Pain relief following oral day case surgery: a pilot study

One hundred consecutive, adult patients attending for bilateral mandibular third molar removal utilising standardised surgical and day case general anaesthetic protocols were recruited into a pilot study to investigate the effectiveness of different peri-operative analgesic regimes. Patients were randomised into five study groups using various pre- or post-operative combinations of non-steroidal anti-inflammatory drugs (NSAID) and/or LA block. Pain scores were recorded pre-operatively and at 30 min intervals for 2 h after surgery, as were details of the first dose of ‘escape analgesia’ (codeine/paracetamol compound preparation). There was no statistically significant difference in overall pain experience between the groups, although the results suggested better pain relief was achieved in those patients who received both post-op NSAID and post-op LA. Further research is required to improve post-operative pain relief for patients undergoing third molar surgery.     

Transversus abdominis plane block: The analgesic efficacy of a new block catheter insertion method

BackgroundLocal anesthetic (LA) administration via a correctly placed block catheter could help optimum deposition in the transversus abdominis plane (TAP). The aim of the study is to assess the postoperative analgesic efficacy of TAP block achieved by initially injecting the LA through a catheter placed by ultrasound-guided Seldinger catheter insertion approach (USCIA).MethodsFifty patients scheduled for open inguinal hernia repair were randomized into two groups. Group USCIA: Patients received USCIA-TAP block. Group control: Patients did not receive TAP block. All patients received patient-controlled intravenous morphine postoperatively. The analgesic efficacy of USCIA-TAP block was assessed measuring the total amount of postoperative morphine requirements over the first 48 h postoperatively. Pain scores and level of patient satisfaction with pain relief after surgery were noted.ResultsThe mean cumulative morphine requirement over the first 48 postoperative hours was significantly lower in USCIA group in comparison with the Control group (18.1 ± 4.1 vs. 57.9 ± 5.3 mg). The success rate of USCIA-TAP block catheter placement was 88%. The pain score of USCIA group was significantly lower at 3, 6, 12, and 24 postoperative hours compared with the Control group. The USCIA group had a significantly higher rate of satisfaction with regard to pain control in comparison with the Control group at the 12th and 24th postoperative hours (9 {8–10} vs. 6 {5–7} and 9 {8–10} vs. 7 {6–8}, respectively).ConclusionThe use of a single dose of USCIA-TAP block reduced the total amount of morphine requirement over the first 48 postoperative hours for patients undergoing abdominal surgery.     

Clinical evaluation of post-operative analgesia comparing suprascapular nerve block and interscalene brachial plexus block in patients undergoing shoulder arthroscopic surgery

BackgroundShoulder arthroscopic surgeries have a high incidence of severe post-operative pain significant enough to interfere with recovery and rehabilitation. A regional anaesthetic technique combined with general anaesthesia reduces intra-operative requirements of anaesthesia and provides a better post-operative pain relief. As the commonly employed technique of interscalene brachial plexus block (ISB) is associated with potential serious complications, suprascapular nerve block (SSB) can be used as a safer alternative.Methods and materialIn this prospective study, 60 ASA 1 or 2 adult patients undergoing shoulder arthroscopic surgery were randomised into two groups – ISB and SSB. In group ISB, ISB with 20 ml of 0.5% bupivacaine mixed with 75 μg clonidine was given. In the SSB group SSB was given with 15 ml of 0.5% bupivacaine with 75 μg clonidine. Pain was assessed using visual analogue scale and verbal pain scale scores and time to first rescue analgesia was noted. We used Student's t test and Chi-square/Fisher Exact test and used a statistical software to compare data.ResultsIn the present study, the mean duration of analgesia was 2.53 ± 2.26 h in SSB group compared to 7.23 ± 6.83 h in group ISB (p value < 0.05). Overall rescue analgesic requirements were higher in SSB group compared to ISB group (63.3% versus 40.0%) but this was statistically not significant (p value > 0.05).ConclusionBoth interscalene and SSB can be used to provide intra-operative and post-operative analgesia in patients undergoing shoulder arthroscopy.     

The effect of post-operative NSAID administration on bone healing after elective foot and ankle surgery

BackgroundPost-operative pain is a common concern following elective foot and ankle surgery. NSAIDs used for pain relief have led to bone-healing complications in animal models and in vitro studies. This retrospective study examined the rate of bone-healing complications in post-surgical patients using NSAIDs.MethodsParticipants underwent elective foot surgeries between January 2016 and May 2018. Radiographs were used to identify bony nonunion at osteotomy sites 12 weeks post-surgery.ResultsTwo-hundred thirty-two patients were evaluated; 59 (25.43%) were prescribed ibuprofen, 62 (27%) ketorolac, 15 (6.47%) acetaminophen, and 92 (40%) hydrocodone-acetaminophen. Two-hundred and twelve (91.38%) patients exhibited radiographic evidence of osseous union at 12 weeks and 20 (8.62%) had radiographic evidence of non-union of the osteotomy sites. There was no significant relationship between NSAID use and osseous non-union (p < 0.05).ConclusionsShort-term use of oral ibuprofen and ketorolac in the post-operative period was not associated with bony non-union.     

Postoperative analgesia after major abdominal surgery: Fentanyl–bupivacaine patient controlled epidural analgesia versus fentanyl patient controlled intravenous analgesia

BackgroundMajor abdominal surgeries induce neurohumoral changes responsible for postoperative pain, various organ dysfunctions and prolonged hospitalization. Inadequate pain control is harmful and costly to patients thus an appropriate pain therapy to those patients must be applicated.MethodsOne hundred patients (ASA I or II) of either sex aged from 20 to 60 years were scheduled for elective major abdominal surgery. Patients were allocated randomly into two groups (fifty patients each) to receive: patient-controlled epidural analgesia with bupivacaine 0.125% and fentanyl (PCEA group), or patient controlled intravenous analgesia with fentanyl (PCIA group). Postoperative pain was assessed over 24 h using Numerical Pain Rating scale (NPRS). The frequency of rescue analgesia, sedation score and overall patient satisfaction were recorded. Any concomitant events like nausea; vomiting, shivering, pruritus or respiratory complications were recorded postoperatively.ResultsThere was a significant less pain in PCEA group at 2, 8 and 12 h. postoperative but PCIA group had less pain at immediate postoperative time. As regard sedation scale, patients of the PCEA group were significantly less sedated than PCIA group at immediate postoperative only. Overall patient satisfaction was significantly more in PCEA group.ConclusionThis study concluded that both PCEA and PCIA were effective in pain relief after major abdominal surgery but PCEA was much better in pain relief, less sedating effect and overall patient satisfaction.     

Dose ranging effects of pregabalin on pain in patients undergoing laparoscopic hysterectomy: A randomized,double blinded,placebo controlled,clinical trial

ObjectiveThe study aimed to investigate the preemptive analgesia efficacy of different concentrations (75, 150 and 300 mg) of preemptive pregabalin for the postoperative pain management after laparoscopic hysterectomy.DesignProspective, randomized, placebo-controlled, double-blind study.SettingThe Gynecology and Obstetrics Center of Arash Hospital, Tehran, Iran, from October 2013 to November 2014.PatientsA total of 96 women with American Association of Anesthesiologist (ASA) physical status I and II underwent elective laparoscopic hysterectomy surgery. Patients were then randomly assigned to four groups, of which groups 1–3 (treatment groups; n = 20) received orally pregabalin concentrations of 75 mg, 150 mg, and 300 mg, respectively, for a night before surgery, 30 min before surgery and 6 h after surgery, whereas group 4 (control group; n = 22) received a matching dosage of placebo at the same scheme.MeasurementsVisual Analog Scale (VAS) scores for postoperative pain at rest and on movement at first 24 h after surgery were evaluated as primary outcome. Drug-related side effects were also evaluated as a secondary outcome. Somnolence was evaluated using Ramsay Sedation Scale, while nausea and vomiting were assessed using numeric scores. The data were analyzed using SPSS.Main resultsPreemptive pregabalin in different concentrations provided better pain relief as compared with placebo. Post-hoc test indicated that there was a significant difference among four groups, indicating where the concentration was increased, the pain score decreased as an independent variable of time. The highest concentration of pregabalin (300 mg) revealed higher sedation scores as compared with other groups.ConclusionOur data demonstrated preemptive administration of 75, 150, and 300 mg pregabalin play an important role in reducing postoperative pain after laparoscopic hysterectomy. Comparison of different concentrations and side effects indicates oral administration of 150 mg pregabalin is an effective and safe method for postoperative pain management after laparoscopic hysterectomy.     

The analgesic efficacy of continuous fascia iliaca block vs. continuous psoas compartment block after hip surgery: A comparative study

BackgroundBoth psoas compartment block and fascia iliaca compartment block have been shown to be reliable blocks for postoperative pain relief for procedures involving the hip joint. This study evaluated the efficacy of continuous psoas compartment block with continuous fascia iliaca block for postoperative analgesia after hip surgery.MethodsIn randomized blinded study Forty, ASA I–III patients aged 30–75 years, with BMI less than 40, scheduled for hip surgery, were divided to one of two groups. Group P: continuous psoas compartment block (n = 18) and group F: continuous fascia iliaca block (n = 19). Standard general anesthesia was induced after finishing the block technique. After recovery 30 ml of 0.125% levobupivacaine was injected through the catheter to all patients. Postoperative 24 h meperidine consumption, patient satisfaction, visual analogue scale pain scores at (1, 6, 12, 18, and 24 h) postoperative, postoperative hemodynamics (HR and MAp), evidence of sensory and motor blockades, and incidence of adverse effects were recorded.ResultsThere was no significant difference between the two groups in 24 h postoperative meperidine requirements, postoperative VAS, patient satisfaction, postoperative hemodynamics, and distribution of sensory and motor block of (femoral, lateral femoral cutaneous, and obturator nerves). The epidural anesthesia occurred in two patients in psoas group (11%).ConclusionBoth continuous fascia iliaca block and continuous psoas compartment block were comparable in providing safe and effective analgesia after hip surgery.     

Role of postoperative continuous subfascial bupivacaine infusion after posterior cervical laminectomy: Randomized control study

IntroductionOne of the major drawbacks of posterior cervical decompression and rigid internal fixation is the severe postoperative neck pain created by extensive soft tissue and muscular dissection. The usual management of acute postsurgical pain consists of systemic opioids or non-steroidal anti-inflammatory drugs. Another satisfying method of postoperative pain relief is continuous local infusion of analgesic agents in posterior subfascial paravertebral space on both sides of the wound using epidural catheters.MethodsSixty patients scheduled for cervical laminectomy with fixation surgery via the posterior midline approach with postoperative epidural catheters placed subfascially on both sides of the wound. They were randomly divided into two groups, bupivacaine group with local infiltration of 0.5% bupivacaine at the rate 2 ml/h, and control group with saline infusion at a rate 2 ml/h. The patient controlled analgesia device (PCA) was given to all patients and set to deliver IV morphine in 1 mg boluses with a lock out at 10 min and a 4 h maximum 10 mg.ResultsThe visual analog score was statistically significant lower in bupivacaine group compared to control group during the first 60 h postoperatively. While in 66 and 72 h postoperatively there was no statistical significant difference was observed between the two groups. The total doses of morphine delivered by PCA in the three postoperative days were statistically significantly higher in control group than bupivacaine group. The incidence of side effects related to narcotics was higher in control than bupivacaine group.ConclusionBilateral subfascial continuous 0.5% bupivacaine infiltration through an ordinary epidural catheter at the rate 2 ml/h for three successive postoperative days is associated with better pain control, reduced narcotics, early ambulation and no serious side effects in the postoperative period in patients undergoing posterior cervical fixation.     

Prehospital fast track care for patients with hip fracture: Impact on time to surgery,hospital stay,post-operative complications and mortality a randomised,controlled trial

IntroductionAmbulance organisations in Sweden have introduced prehospital fast track care (PFTC) for patients with suspected hip fracture. This means that the ambulance nurse starts the pre-operative procedure otherwise implemented at the accident & emergency ward (A&E) and transports the patient directly to the radiology department instead of A&E. If the diagnosis is confirmed, the patient is transported directly to the orthopaedic ward. No previous randomised, controlled studies have analysed PFTC to describe its possible advantages.The aim of this study is to examine whether PFTC has any impact on outcomes such as time to surgery, length of stay, post-operative complications and mortality.MethodsThe design of this study is a prehospital randomised, controlled study, powered to include 400 patients. The patients were randomised into PFTC or the traditional care pathway (A&E group).ResultsTime from arrival to start for X-ray was faster for PFTC (mean, 28 vs. 145 min; p < 0.001), but the groups did not differ with regard to time from start of X-ray to start of surgery (mean 18.40 h in both groups). No significant differences between the groups were observed with regard to: time from arrival to start of surgery (p = 0.07); proportion operated within 24 h (79% PFTC, 75% A&E; p = 0.34); length of stay (p = 0.34); post-operative complications (p = 0.75); and 4 month mortality (18% PFTC, 15% A&E p = 0.58).ConclusionPFTC improved time to X-ray and admission to a ward, as expected, but did not significantly affect time to start of surgery, length of stay, post-operative complications or mortality. These outcomes were probably affected by other factors at the hospital. Patients with either possible life-threatening conditions or life-threatening conditions prehospital were excluded.     

Factors associated with patient satisfaction with foot and ankle surgery in a large prospective study

BackgroundThere is minimal published research on outcomes and satisfaction with foot and ankle surgery.ObjectiveTo investigate patient-reported outcomes and satisfaction, and investigate which factors influence satisfaction at 9 months following foot or ankle surgery.MethodsProspective study of 671 adult patients having foot or ankle surgery. Pre-and post-surgery, patients self-completed MOXFQ, SF-36 and EQ-5D questionnaires. Using ratings to a satisfaction item, patients who were ‘very pleased’ with the outcome were compared with everyone else, using multiple logistic regression, regarding their pre-, peri- and post-operative characteristics.ResultsOf 628 eligible patients, 491 (73%) completed pre-and post-operative questionnaires. Following adjustment, satisfaction with surgery was influenced by patients’ perceptions of their foot/ankle's appearance (OR 0.12, 95% CIs 0.06–0.23, p < 0.001); wearable range of shoes (OR 0.36, 95% CIs 0.17–0.79, p = 0.01); continued foot/ankle pain (OR 0.06, 95% CIs 0.03–0.14, p < 0.001); impairment in Social-Interaction (MOXFQ SI scale) (OR 0.98, 95% CIs 0.96–0.99, p = 0.009). The final explanatory model explained 67% of the variance in patient satisfaction.ConclusionsFoot appearance, wearable shoe range, the (full) alleviation of pain and the ability/confidence to interact socially are crucial to peoples’ satisfaction with their foot or ankle surgery.     

Bloqueio PECS I para analgesia pós‐operatória em pacientes submetidos a mamoplastia de aumento: estudo randomizado,duplo‐cego,controlado por placebo

Background and objectivesPECS I block was first described for surgery involving the pectoralis muscles. No randomized clinical trial has been conducted on surgeries that directly involve these muscles, such as subpectoral breast augmentation. We hypothesized that PECS I block would decrease pain in the postoperative period in this population.MethodsThis was a randomized, double‐blind, placebo‐controlled trial in women undergoing subpectoral breast augmentation surgery. PECS I block was performed using 0.4 mL.kg^‐1 of 0.9% saline on one side and bupivacaine (0.25%) on the other side, each patient being her own control. Numeric Rating Scale (NRS) pain scores (0 − 10) were measured at rest and during movement. The primary outcome was pain score at rest 30 minutes after arrival in the PACU. To detect a clinically significant difference of 50% in pain reduction, 14 volunteers were enrolled (power of 90% and alpha < 0.05).ResultsIn the PACU, three patients had no difference in pain between sides, five had reduced pain on the placebo side, and six had reduced pain on the bupivacaine side. In the bupivacaine group, pain scores at rest at 5, 30 and 60 minutes and 24 hours were 4.89 (4.23 − 5.56; mean 95% CI), 3.75 (3.13 − 4.37), 3.79 (2.93 − 4.64), and 2.29 (1.56 − 3.01), respectively, whereas in the placebo group, they were 4.96 (4.32 − 5.60), 4.00 (3.50 − 4.49), 3.93 (3.12 − 4.73), and 2.29 (1.56 − 3.01), respectively.ConclusionsPECS I block in patients undergoing breast augmentation surgery does not provide better pain relief than placebo. Therefore, the indications for PECS I block in breast augmentation surgery should be reconsidered.     

Subcutaneous analgesic system versus epidural for post-operative pain control in surgical pediatric oncology patients

Background/PurposePediatric oncology patients often undergo open operations for tumor resection, and epidural catheters are commonly utilized for pain control. Our purpose was to evaluate whether a subcutaneous analgesic system (SAS) provides equivalent post-operative pain control.MethodsAn IRB approved, retrospective chart review of children age < 18 undergoing open abdominal, pelvic or thoracic surgery for tumor resection between 2017 and 2019 who received either epidural or SAS for post-operative pain control was performed. Comparisons of morphine milligram equivalents (MME), pain scores, and post-operative course were made using parametric and non-parametric analyses.ResultsOf 101 patients, median age was 7 years (2 months–17.9 years). There were 65 epidural and 36 SAS patients. Transverse laparotomy was the most common incision (41%), followed by thoracotomy (29%). Pain scores, MME, urinary catheter days, and post-operative length of stay (LOS) were similar between the two groups. Urinary catheter use was more common in epidural patients (70% vs 30%, p = < 0.001). SAS patients had faster time to ambulation and time to regular diet by 1 day (p = 0.02). Epidural patients more commonly had a complication with the pain device (20% vs 3%, p = 0.02) and were more likely to be discharged with narcotics (60% vs. 40%, p = 0.04). Charges associated with the hospital stay were similar between the two groups.ConclusionIn pediatric oncology patients undergoing open abdominal, pelvic, and thoracic surgery, SAS may provide similar pain control to epidural, but with faster post-operative recovery, fewer complications, and less discharge narcotic use. A prospective study is needed to validate these results.Type of StudyRetrospective ComparativeLevel of EvidenceLevel III     

The effect of multimodal balanced anaesthesia and long term gabapentin on neuropathic pain,nitric oxide and interleukin-1β following breast surgery

ObjectivesTo evaluate the effect of multimodal balanced anaesthesia and gabapentin (6 months) on neuropathic pain qualities, nitric oxide (NO) and interleukin 1-beta (IL-1β).MethodologyThis randomized study was conducted on 50 women scheduled for conservative breast surgery for cancer followed by chemotherapy and/or radiotherapy. Women enrolled into two groups; either to receive balanced general anaesthesia (GA) (control group) or ultrasound guided thoracic paravertebral with GA, multimodal balanced anaesthesia, (intervention group). Nociceptive pain was evaluated for 24 h. Neuropathic pain was evaluated using pain questionnaire 1 month postoperatively and neuropathic pain scale at 1, 3, 6 and 9 months. Gabapentin was prescribed to women reporting neuropathic pain 1 month postoperatively and for 6 months. NO and IL-1β were measured before operation, 1, 3, 6 & 9 months, postoperatively. Their relationship with neuropathic pain was assessed.ResultsNociceptive pain was less in intervention group than control group immediately post operative, 4 h after surgery at rest and 8 h with movement. Neuropathic pain started few days postoperatively, in both groups. Its onset, sites, duration and precipitating factors did not differ between the groups. Sensitive, hot pain and unpleasantness reduced significantly 1 month postoperatively, in intervention group. Two months later, itchy, dull and sharp pain was significantly less in intervention group. At 6 months, most of neuropathic pain items except sharp and deep pain lowered significantly in intervention group. At 9 months, hot and superficial pain was still less in intervention group. NO decreased significantly 1 and 3 months postoperatively, while IL-1β was significantly lower through different times, in intervention group. IL-1β correlated well with neuropathic pain intensity and unpleasantness.ConclusionBreast surgery for cancer was associated with neuropathic pain that continued for 9 months after surgery. Multimodal balanced GA had positive impact on acute nociceptive and neuropathic pain. Gabapentin reduced almost all neuropathic pain qualities.     

The management of right iliac fossa pain – Is timing everything?

BackgroundRight iliac fossa (RIF) pain remains the commonest clinical dilemma encountered by general surgeons. We prospectively audited the management of acute RIF pain, examining the relationship between symptom duration, use of pre-operative radiological imaging and patient outcome.MethodsOver a six-month period, 302 patients, median age 18 years, 59% female, were admitted with RIF pain. Symptoms, clinical findings and laboratory results were documented. Patient management, timing of radiological investigations and operations, and outcome were recorded prospectively.ResultsNon-specific abdominal pain (26%), gynaecological (22%) and miscellaneous causes (14%) accounted for most admissions. Ultimately, 119 patients (39%) had appendicitis. Anorexia, tachycardia or rebound tenderness in the RIF significantly predicted a final diagnosis of appendicitis. Patients with perforated appendicitis (n = 29) had a longer duration of pre-hospital symptoms (median 50 h) compared to those with simple appendicitis (median 17 h) (p < 0.001). The use of pre-operative imaging resulted in an increased time to surgery but was not associated with increased post-operative morbidity or perforated appendicitis.ConclusionThe majority of patients presenting to hospital with RIF pain did not have appendicitis. Increased duration of pre-hospital symptoms was the main factor associated with perforated appendicitis. However, increased in-hospital time to theatre was not associated with perforated appendicitis or post-operative morbidity.     

Bilateral sphenopalatine ganglion block as adjuvant to general anaesthesia during endoscopic trans-nasal resection of pituitary adenoma

BackgroundThis study was conducted to investigate the anaesthetic, vasodilator, and post-operative analgesic sparing effect of bilateral sphenopalatine ganglion block (SPGB) in patients undergoing endoscopic endo-nasal trans-sphenoidal surgery.MethodsThirty adult patients of ASA (I, II), aged 20–60 years, were randomly allocated to either the block group or the non-block group (n = 15, for each). After establishment of general anesthesia with sevoflurane and 100% oxygen, the patients received bilateral SPGB with 1.5 ml of either 0.5% bupivacaine (block group) or 0.9% NaCl (non-block group). Intra-operative mean arterial pressure (MAP) was maintained at 60–65 mmHg by using nitroglycerine. End-tidal sevoflurane concentration required to maintain bispectral index values (40–50) throughout the operation was recorded. Nitroglycerine and propranolol consumption, blood loss, recovery profile, perioperative catecholamines, post-operative pain and meperidine consumption were evaluated.ResultsBlock group showed significant decrease in sevoflurane and nitroglycerine consumption, blood loss, emergence time and time needed to achieve ?9 Aldrete score, P < 0.0001. All patients in non-blockade group (100%) were supplemented by nitroglycerine to achieve the target MAP versus 9 patients (60%) in the block group (P < 0.01). Propranolol administration was necessary in 9 patients (60%) in the non-block group versus 3 patients (20%) in the block group, P < 0.05. At PACU, visual analogue pain score and number of patients received meperidine analgesia were significantly less in the block group versus non-block group, P < 0.0001 and P < 0.001, respectively. Intra- and post-operative plasma epinephrine and nor-epinephrine levels were significantly higher in the non-block group than the block group, P < 0.05.ConclusionBilateral SPGB has anaesthetic, vasodilator and analgesic sparing effect when combined with general anaesthesia during endoscopic endo-nasal trans-sphenoidal resection of pituitary adenoma.     

Efficacy and side effects of small versus large bolus size morphine patient controlled analgesia combined with paracetamol

IntroductionPatient controlled analgesia (PCA) provides a better analgesia over conventional opioid treatment. The reduction of bolus size and its efficacy on pain relief and associated side effects were not enormously studied. This study was constructed to evaluate small versus traditional bolus size PCA, including pain relief, and side effects of both regimens.MethodsSeventy-seven patients were included in the study. All patients received general anesthesia. Patients were randomly distributed between two groups; traditional group (M1) received a bolus dose of Morphine as 0.02 mg/kg body weight to a maximum of 1.5 mg, and group (M2) where 0.01 mg/kg body weight to a maximum of 0.75 mg is the bolus dose. PCA machines were set up at 6 min lockout interval and a maximum dose of 0.15 mg/kg/h to a maximum of 10 mg/h. Rescue doses were given according to pain scores and reported. 1000 mg Paracetamol every 6 h were given. Morphine consumption at 24 and 48 h, VAS at 1, 2 then every 4 h for 48 h were measured. Reported complications as respiratory depression, over sedation, constipation, pruritus, nausea and vomiting were analyzed.ResultsMorphine consumption in small bolus size group M2 during the first (36.38 ± 17.75) and second 24 h (30.22 ± 17.15) were less when compared to large bolus size group M1 (39.20 ± 17.97 and 36.38 ± 17.75), the change was insignificant. In spite of using small bolus size Morphine in group M2, pain scores were close to group M1 and statistically insignificant. The frequency of occurrence of side effects was statistically insignificant when comparing the two groups.ConclusionsSmall bolus size of Morphine PCA produces efficient pain relief but does not reduce total morphine consumption nor did morphine associate side effects.     

Outcome of patients in laparoscopic training courses compared to standard patients

Background & aimCurrent Laparoscopic simulators have limited usefulness and patients have been used for training since the dawn of surgery. NUGITS (Northumbrian Upper Gastro Intestinal Team of Surgeons) Laparoscopic Skills courses utilise hands-on experience with simulators moving to live operating on volunteer patients. It is vital to know that the volunteer patient is not disadvantaged by greater surgical risk.MethodsThis was a case-controlled prospective comparison of patients undergoing both Laparoscopic Cholecystectomy (LC) [n = 51] and Laparoscopic Inguinal Hernia (LIH) [n = 62] during NUGITS training courses. They are compared with a matched (age, sex and ASA grade) control group LC (n = 51) and LIH (n = 62) operated on by consultants. The outcome measures were surgical peri-and post-operative complications, post-operative hospital stay, readmission and early recurrence of inguinal hernia (<6 months).ResultsIn the LC cohort, there was no significant difference in the length of hospital stay (p = 0.07) or readmission (p = 0.16) in both the groups. The mean operating time was higher in the trainee compared to the control group (p = 0.001). There was no difference in the post-operative morbidity or mortality in either group. In LIH cohort, the mean operating time was higher in the trainee compared with the control group. There was no significant difference in post-operative complications (p > 0.05) and early post-operative recurrence of hernia (p > 0.05).ConclusionThe post-operative outcomes of patients undergoing laparoscopic surgery during laparoscopic training courses are similar to consultant-operated patients. Thus, it is acceptable and safe to encourage patients to volunteer for laparoscopic training courses.     

Factors influencing postoperative pain following discharge in pediatric ambulatory surgery patients

Study objectiveTo identify demographic, intraoperative, and parental factors that influence the postoperative pain experience in ambulatory surgery pediatric patients. We also monitored postoperative maladaptive behavior changes (PMBCs) to investigate the relationship between pain and PMBCs.DesignProspective cohort study.SettingDischarge period after ambulatory surgery.Patients204 patients ages 1–6 years undergoing ambulatory orthopedic, urology, general surgery, and otolaryngology surgical procedures who were American Society of Anesthesiologists (ASA) physical status I or II.InterventionsNone.MeasurementsWe administered telephone questionnaires to parents of ambulatory surgery patients 1–6 years old exploring pain ratings, behavior change ratings, and medication compliance at 2–3 days and 1–2 weeks after surgery. Pain and behavioral change scores were obtained using the Parents Postoperative Pain Measure (PPPM) and Post-Hospital Behavior Questionnaire (PHBQ). Parental medication compliance was defined as parents who followed the discharge instructions for pain medication administration.Main resultsFor our cohort, 69% of patients experienced pain after 2–3 days and 17% after 1–2 weeks post-discharge. PMBCs were reported in 55% after 2–3 days, and in 15% after 1–2 weeks. In addition, PMBCs occurred in the absence of pain (PPPM = 0) at rates of 20% and 5% at 2–3 days and 1–2 weeks after surgery, respectively. Female sex, anesthesia duration, and otolaryngology procedures correlated with higher postoperative pain (PPPM) scores in univariate and multivariate analysis. Intraoperative medications did not correlate with PPPM or PHBQ scores. Higher pain scores were associated with parents who were compliant with discharge instructions for pain medications.ConclusionsMany pediatric patients experienced short-term pain and PMBCs after ambulatory surgery, but these largely resolved by 1–2 weeks following discharge. Patient sex, anesthesia duration, and surgical procedure influenced postoperative pain and/or PMBCs. Furthermore, PMBCs were associated with, but not solely a manifestation of, postoperative pain.     

Perioperative haemodynamic changes in patients undergoing laparoscopic adrenalectomy for phaeochromocytomas and other adrenal tumours

BackgroundPerioperative haemodynamic changes are well recognised sequelae of adrenalectomy for phaeochromocytomas. The aim of this study was to compare haemodynamic changes in patients undergoing laparoscopic adrenalectomy (LA) for phaeochromocytomas and other adrenal tumours.MethodPatients were identified from a prospective database (Jan 1999–Feb 2008). All patients were managed by a multi-disciplinary team. Haemodynamic variables were: pulse, blood pressure and the requirement of antihypertensive or vasopressor therapies in the perioperative period.ResultsOver the nine-year period, 34 consecutive patients underwent laparoscopic phaeochromocytoma resection (one patient had delayed contralateral LA) and 104 consecutive patients underwent LA for other tumours (two patients had delayed contralateral LA). 5 out of 35 resections in the phaeochromocytoma group experienced severe hypertension (systolic blood pressure (SBP) >200 mm Hg) compared to two out of 106 resections in the non phaeochromocytoma group (p = 0.010). No patient in either group had a transient or persistent (>10 min) SBP >220 mm Hg. Intraoperative antihypertensive use was significantly increased in the phaeochromocytoma group (p < 0.005). There were no significant differences between groups for persistent hypotension (SBP <80 mm Hg), heart rate >120/min and recovery room haemodynamic parameters.ConclusionLA for phaeochromocytoma can be accomplished with low perioperative haemodynamic complications when compared to LA for other adrenal tumours.     

Efficacy of Intravenous Paracetamol and Ibuprofen on Postoperative Pain and Morphine Consumption in Lumbar Disc Surgery: Prospective,Randomized, Double-Blind,Placebo-Controlled Clinical Trial

ObjectivesEffective postoperative pain management after lumbar disc surgery reduces complications and improves postoperative care. The purpose of this prospective, randomized, double-blind, placebo-controlled clinical study is to evaluate the effects of IV paracetamol and ibuprofen on postoperative pain, morphine consumption and side effects of morphine in patients who underwent lumbar disc surgery.Materials and methodsSeventy-five patients aged 18-85 years scheduled for lumbar disk surgery with a single level laminectomy included in this study. All patients received morphine with an IV patient-controlled analgesia device during the first postoperative 24 hour. The patients were divided randomly and double-blinded into three groups (control, paracetamol and ibuprofen). The demographic characteristics and procedure data, VAS score, cumulative morphine consumption, opioid-related side effects were recorded.ResultsThere was no significant difference regarding to demographic characteristics, comorbidities, and durations of anesthesia and surgery. There was a significant difference between all groups regarding to total morphine consumption (P < 0.001). IV ibuprofen significantly reduced the total morphine consumption in comparison with control and paracetamol (P < 0.001). Repeated measures ANOVA showed in all periods of the study that VAS score was significantly lower in ibuprofen (P < 0.001), but not in paracetamol (P = 0.394) in comparison with control. There was no difference between groups regarding postoperative heart rate, mean arterial pressure, nausea-vomiting, pruritus and urinary retention.ConclusionsThis study showed that pain scores and morphine consumption, but not the side effects of patient-controlled analgesia during 24 hours after the lumbar disk surgery, were significantly reduced by IV ibuprofen as a supplemental analgesic when compared with controls and paracetamols.