A pilot study of the rectus sheath block for pain control after umbilical hernia repair

BACKGROUND: Umbilical hernia repair, a common day surgery procedure in children, is associated with significant postoperative discomfort. The rectus sheath block may offer improved pain management following umbilical hernia repair. In this pilot study, we compared the efficacy of the rectus sheath block with that of our current standard practice--local anesthetic infiltration into the surgical wound--for pain control after umbilical hernia repair in children. METHODS: Fourteen children, aged 1-8 years, undergoing umbilical hernia repair were randomly assigned to receive either a rectus sheath block or local anesthetic infiltration into the surgical wound at completion of surgery. Anesthetic management was standardized. Each analgesic technique was performed using 0.8 ml x kg(-1) of 0.25% bupivacaine with epinephrine 1:200,000. Postoperatively, an investigator who was blinded to the analgesic technique recorded the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) scores and sedation scores every 10 min, and administered intravenous morphine 50 microg x kg(-1) for cases with CHEOPS scores > or = 8. Total morphine dose was recorded. Parents were telephoned the day after surgery to determine the overall satisfaction with pain control. RESULTS: Total postoperative morphine consumption did not differ significantly between groups, averaging 0.10 +/- 0.09 and 0.10 +/- 0.07 mg x kg(-1) for the local infiltration and rectus sheath groups, respectively. There were no significant differences in pain or sedation scores, and no complications related to either analgesic technique. DISCUSSION: Our results suggest that the rectus sheath block has no advantage over infiltration of local anesthetic into the surgical wound for postoperative pain management in children undergoing umbilical hernia repair.     

The combination of morphine with local anaesthetic in rhinoplasty - no evidence of a peripheral morphine effect

Background: The recognition of a peripheral opioid action has prompted a number of clinical reports demonstrating a prolonged analgesic effect of peripheral opiate. As most studies have used a model of intraarticular instillation of narcotic we examined direct morphine infiltration of the surgical site in a unique clinical model. Methods: Sixty patients undergoing primary rhinoplasty were entered into this prospective, randomized, double-blind study. Patients received a standard protocol of premedication, intravenous sedation, and nasal block. Two 2 ml syringes containing saline or morphine 3 mg in saline were provided for IM injection and for addition to the local anesthetic (IW, intrawound): Group I (control) - saline IW, saline IM; Group II -morphine IW, saline IM; Group III - saline IW, morphine IM. Intraoperative assessments included need for further sedation, need for further local anesthetic, and degree of bleeding. Recovery room analgesic requirements, pain scores, and recall of intraoperative pain were recorded prior to discharge. Followup phone calls at 24 hours recorded home pain scores and analgesic use during the first postoperative day. Results: Significantly more patients in Group II (9/20) required supplemental local anesthetic intraoperatively compared to Group I (2/20) and Group III (0/20). Significantly more patients in Group II (6/20) recalled their surgical experience as painful compared to Group I (1/20) and Group III (1/20). Group II patients also evidenced significantly more operative bleeding. There were no differences in postoperative pain scores, but Group I patients required analgesic in the recovery room significantly more than in Groups II and III (85% vs 45% and 50%, respectively). There were no differences between groups in analgesic consumption at home. Conclusions: The results of this study indicate that the preoperative injection of intrawound morphine in combination with the local anesthetic both promotes bleeding and has an early pain-enhancing effect while providing no late analgesic benefit beyond that of IM morphine.     

Anesthetic experience with cardiac transplantation.

The anesthetic management of 17 patients undergoing cardiac transplantation is described. Recipients had severe biventricular failure and pulmonary hypertension. Careful administration of diazepam and morphine was the preferred induction method, and pancuronium was the favored relaxant for both intubation and maintenance. Sterile technique was used in placing endotracheal tubes. Relatively small doses of morphine and diazepam, combined with 50 percent nitrous oxide, were satisfactory for the maintenance of anesthesia. Postperfusion problems were few but included poor tolerance of hypovolemia and an exaggerated hypotensive response to protamine. Isoproterenol was required to support ventricular performance, but no other cardiac stimulants were needed. Postoperative courses were uneventful. There were no operative deaths and no recall of awareness during the operation with the described method of "light" anesthesia.     

Preoperative infiltration of bupivacaine - effects on pain relief and trauma response (cortisol and interleukin-6)

Hypothesis: Subcutaneous infiltration of bupivacaine before skin incision can reduce postoperative pain and modulate the stress response.
Methods: In a randomized study on pain relief after hysterectomy 29 patients were referred into one of three groups, receiving 30 ml of bupivacaine 0.25% with adrenaline, 30 ml of saline or no infiltration along the line of the proposed incision 10 min before start of surgery. A Visual Analogue Scale was used for repeated pain ratings. Postoperative pain relief was provided with patient-controlled analgesia with intravenous morphine 0.04 mg/kg. Lockout time was 10 min. The immuno-logical and endocrine stress response to trauma was reflected by blood interleukin-6 (IL-6) and cortisol concentrations measured during 72 h following skin incision.
Results: There were large individual variations in the accumulated postoperative consumption of morphine at 20 h after start of surgery. It was significantly reduced in patients receiving infiltration of bupivacaine. They used 39 mg (9–62) median (range) of intravenous morphine whereas the patients in the saline group used 65 mg (47–120) and patients in the control group used 54 mg (36–130) ( P <0.05). Significant elevation of plasma IL-6 and serum cortisol levels appeared in all groups with peak values at 3 h. There were no differences between the groups. There was a correlation between cortisol and IL-6. Six of the 29 patients had a postoperative infection which was reflected in increased IL-6 levels.
Conclusion: Preoperative subcutaneous infiltration of bupivacaine significantly reduced the postoperative consumption of intravenous morphine.     

A multimodal analgesia protocol for total knee arthroplasty. A randomized, controlled study

BACKGROUND: Although numerous methods of postoperative analgesia have been investigated in an attempt to improve pain control after total knee arthroplasty, parenteral narcotics still play a major role in postoperative pain management. Local anesthetics have the advantage of blocking pain conduction at its origin and minimizing the systemic side effects associated with postoperative narcotic use. This study was performed to evaluate the benefits and safety of a multimodal analgesia protocol that included periarticular injection of large doses of local anesthetics in patients undergoing total knee arthroplasty. METHODS: We compared morphine consumption during the first twenty-four hours after unilateral total knee arthroplasty in forty-two patients who had been randomized to receive either (1) a perioperative infiltration mixture, consisting principally of local anesthetic, and self-administered morphine or (2) self-administered morphine only. Narcotics consumption, pain control, medication-related side effects, plasma levels of the local anesthetic (ropivacaine), and postoperative rehabilitation were monitored. RESULTS: Although there was high satisfaction and good pain control in both groups, morphine consumption was significantly lower in the local analgesia group than it was in the control group (28.8 +/- 17.4 mg compared with 50.3 +/- 25.4 mg twenty-four hours after surgery, and 46.7 +/- 19.4 mg compared with 68.6 +/- 38.6 mg forty hours after surgery). Both groups achieved a similar amount of knee flexion on the fifth postoperative day. Over the five-day period after the procedure, the patients in the local analgesia group reported a total of 2.6 +/- 3.9 hours of nausea compared with 7.1 +/- 12.2 hours in the control group. No complications related to the infiltration of the local anesthetic were observed, and all plasma concentrations of the local anesthetic were below the toxic range. CONCLUSIONS: This multimodal perioperative analgesia protocol that included infiltration of a local anesthetic offered improved pain control and minimal side effects to patients undergoing total knee arthroplasty. Our study also confirmed the safety of the protocol.     

Assessment of wound infiltration with bupivacaine in women undergoing day-case gynecological laparoscopy

BACKGROUND AND OBJECTIVES: The effectiveness of local anesthetic wound infiltration for treatment of postoperative pain appears to be variable and partly dependent on the surgical procedure. Although evidence was lacking, it was common practice at our institution to infiltrate the trocar wound of patients undergoing day-case laparoscopic procedures with long acting local anesthetic agents. The aim of this study was to investigate the analgesic efficacy, and the influence of the timing, of local anesthetic infiltration into surgical wounds for day-case diagnostic gynecological laparoscopy. METHODS: A double-blind, randomized trial was conducted on 100 women having general anesthesia for day-case gynecological laparoscopy. Ninety-two patients who had been randomized to 1 of 4 groups for trocar wound infiltration with 30 mL of 0.25% bupivacaine or saline either before or after surgery completed the study. Incisional pain, pain on pressing the umbilicus, severity of nausea, and patient satisfaction with anesthetic technique were all assessed postoperatively until discharge and on the following day through a telephone interview. A P value of <.05 was considered significant. RESULTS: There was no difference between groups in the mean pain scores or analgesic requirements for incisional pain, pain on pressing firmly on the umbilicus, or for patient satisfaction. There was a trend for those patients who had received bupivacaine to use less postoperative morphine (P =.079). CONCLUSIONS: Wound infiltration with local anaesthetic did not significantly reduce pain or opioid requirement after gynecological laparoscopy.     

Multi-regional local anesthetic infiltration during laparoscopic cholecystectomy in patients receiving prophylactic multi-modal analgesia: a randomized, double-blinded, placebo-controlled study.

Pain is the dominant complaint after laparoscopic cholecystectomy. No study has examined the combined effects of a somato-visceral blockade during laparoscopic cholecystectomy. Therefore, we investigated the effects of a somato-visceral local anesthetic blockade on pain and nausea in patients undergoing elective laparoscopic cholecystectomy. In addition, all patients received multi-modal prophylactic analgesic treatment. Fifty-eight patients were randomized to receive a total of 286 mg (66 mL) ropivacaine or 66 mL saline via periportal and intraperitoneal infiltration. During the first 3 postoperative h, the use of morphine and antiemetics was registered, and pain and nausea were rated hourly. Daily pain intensity, pain localization, and supplemental analgesic consumption were registered the first postoperative week. Ropivacaine reduced overall pain the first two hours and incisional pain for the first three postoperative hours (P < 0.01) but had no apparent effects on intraabdominal or shoulder pain. During the first 3 postoperative h, morphine requirements were lower (P < 0.05), and nausea was reduced in the ropivacaine group (P < 0.05). Throughout the first postoperative week, incisional pain dominated over other pain localizations in both groups (P < 0.01). We conclude that the somato-visceral local anesthetic blockade reduced overall pain during the first 2 postoperative h, and nausea, morphine requirements, and incisional pain were reduced during the first 3 postoperative h in patients receiving prophylactic multi-modal analgesic treatment. IMPLICATIONS: A combination of incisional and intraabdominal local anesthetic treatment reduced incisional pain but had no effect on deep intraabdominal pain or shoulder pain in patients receiving multimodal prophylactic analgesia after laparoscopic cholecystectomy. Incisional pain dominated during the first postoperative week. Incisional infiltration of local anesthetics is recommended in patients undergoing laparoscopic cholecystectomy.     

A prospective study of nerve root infiltration in the diagnosis of sciatica. A comparison with radiculography, computed tomography, and operative findings

Fifty nerve root infiltration studies were evaluated prospectively in a consecutive series of 50 patients referred to the Sheffield Problem Back Clinic with complicated back problems. All were over 35 years of age (mean, 51 years). Ten (20%) demonstrated abnormal segmentation of the lumbar spine. Sixteen (32%) had undergone previous surgery. Before nerve root infiltration all patients were investigated by radiculography and computed tomography. Nerve root infiltration identified two types of response. In 20 patients, infiltration reproduced the symptomatic pain, which then was abolished by local anesthetic--the positive result. These patients were considered suitable for surgery. One patient in this group had spontaneous resolution of pain and thus did not undergo operative treatment. In 30 patients, infiltration did not reproduce the symptomatic pain regardless of the level studied, or only partially reproduced the pain at two or more levels--the negative result. Radiculography and computed tomography in these patients also was inconsistent. This group were considered unsuitable for surgery. In those patients undergoing surgical decompression, nerve root infiltration correctly identified the symptomatic level in 18 of the 19. Computed tomography and radiculography identified the level in 14 and 12 patients, respectively.     

Effectiveness of local anesthetic injection in geriatric patients following operative management of proximal and diaphyseal femur fracture

IntroductionGeriatric fracture patients are at risk for poorly controlled pain and side effects of opioid medications. The arthroplasty literature has demonstrated that infiltration of long-acting local anesthetic or anesthetic cocktails improves pain control and reduces post-operative opioid use resulting in better postoperative mobility without the deleterious effects of narcotics. Despite having a higher risk for adverse events, there is limited data among geriatric trauma patients. The aim this study was to evaluate whether local anesthetic infiltration (LAI) into the soft tissues surrounding the surgical field reduces narcotic use or pain scores in patients undergoing surgical management of proximal and diaphyseal femur fractures.Materials and methodsA retrospective review was performed of patients age >65 undergoing operative intervention for proximal and diaphyseal femur fracture. The electronic record was utilized to determine if local anesthetic was injected into the surgical wound, the amount of narcotics administered over 48 h in four-hour intervals, and to obtain visual analog scale (VAS) pain scores associated with patients post-operative course in four-hour intervals. The amount of narcotics was converted to morphine milligram equivalents (MME).ResultsAmong 477 patients with femur fracture, 358 did not receive LAI and 119 patients received LAI. Baseline demographics, fracture types, and surgical procedure were equivalent between the groups. In the first 28 h following surgery, compared with those who did not receive LAI, those who did required significantly less opioid (57.8 MME versus 94.3 MME, p = 0.034) and despite decreased narcotics, had equal pain scores (mean difference 0.37, p = 0.22). There was no difference in rates of post-operative complications.ConclusionLAI is associated with a reduction in opioid consumption in geriatric fracture patients with equivalent pain scores. Optimizing pain control is a critical issue in caring for geriatric fracture patients since both under-treated pain and opioid medications are implicated in postoperative delirium, complications, and ability to mobilize early. More research is needed to identify effective ways to optimize pain management in this at-risk patient population.     

Efficacy and safety of single and repeated administration of 1 gram intravenous acetaminophen injection (paracetamol) for pain management after major orthopedic surgery

BACKGROUND: Intravenous acetaminophen injection (paracetamol) is marketed in Europe for the management of acute pain. A repeated-dose, randomized, double-blind, placebo-controlled, three-parallel group study was performed to evaluate the analgesic efficacy and safety of intravenous acetaminophen as compared with its prodrug (propacetamol) and placebo. Propacetamol has been available in many European countries for more than 20 yr. METHODS: After orthopedic surgery, patients reporting moderate to severe pain received either 1 g intravenous acetaminophen, 2 g propacetamol, or placebo at 6-h intervals over 24 h. Patients were allowed "rescue" intravenous patient-controlled analgesia morphine. Pain intensity, pain relief, and morphine use were measured at selected intervals. Safety was monitored through adverse event reporting, clinical examination, and laboratory testing. RESULTS: One hundred fifty-one patients (intravenous acetaminophen: 49; propacetamol: 50; placebo: 52) received at least one dose of study medication. The intravenous acetaminophen and propacetamol groups differed significantly from the placebo group regarding pain relief from 15 min to 6 h (P < 0.05) and median time to morphine rescue (intravenous acetaminophen: 3 h; propacetamol: 2.6 h; placebo: 0.8 h). Intravenous acetaminophen and propacetamol significantly reduced morphine consumption over the 24-h period: The total morphine doses received over 24 h were 38.3 +/- 35.1 mg for intravenous acetaminophen, 40.8 +/- 30.2 mg for propacetamol, and 57. 4 +/- 52.3 mg for placebo, corresponding to decreases of -33% (19 mg) and -29% (17 mg) for intravenous acetaminophen and propacetamol, respectively. Drug-related adverse events were reported in 8.2%, 50% (most of them local), and 17.3% of patients treated with intravenous acetaminophen, propacetamol, and placebo, respectively. CONCLUSION: Intravenous acetaminophen, 1 g, administered over a 24-h period in patients with moderate to severe pain after orthopedic surgery provided rapid and effective analgesia and was well tolerated.     

A prospective study of pain and analgesic use in outpatient endoscopic anterior cruciate ligament reconstruction

A prospective study was undertaken to evaluate the postoperative pain and analgesic profiles of a group of 50 patients undergoing outpatient anterior cruciate ligament (ACL) reconstruction and to compare their profiles with those of a group of 50 patients undergoing outpatient non- ACL arthroscopic surgery. All patients received preoperative and postoperative ketorolac, intraincisional/intra-articular bupivacaine, intraoperative ketorolac, and propofol anesthetic. The percentage of patients receiving supplemental analgesia in the recovery room was 49% (average, 2.2 mg intravenous morphine sulfate) for the ACL group and 31% (average, 1.2 mg intravenous morphine sulfate) in the non-ACL group. Narcotic use and pain scores peaked in both groups on postoperative days 1 and 2. The ACL group used significantly more narcotic and had higher pain scores in the first week after surgery than did the non-ACL group. However, there were no subsequent admissions, readmissions, or emergency room visits for pain. All were satisfied with the outpatient nature of this surgery. Patients tolerate outpatient endoscopic ACL reconstruction with moderate pain and narcotic use. Outpatient endoscopic ACL reconstruction can be performed safely, effectively, and with considerable cost savings.Arthroscopy 1998 Sep;14(6):613-6     

Intrathecal Anesthesia and Recovery from Radical Prostatectomy: A Prospective, Randomized, Controlled Trial

Background: Previous studies suggest that intraoperative anesthetic care may influence postoperative pain and recovery from surgery. The authors tested the hypothesis that the addition of intrathecal analgesia to general anesthesia would improve long-term functional status and decrease pain in patients undergoing radical retropubic prostatectomy.

Methods: One hundred patients received either general anesthesia supplemented with intravenous fentanyl or general anesthesia preceded by intrathecal administration of bupivacaine (15 mg), clonidine (75 [mu]g), and morphine (0.2 mg). Patients and providers were masked to treatment assignment. All patients received multimodal pain management postoperatively. Primary outcomes included pain and functional status over the first 12 postoperative weeks.

Results: Patients receiving intrathecal analgesia required more intravenous fluids and vasopressors intraoperatively. Pain was well controlled throughout the study (mean numerical pain scores < 3 in both groups at all times studied). Intrathecal analgesia decreased pain and supplemental intravenous morphine use over the first postoperative day but increased the frequency of pruritus. Pain and functional status after discharge from the hospital did not differ between groups. Intrathecal analgesia significantly decreased the duration of hospital stay (from 2.8 +/- 2.0 to 2.1 +/- 0.5 days; P < 0.01) as a result of five patients in the control group who stayed in the hospital more than 3 days.     

Prevention of postoperative pain after thyroid surgery: a double-blind randomized study of bilateral superficial cervical plexus blocks

Local anesthetic infiltration may reduce postthyroidectomy pain. We performed a double-blinded, randomized, placebo-controlled trial to assess the analgesic efficacy of bilateral superficial cervical plexus blocks performed at the end of surgery. Ninety patients undergoing elective thyroid surgery by the same surgeon under general anesthesia were randomized to receive 20 mL isotonic sodium chloride or 20 mL bupivacaine 0.25% with 1:200,000 epinephrine. Postoperative pain was assessed every 4 h using an 11-point numeric rating scale (NRS-11). All patients received acetaminophen every 6 h. In addition, morphine was administered following a standardized protocol if the NRS-11 score was > or = 4. The main outcome variables were pain scores (NRS-11), the proportion of patients given morphine at any time during the 24-h period, and the amount of morphine administered. The Bupivacaine group had a smaller proportion of patients given morphine (66.0% vs 90.0%; P = 0.016), and lower initial median pain scores (P = 0.002). We conclude that bilateral superficial cervical plexus blocks significantly reduce pain intensity in the postoperative period after thyroid surgery but do not provide optimal pain relief alone.     

Perineural injection of morphine fails to relieve postoperative pain in humans

Ten patients scheduled for bilateral foot surgery were given general anesthesia plus ankle blocks. One side was blocked with 0.02% morphine and the other with 0.9% saline. A second group of 10 patients for bilateral foot surgery had one side blocked with 0.02% morphine and the other with 0.01% morphine. A within-patient blind comparison of postoperative analgesia between the two sides was performed by nurse observers, using categorical and visual analogue scales for both pain intensity and pain relief. Postoperative analgesia recorded by the nurse observer was not significantly different between morphine and saline. Similarly, there was no significant difference in postoperative analgesia between legs blocked with the higher or lower dose of morphine. Thus, perineural morphine does not relieve postoperative pain at doses equivalent to 2-4 mg in a 70-kg man.     

Efficacy and Safety of Single and Repeated Administration of 1 Gram Intravenous Acetaminophen Injection (Paracetamol) for Pain Management after Major Orthopedic Surgery

Background: Intravenous acetaminophen injection (paracetamol) is marketed in Europe for the management of acute pain. A repeated-dose, randomized, double-blind, placebo-controlled, three-parallel group study was performed to evaluate the analgesic efficacy and safety of intravenous acetaminophen as compared with its prodrug (propacetamol) and placebo. Propacetamol has been available in many European countries for more than 20 yr.

Methods: After orthopedic surgery, patients reporting moderate to severe pain received either 1 g intravenous acetaminophen, 2 g propacetamol, or placebo at 6-h intervals over 24 h. Patients were allowed "rescue" intravenous patient-controlled analgesia morphine. Pain intensity, pain relief, and morphine use were measured at selected intervals. Safety was monitored through adverse event reporting, clinical examination, and laboratory testing.

Results: One hundred fifty-one patients (intravenous acetaminophen: 49; propacetamol: 50; placebo: 52) received at least one dose of study medication. The intravenous acetaminophen and propacetamol groups differed significantly from the placebo group regarding pain relief from 15 min to 6 h (P < 0.05) and median time to morphine rescue (intravenous acetaminophen: 3 h; propacetamol: 2.6 h; placebo: 0.8 h). Intravenous acetaminophen and propacetamol significantly reduced morphine consumption over the 24-h period: The total morphine doses received over 24 h were 38.3 +/- 35.1 mg for intravenous acetaminophen, 40.8 +/- 30.2 mg for propacetamol, and 57. 4 +/- 52.3 mg for placebo, corresponding to decreases of -33% (19 mg) and -29% (17 mg) for intravenous acetaminophen and propacetamol, respectively. Drug-related adverse events were reported in 8.2%, 50% (most of them local), and 17.3% of patients treated with intravenous acetaminophen, propacetamol, and placebo, respectively.     

Intravenous sedation in dental surgery

A study on intravenous sedation in dental surgery was conducted comparing diazepam and fentanyl with midazolam and fentanyl. The total number of patients was one hundred and eighty patients. One hundred and twenty patients received diazepam and fentanyl, and later when midazolam was available sixty patients received this drug with fentanyl. The cardiovascular effects, the anterograde amnesia and adverse venous sequelae were investigated. Both drugs gave safe and acceptable sedation. The diazepam group had more venous sequelae. The midazolam group had better amnesia effects with no incidence of venous sequelae.     

Effects of diazepam premedication and epinephrine-containing local anesthetic on cardiovascular and plasma catecholamine responses to oral surgery

The effects of diazepam premedication and administration of an epinephrine-containing local anesthetic on plasma catecholamine levels and cardiovascular parameters were evaluated prior to and during a minor surgical procedure, the removal of impacted third molars. Significant elevations in circulating epinephrine levels (203% above control) and cardiac output (30%) were seen in unsedated patients after administration of lidocaine with epinephrine before surgery, while no changes were seen after lidocaine alone. Unsedated patients had increased norepinephrine (24%) and epinephrine (57%) levels during surgery. Diazepam premedication decreased norepinephrine levels 29% below preoperative levels, followed by an increase during surgery to preoperative levels. These results indicate that intraoral injections of epinephrine-containing local anesthetics result in increased circulating epinephrine levels that are associated with cardiovascular changes and that diazepam premedication decreases plasma norepinephrine levels and attenuates the sympathoadrenal response to surgical stress.     

Ketamine-diazepam protocol for intravenous sedation: The cosmetic surgery hospital experience

Rising hospital costs and operating room scheduling difficulties have influenced plastic surgeons to rely more often on intravenous sedation in office surgical settings. The use of ketamine as an intravenous sedation agent has enjoyed some popularity, but this has been far from universal. Its reputation for producing psychological sequelae such as nightmares, flashbacks and schizophrenic-like reactions have made many anesthesiologists and plastic surgeons reluctant to use this drug.The authors’ experience using a ketamine/diazepam protocol with approximately 11,400 patients since 1971 at the Cosmetic Surgery Hospital in Woodbridge, Ontario is presented. The methodology consists of intravenous diazepam followed with low-dose ketamine (0.5 mg/kg to a maximum of 40 mg) 2 min later. This provides the surgeon with a period of profound amnesia to allow for infiltration of the local anesthetic. It is this local anesthetic delivered during the dissociative state that provides prolonged analgesia throughout the surgery. The patient is maintained throughout the procedure with increments of diazepam and midazolam.This protocol is found to be effective, reliable and reproducible, and the experience of the patient and plastic surgeon has been overwhelmingly favourable.     

Parasternal block and local anesthetic infiltration with levobupivacaine after cardiac surgery with desflurane: the effect on postoperative pain, pulmonary function, and tracheal extubation times

Early tracheal extubation has become common after cardiac surgery. Anesthetic techniques designed to achieve this goal can make immediate postoperative analgesia challenging. We conducted this randomized, placebo-controlled, double-blind study to investigate the effect of a parasternal block on postoperative analgesia, respiratory function, and extubation times. We enrolled 20 patients having cardiac surgery via median sternotomy; 17 patients completed the study. A de-sflurane-based, small-dose opioid anesthetic was used. Before sternal wire placement, the surgeons performed the parasternal block and local anesthetic infiltration of sternotomy and tube sites with either 54 mL of saline placebo or 54 mL of 0.25% levobupivacaine with 1:400,000 epinephrine. Effects on pain and respiratory function were studied over 24 h. Patients in the levobupivacaine group used significantly less morphine in the first 4 h after surgery (20.8 +/- 6.2 mg versus 33.2 +/- 10.9 mg in the placebo group; P=0.013); they also had better oxygenation at the time of extubation. Four of nine in the placebo group needed rescue pain medication, versus none of eight in the levobupivacaine group (P=0.08). Peak serum levobupivacaine concentrations were below potentially toxic levels in all patients (0.64 +/- 0.43 microg/mL; range, 0.24-1.64 microg/mL). Parasternal block and local anesthetic infiltration of the sternotomy wound and mediastinal tube sites with levobupivacaine can be a useful analgesic adjunct for patients who are expected to undergo early tracheal extubation after cardiac surgery.     

Propofol anesthesia for ambulatory surgery in adults

We reported 131 cases of ambulatory surgery in adults mainly anaesthetized with propofol infusion. Without any premedication, anesthesia was induced with propofol and fentanyl. A laryngeal mask airway was inserted using intravenous injection of vecuronium. Anesthesia was maintained with continuous infusion of propofol and intermittent fentanyl administrations, and local anesthetic infiltration was combined. All patients received air and oxygen mixture (FIO2 0.4) throughout the procedure. During surgery, metoclopramide and flurbiprofen axetil were given to prevent postoperative pain, nausea and vomiting. After surgery, patients were observed at the daycare unit in ward. Average age was 42 years and ASA risk was 1.3. Operation time and anesthesia time and hospital stay were 43.4 minutes, 70.6 minutes and 332 minutes, respectively. In 25 patients (19%) analgesics were needed for postoperative pain. Although 3 patients (2.3%) were unsuccessful as ambulatory surgery due to excessive pain, all patients including these three could be discharged within 24 hours after surgery. We conclude that combined anesthesia with propofol, fentanyl and local anesthetic is suitable for ambulatory surgery in adults.