tympanoplasty

Purpose

To evaluate the effects on PONV and headache after tympanoplasty of prochlorperazine 0.2 mg·kg^?1 im, ondansetron 0.06 mg·kg^?1 iv or placebo (isotonic saline) 0.02 ml·kg^?1 iv given immediately after induction of anaesthesia prior to tracheal intubation.

Methods

The study was randomised, double blind and prospective. One hundred and forty-eight patients, aged 9–61 yr, received a standardised balanced inhalational anaesthetic with controlled ventilation and induced hypotension. Postoperatively, the frequencies of retching and vomiting in the PACU and of nausea, retching, vomiting, headache, analgesic and antiemetic requirements in the surgical ward for 24 hr were recorded.

Results

The four test groups (n = 37 each) were comparable. The incidences of vomiting in the PACU were similar. During the first 24 hr after surgery the antiemetics produced no reductions in the incidence of nausea alone or of vomiting alone. However, the combination of nausea and vomiting was reduced from 53% (placebo) to 16% (P < 0.0005), 19% (P < 0.0005) and 30% (P < 0.05) by im. prochlorperazine, iv ondansetron and iv prochlorperazine, respectively. The frequency of those experiencing no PONV was increased from 27% (placebo) by prochlorperazine im to 57% (P < 0.01), by ondansetron iv to 62% (P < 0.005) and by prochlorperazine iv to 43% (P = NS). The. onset of PONV was delayed in those given prochlorperazine im, and vomiting was less severe in those given ondansetron iv. Headache occurred with similar frequency in each group.

Conclusion

Prophylactic prochlorperazine 0.2 mg·kg^?1 im and ondansetron 0.06 mg·kg^?1 iv are similarly efficacious in reducing nausea with vomiting after tympanoplasty, while prochlorperazine 0.1 mg·kg^?1 iv is less efficacious. Neither drug given as described appeared to reduce the frequency of postoperative nausea alone or vomiting alone.     

Effect of dexamethasone on postoperative morbidity after dental rehabilitation in children

Purpose

Dexamethasone reduces postoperative morbidity after adenotonsillectomy, strabismus surgery, and third molar extraction. Our hypothesis was that dexamethasone would reduce pain and other morbidity in children undergoing dental surgery for up to 24 hr postoperatively.

Methods

A triple-blinded, randomized, controlled trial was carried out on 200 children undergoing prolonged dental rehabilitation under general anesthesia. Subjects were randomized into two groups: group D, given dexamethasone 0.3?mg·kg^?1; group S, given normal saline. The primary outcome measure was pain over 24 hr as evaluated by a parental 0-10 numerical rating scale (NRS). Key secondary outcomes included oral intake on a four-point scale at 24 hr and the overall incidence of postoperative vomiting (POV). Analysis for the primary outcome consisted of comparison of means in the NRS with the Wilcoxon rank sum test and for occurrence of POV with Fisher??s test.

Results

After eliminating 22 subjects for protocol violations and withdrawals, 178 subjects were analyzed. There was no significant difference in pain scores (NRS) at 24 hr or the worst NRS experienced over the preceding 24 hr. There was no difference in the quality of oral intake between the groups. There was a significant difference in the percentage of patients who vomited during the first 24 hr: eight of 91 in group S and one of 87 in group D. Therefore, 7.74% more vomited in group S (P?=?0.045), with a 95% confidence interval of 0.32 to15.16 for the difference in percentages.

Conclusions

Dexamethasone, 0.3?mg·kg^?1, did not reduce pain over 24 hr in healthy children undergoing dental rehabilitation under general anesthesia. The quality of oral intake was also unaffected by dexamethasone at 24 hr. Dexamethasone did produce a significant reduction in postdischarge vomiting, beyond the incidence found with ondansetron alone.     

Minor sequelae of ambulatory anesthesia

Voluntary abortions in day hospitals fulfill the need for shorter hospital stays and minimal interference with patient activities; on the other hand, it makes it more difficult to evaluate the possible complications of anesthesia. 1820 patients who received general anesthesia for voluntary abortion were given a questionnaire before they were discharged; items queried included drowsiness, headache, dizziness, nausea or vomiting, sore throat or mouth, abdominal cramps, pain at IV site, backache or muscular cramps, inability to perform daily activities. Only 465 patients returned the questionnaire. The most frequent complaint was sleepiness or drowsiness (19.8%), headache (7.1%), dizziness (15.1%), nausea or vomiting (8.2%), abdominal cramps (24.7%), and backache (16.7%). There seems to be less nausea or vomiting with the use of pentothal rather than alothane. Ketamine was never used on its own. The findings seen to suggest that the simplest combinations of drugs result in fewer and less severe complications than the use of several drugs.     

Intravenous ketamine compared with diclofenac suppository in suppressing acute postoperative pain in women undergoing gynecologic laparoscopy

Purpose

We aimed to compare the analgesic effects of low-dose intravenous ketamine with the effects of diclofenac suppositories in acute postoperative pain management in women undergoing gynecologic laparoscopic surgery under general anesthesia.

Methods

In a double-blind, randomized clinical trial, 80 patients were selected and entered the study. After the induction of general anesthesia, one group received 0.15?mg/kg intravenous ketamine and the other group received a 100-mg rectal diclofenac suppository. The two groups were compared regarding acute pain scores, postoperative morphine requirements, and untoward complications.

Results

Pain scores and morphine requirements were lower in the rectal diclofenac suppository group at the 1st, 3rd, and 6th postoperative hours. Higher incidences of postoperative nausea and vomiting (PONV), delusions, and oral secretions were observed in the ketamine group.

Conclusions

Diclofenac 100-mg suppositories were more effective in suppressing acute pain than 0.15?mg/kg intravenous ketamine in women undergoing elective gynecologic laparoscopy, with fewer untoward complications.     

The incidence of side effects and their relation with anesthetic techniques after ambulatory surgery

The aim of this study was to evaluate the incidence of side effects and their relation with anesthetic techniques in patient undergoing ambulatory surgery. 654 patients, ASA I–II, aged between 20 and 70 years scheduled for ambulatory surgery were enrolled into the study protocol. Patients were requested to record the existence of headache, sore throat, postoperative pain, nausea, vomiting, muscle weakness, lack of appetite, drowsiness, sleep disturbances, dizziness, dysuria, and lumbar pain during first week postoperatively. Postoperative pain was significantly higher after peripheral neural blockage. Muscle weakness, sore throat, lack of appetite, dysuria, sleep disturbances, headache, and dizziness were significantly higher after inhalational anesthesia (P<0.05). It was concluded that total intravenous anesthesia or neural blockade should be preferred for ambulatory surgery and an effective postoperative analgesic therapy should be planned before discharge.     

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.     

Comparison of tramadol and morphine via subcutaneous PCA following major orthopaedic surgery

Purpose

To compare subcutaneous PCA tramadol with subcutaneous PCA morphine for postoperative pain relief after major orthopaedic surgery and for the incidence of side-effects.

Methods

In a double-blind randomised controlled study 40 patients (20 in each group) self-administered either tramadol or morphine for 72 hr after surgery viasc PCA The following variables were recorded at various time intervals: (i) pain score by means of a visual analogue scale, (ii) drug consumption and total PCA demands, (iii) vital signs (blood pressure and heart rate), (iv) oxygen saturation and respiratory rate, and (v) side-effects (sedation, nausea/vomiting, pruritus, urinary retention and constipation).

Results

Both drugs provided effective analgesia. The mean consumption in the first 24 hr was 792 ± 90 mg tramadol and 42 ± 4 mg morphine. Thereafter, consumption of both drugs declined markedly. Moderate haemodynamic changes were observed in both the tramadol and morphine groups (with a maximum 20% decrease in mean blood pressure and a maximum 17% increase in heart rate) during the 72 hr period. Both tramadol and morphine were associated with a clinically and statistically significant (P < 0.001) decrease in oxygen saturation, but without changes in respiratory rates. Desaturation was less marked with tramadol. Tramadol appeared to cause more nausea and vomiting than morphine. Sedation was mild and only seen during the first few hours after surgery in both groups.

Conclusion

Tramadol is an effective analgesic agent for the relief of acute postoperative pain when administered by PCA via the subcutaneous route. Under these conditions tramadol behaves much like morphine with a similar side-effect profile.     

Paravertebral block for breast cancer surgery

Purpose

Major breast cancer surgery is associated with a high incidence of postoperative nausea, vomiting and pain. Regional anaesthesia, with intraoperative sedation, would seem an ideal alternative to general anaesthesia for this type of surgery. We report our initial experience using paravertebral blocks (PVB) to provide anaesthesia for major breast surgery.

Methods

Twenty-five patients agreeing to have surgery performed under paravertebral blocks were studied. Procedures performed varied from simple lumpectomy with axillary dissection to modified radical mastectomy with axillary dissection. During monitored sedation, blocks opposite spinous processes of C₇– T₆ were performed using bupivacaine 0.5% with epinephrine, 3– 4 ml per segment. Patients were evaluated for 72 hr and were requested to document:(i) when sensation returned (ii) incidence and frequency of nausea or vomiting (iii) degree of discomfort and medication taken.

Results

Twenty patients had blocks that required no supplementation. Five patients had blocks that were incomplete. No complications were attributed to the blocks. Post-operatively, patients with successful blocks had minimal nausea, vomiting and pain. No patients found the procedure unsatisfactory. Patients with successful blocks were all very satisfied.

Conclusion

Our initial results show that PVB for breast cancer surgery can be successfully performed in a majority of patients with few side effects. All patients with successful blocks were returned to the ambulatory care unit, bypassing the recovery room. That breast cancer surgery under regional anaesthesia can be safely performed as an ambulatory procedure has the potential for accomplishing major cost-saving.     

Prophylactic oral dolasetron mesylate reduces nausea and vomiting after abdominal hysterectomy

Purpose

The incidence of postoperative nausea and vomiting (PONV) varies from 50% to 75% after gynaecological surgery under general anaesthesia. This study evaluates the dose-response relationships, safety, and efficacy of the new 5-HT₃ antagonist, dolasetron mesylate, in the prevention of PONV in women undergoing total abdominal hysterectomy (TAH).

Methods

Three hundred and seventy four women scheduled for TAH under general anaesthesia were studied at 13 Canadian centres. Patients received in a randomized, double-Wind manner 25, 50, 100, or 200 mg dolasetron or placebo po one to two hours before induction of anaesthesia. The anesthetic protocol was standardized. Efficacy was evaluated for 24 hr after surgery by companng the number of emetic episodes, administration of rescue medication, seventy of nausea, and patient satisfaction.

Results

Analysis of complete response (no emetic episodes and no rescue for 24 hr) revealed a linear doseresponse relationship across dolasetron groups (P < 0.002). Dolasetron 100 mg (P < 0.003) and 200 mg (P < 0.01) were superior to placebo. The percentage of patents with no emetic episodes increased from 29.3% (placebo) to 54.1 % (100 mg). Subgroup analysis revealed ASA status (I > II), previous history of PONV, previous history of motion sickness, and total morphine dose (> 55 mg associated with less PONV than < 55 mg) influenced the incidence of emetic symptoms, but did not alter the results of the primary analysis.

Conclusion

Prophylactic dolasetron (100 mg and 200 mg) reduces the incidence of PONV in patients having total abdominal hysterectomy.