Effect of pre- vs postoperative tonsillar infiltration with local anesthetics on postoperative pain after tonsillectomy

Background : Since pre-incisional peritonsillar infiltrations of local anesthetic solutions have been suggested to reduce postoperative pain after tonsillectomy, we compared the efficacy of either pre- or postoperative local anesthetic infiltration upon post-tonsillectomy pain. Methods : After the induction of general anesthesia, 68 consecutive healthy patients, ranging in age from 8 to 65 years, were randomly allocated to either receive peritonsillar infiltration with 0.25% bupivacaine (group 1) or normal saline (group 2) before incision. A third group (group 3) had their peritonsillar region infiltrated with 0.25% bupivacaine after the completion of surgery but before the patients were awakened from anesthesia. All the patients were treated in the same way in the postoperative period: NSAIDs were given intravenously to adults and rectally to children. Acetaminophen was given intravenously or rectally (children aged < 15 yr) if additional analgesic support was requested by the patient. Additional acetaminophen consumption was recorded daily. Pain scores were assessed on every patient with the use of a visual analogue scale (VAS) at rest, 1, 5, 9, 13, 17, 21 and 36 h after surgery, and also on swallowing during the first postoperative day. Results : Global VAS pain scores were lower in the groups treated with bupivacaine infiltration during the first 24 h after surgery (P < 0.05). Supplementary analgesic consumption was lower in group 3 than in group 2 during the 0–9 h interval immediately following surgery (P < 0.05). There were no statistically significant differences for any other parameters between the 3 groups. Conclusion : These results suggest that the timing of peritonsillar infiltration with bupivacaine is not of clinical importance and does not affect the quality of postoperative analgesia in patients undergoing tonsillectomy.     

The effect of halothane and isoflurane on plasma cytokine levels

The aim of this study was to investigate the effect of halothane vs. isoflurane on cytokine production during minor elective surgery. Forty adult patients, ASA I-II were randomly allocated to receive halothane or isoflurane. Venous samples for interleukin (IL)-1beta, IL-2, IL-6, tumour necrosis factor-alpha (TNF-alpha) and interferon-gamma (IFN-gamma) were taken before anaesthesia, before incision, at the end of anaesthesia and 24 h postoperatively. In both groups, IL-6 and TNF-alpha levels remained low throughout the study period. Before incision, in both groups IL-1beta and IFN-gamma showed a decrease (p<0.01 for IL-1beta in isoflurane group and p<0.05 for the others) compared with pre-induction. By the end of anaesthesia and surgery, IL-1beta had increased significantly (p<0.05) and IFN-gamma had decreased significantly (p<0.05) in both groups compared with pre-incisional levels. By 24 h postoperatively in both groups, IL-1beta had decreased significantly (p<0.05), whereas IFN-gamma had increased significantly (p<0.05) compared with the end of anaesthesia and surgery level. Pre-incisionally, IL-2 increased in the halothane group (p<0.01), whereas it decreased significantly in the isoflurane group (p<0.001) compared with the pre-induction level. By the end of anaesthesia and surgery and by 24 h postoperatively, IL-2 had decreased significantly in the halothane group (p<0.001), whereas it increased significantly in the isoflurane group (p<0.001) compared with pre-incision and end of anaesthesia and surgery levels, respectively.     

Pre-incisional epidural ketamine, morphine and bupivacaine combined with epidural and general anaesthesia provides pre-emptive analgesia for upper abdominal surgery

BACKGROUND: Previous studies have shown that N-methyl-D-asparate (NMDA) receptor antagonists provide a pre-emptive analgesic effect in humans. This study investigated the benefits of pre-emptive analgesia for upper abdominal surgery, using pre-incisional epidural ketamine + morphine + bupivacaine (K+M+B) treatment for achieving postoperative pain relief. METHODS: Sixty ASA 1-2 patients scheduled for upper abdominal surgery were allocated to three groups in a randomized, single-blinded study. Patients in the control group (I) received general anaesthesia followed by an infusion of normal saline. Group II and III patients received general anaesthesia with a continuous epidural infusion of 2% lidocaine. Thirty minutes after the incision in groups I and II, an epidural pain control regimen was administered using ketamine (10 mg) and morphine (1 mg) in 10 ml of 0.085% bupivacaine (K+M+B). Group III patients also received K+M+B, but it was administered 10 min after the 2% lidocaine injection and 30 min before skin incision. All patients received an epidural pain control regimen (q12 h) for 3 days after their first injection. Patient-controlled analgesia (PCA) with morphine was used to control subsequent postoperative pain. During the 3-day period following surgery, duration to PCA trigger (h), morphine consumption (mg), pain intensity at rest and when coughing/moving, and analgesic-related adverse effects were recorded. The VAS scale (0-10) was used to assess pain intensity. RESULTS: Median times to first PCA trigger were 1.2 (0.5-2.0) h, 3.0 (0.7-4.2) h, and 4.0 (2.5-7.5) h for groups I, II, and III, respectively. Both the incident and resting pain scores were consistently lower for group III patients than groups I and II. The number of PCA triggers (all attempts/successful triggers) during the day following surgery were 14.0 (3-30)/8.0 (3-24) times, 10.0 (3-23)/6.0 (2-20) times, and 7.0 (3-12)/4.5 (1-10) times for groups I, II, and III. Total morphine consumption for the 3-day observation period was 12.5 (3-42) mg, 10.5 (2-29) mg, and 6.0 (1-20) for groups I, II, and III, respectively. CONCLUSION: Pre-incisional epidural K+M+B treatment combined with continuous epidural anaesthesia and general anaesthesia provides an ideal pre-emptive analgesic therapy, exhibiting better postoperative pain relief than general anaesthesia and post-incisional K+M+B treatment.     

Efficacy of Pre-incisional Bupivacaine Infiltration on Postoperative Pain Relief after Appendectomy: Prospective Double-blind Randomized Trial

Pain is the most undesirable and threatening experience for surgical patients. This study aims to determine the efficacy of pre-incisional analgesic bupivacaine infiltration (preemptive analgesia) on postoperative pain relief after appendectomy. A prospective randomized double-blinded study was conducted on 123 patients aged 13–45 years with a preoperative and-postoperative diagnosis of acute appendicitis admitted to Siriraj Hospital, Bangkok, from January to May 2002. They were randomly set into two groups: the control (61 patients) and the preemptive (62 patients). In the preemptive group, bupivacaine (Marcaine) was infiltrated into the skin and subcutaneous tissue along the proposed wound line before gridiron incision, and also into the muscle layer after incision. The control group received no injection. Routine appendectomy was done. Pain score was assessed by the patients in the first 48 hr while they were lying supine and as they moved to a sitting position at 24 and 48 hr after operation. Morphine injection was given on patients request with pain score = 5 every 4 hr in the first 48 hr or until analgesic paracetamol could be taken orally. The pain score during the first 6, 12, 24, and 48 hr, including the score while sitting up, were all significantly lower (p < 0.001) in the preemptive group. So were the total number of morphine injections and the amount of morphine used postoperatively. The pain reduction could be due to interruption of inflammatory or pain mediator cascades that normally occur during an operation. This study showed that pre-incisional bupivacaine infiltration is an effective and simple method of reducing postoperative pain for patients undergoing appendectomy.     

Caudal neostigmine for postoperative analgesia in paediatric surgery

BACKGROUND: This study was conducted to evaluate analgesia and side-effects of caudal neostigmine coadministered with bupivacaine in paediatric surgery. METHODS: We studied children, aged 1-5 years, undergoing elective surgery (inguinal hernia and hypospadias). After standard induction of anaesthesia, caudal anaesthesia was performed. Group 1 received 0.25% bupivacaine 0.5 ml.kg-1 and Group 2 received 0.25% bupivacaine 0.5 ml x kg-1 with 1 microg x kg-1 neostigmine via the caudal route. Heart rate, mean arterial pressure, peripheral oxygen saturation were recorded before induction, after induction but before caudal anaesthesia, and then every 5 min after caudal anaesthesia. Haemodynamic, Toddler, Preschooler, Postoperative Pain Scale (TPPPS) pain score and sedation score values were recorded 30 min after extubation and at hours 2, 4, 6, 12 and 24. A pain score >3/10 resulted in administration of rectal paracetamol. The duration of postoperative analgesia was defined as the time between caudal drug injection and the first rectal paracetamol administration. RESULTS: There were no differences between the groups in demographic and haemodynamic date, duration of surgery and anaesthesia, time to extubation or sedation scores. The duration of postoperative pain relief did not differ between the two groups; 15.40 +/- 10.97 h for group 1 vs. 15.45 +/- 10.99 h for group 2 (P > 0.05). The incidence of nausea (three patients in group 2 and one patient in group 1) was not statistically significant. No other side-effects were seen. CONCLUSIONS: We found that a single caudal injection of 1 microg x kg-1 neostigmine mixed with bupivacaine offers no significant advantage over bupivacaine alone for postoperative pain relief in children undergoing genitourinary surgery.     

Prospective double-blind randomised study of a new regimen of pre-emptive analgesia for inguinal hernia repair: evaluation of postoperative pain course.

OBJECTIVE: To evaluate the effectiveness of a new regimen of pre-emptive analgesia on the development of postoperative pain after inguinal hernia repair. DESIGN: Prospective, double-blind, randomised study. SETTING: University Hospital, Germany. SUBJECTS: 70 consecutive patients who had primary unilateral inguinal hernia repairs. INTERVENTIONS: A new regimen of pre-emptive analgesia with bupivacaine that was infiltrated preoperatively, intraoperatively, and postoperatively was tested. The control group were given saline infiltrations at the same times. Pain was measured up to postoperative day 30 using the visual analogue scale (VAS), the verbal rating scale (VRS), and by recording patient-controlled use of ibuprofen suppositories. RESULTS: Pain was significantly less in the pre-emptive analgesia group than in the control group during the first 10 days postoperatively as assessed by VAS and VRS (p < 0.05). Analgesic consumption was also significantly reduced in the pre-emptive analgesia group (p < 0.05). Multivariate analysis showed that bupivacaine infiltration (pre-emptive analgesia) was associated with significantly less postoperative pain (p < 0.0001). CONCLUSION: This regimen of pre-emptive analgesia is an effective and safe method of reducing postoperative pain and analgesic consumption after inguinal hernia repair.     

Efficiency of Infiltration with Bupivacain after Modified Radical Mastectomy

Background : Pre-incisional infiltration of anaesthetic is proven to reduce postoperative pain in breast cancer surgery. However, studies of post-incisional infiltration for modified radical mastectomy are rare. The purpose of this study was to investigate whether post-incisional infiltration with bupivacaine provides improved postoperative pain relief and a cost-effective benefit.

methods : This is a retrospective study. Between January 1006 and May 1008, 139 patients who received modified radical mastectomy were recruited to participate in the study. Patients receiving local infiltration received bupivacaine (0.5% bupivacaine, 5 ml diluted to 10 ml with distilled water) injected into the dermis surrounding the incision after wound suture. Pain intensity was evaluated using a Visual Analogue Scale (VAS) score and measurement of the required doses of meperidine and acetaminophen. The pain score was recorded every eight hours for three days. Results : All patients were female. Seventy-two patients received local infiltration with bupivacaine after wound suture and 67 patients did not. There were no significant differences between the two patient groups in age, body weight and height, length of general anaesthesia and operative time. Hospital stay was significantly shorter for patients receiving local infiltration of bupivacaine. The VAS score was higher up to 16 hours post-surgery for patients who did not receive local infiltration. Meperidine and acetaminophen consumption was less for patients who received local infiltration (P = 0.010).

Conclusion : Post-incisional wound infiltration with bupivacaine can relieve pain during the first 16 hours after surgery and shorten hospital stay, and it provides a cost-effective benefit.     

Oxycodone and ketobemidone for oral premedication

In a prospective, randomised and double-blinded study the preoperative sedative effect and the postoperative use of analgesics were compared in 90 patients undergoing inguinal hernia repair under general anaesthesia, premedicated orally with ketobemidone 10 mg, sustained-release oxycodone 10 mg or placebo. All patients had a local infiltration with bupivacaine after wound closure. Oral paracetamol 1 g×4 and dextropropoyphene 100 mg×4 were given postoperatively and iv ketobemidone was added if the pain score was >3 on a visual analogue scale from 0 to 10. Oxycodone, ketobemidone and placebo had a similar sedative effect before surgery. The use of ketobemidone after surgery was reduced by 40% in the oxycodone group compared to placebo (P<0.05). No reduction was noted in the ketobemidone group. Conclusion: Sustained-release oxycodone—but not ketobemidone—for oral premedication reduced the postoperative use of opioids after surgery.     

Oxycodone and ketobemidone for oral premedication

In a prospective, randomised and double-blinded study the preoperative sedative effect and the postoperative use of analgesics were compared in 90 patients undergoing inguinal hernia repair under general anaesthesia, premedicated orally with ketobemidone 10 mg, sustained-release oxycodone 10 mg or placebo. All patients had a local infiltration with bupivacaine after wound closure. Oral paracetamol 1 g×4 and dextropropoyphene 100 mg×4 were given postoperatively and iv ketobemidone was added if the pain score was >3 on a visual analogue scale from 0 to 10. Oxycodone, ketobemidone and placebo had a similar sedative effect before surgery. The use of ketobemidone after surgery was reduced by 40% in the oxycodone group compared to placebo (P<0.05). No reduction was noted in the ketobemidone group. Conclusion: Sustained-release oxycodone—but not ketobemidone—for oral premedication reduced the postoperative use of opioids after surgery.     

Pre-emptive analgesia with local anaesthetic for herniorrhaphy

There is little evidence that local anaesthetics produce pre-emptive analgesia and one reason may be the short duration of action of the drugs studied. We examined the pre-emptive analgesic effect of a bupivacaine field block on postoperative pain in 40 patients following herniorrhaphy in a double-blind, randomised trial. Patients received the block either after induction but before surgery, or after surgery but before the end of anaesthesia. There was no difference in pain scores or analgesic consumption up to 7 days after surgery between the two groups. We have demonstrated that bupivacaine does not appear to provide significant pre-emptive analgesia following a field block for herniorrhaphy. This study does not support the hypothesis that pre-emptive analgesia with local anaesthetic depends upon the duration of action of the drug.     

INFLUENCE OF EXTRADURAL MORPHINE ON THE ADRENOCORTICAL AND HYPERGLYCAEMIC RESPONSE TO SURGERY

Plasma cortisol and glucose concentrations were measured repeatedlyfrom before the induction of anaesthesia until 9 h after skinincision in 36 patients undergoing abdominal hysterectomy. Twelvepatients received general anaesthesia (halothane), and systemicopiates for postoperative pain; a further 12 patients underwentcontinuous extradural analgesia with a local anaesthetic agent(bupivacaine) and in the remaining 12 patients general anaesthesia(halothane) plus extradural morphine (4 mg before skin incisionand an additional 4 mg at skin closure) were used. Patientsreceiving extradural morphine or bupivacaine were free of pain.The physiological cortisol and glucose response to surgery wasblocked by the extradural analgesia with bupivacaine. Extraduralmorphine did not modify the initial increase in plasma cortisoland glucose concentrations during surgery, but suppressed thehypcrglycaemic and cortisol response following surgery whencompared with the general anaesthesia group receiving systemicopiates. However, cortisol and glucose concentrations were greaterafter operation in patients receiving extradural morphine comparedwith extradural bupivacaine, suggesting that the endocrine metabolicresponse to surgery is predominantly released by neurogenicstimuli other than pain stimuli involving opiate receptor-dependentnociceptive pathways ^* Present address for correspondence. Kommunehospitalet, SurgicalDepartment I, øster Farimagsgade 5, DK-1399 Copenhagen.     

Pre-emptive infiltration of Bupivacaine in laparoscopic total extraperitoneal hernioplasty: a randomized controlled trial

Aim  To investigate the effectiveness of pre-emptive preperitoneal infiltration of 0.5% Bupivacaine in postoperative pain control in laparoscopic total extraperitoneal (TEP) hernioplasty. Method  We conducted a prospective randomized controlled three-arm study. Consecutive patients aged 18–75 years with reducible groin hernia undergoing laparoscopic TEP hernioplasty in our day surgery unit were recruited. They were randomized into three groups. The pre-emptive Bupivacaine group (PBU) received infiltration of 10 ml 0.5% Bupivacaine to port sites before skin incision and another 10 ml to the preperitoneal space immediately after the creation of a first working port before further dissection. The standard Bupivacaine group (SBU) received infiltration of Bupivacaine after mesh placement, while in the control group (CO), the same amount of saline was injected instead. All operations were performed with the same surgical technique by a single surgeon. Postoperative pain was recorded at 2, 6, and 24 h by an independent assessor using a 0–10 verbal rating scale. The operative time, complications, and analgesia consumption, as well as patient satisfaction were also measured. Results  Ninety patients were randomized into three groups of 30. There were no differences in age, American Society of Anesthesiologists (ASA) risk classification, number of bilateral diseases, and operation time. The pain score was significantly reduced by Bupivacaine compared with control patients, while pre-emptive Bupivacaine was better than standard Bupivacaine. Fourteen out of ninety patients (15.6%) had seroma formation. All patients were discharged on the same day of operation. Conclusion  Pre-emptive preperitoneal infiltration of 0.5% Bupivacaine significantly reduces postoperative pain in laparoscopic TEP hernioplasty.     

Hormonal changes induced by etomidate in children during the first 24 postoperative hours

The hormonal effects of an etomidate infusion were assessed postoperatively in children undergoing hypospadias or clubfoot repair. The study was carried out in 12 children, aged between 9 and 70 months, randomly assigned to two equal groups. The anaesthetic protocol was identical for all the children, consisting in a light general anaesthesia (halothane induction, intubation after 60 to 80 micrograms.kg-1 vecuronium) combined with lumbar epidural anaesthesia (initial dose of 0.75 ml.kg-1 bupivacaine with adrenaline, with repeat injections of half the previous dose when there was a change in the haemodynamic parameters suggesting inadequate analgesia). Anaesthetic maintenance was different in both groups: 1 to 1.5 vol% enflurane in a nitrous oxide-oxygen mixture (1/1 v/v) in the control group, and 16.8 +/- 3.0 mg.kg-1.min-1 etomidate infusion in the etomidate group. Venous blood samples were collected after induction of anesthesia (before starting the epidural anaesthesia and the etomidate infusion), at the end of surgery (H0), at the 3rd (H3), 6th (H6), 12th (H12) and 24th h (H24) following surgery. The following hormonal blood concentrations were measured: cortisol, 11 beta-desoxycortisol, aldosterone, 11 beta-desoxycorticosterone, dehydroepiandrosterone (DHA) and DHA sulphate (DHA-S). In the control group, cortisol and DHA-S concentrations decreased significantly at H0, aldosterone levels also being significantly lower at H24. In the etomidate group, cortisol concentrations remained significantly lower at H0, H3 and H6; aldosterone concentrations were also significantly lower than control values throughout the study period. There was an important prolonged rise in the concentrations of their precursors. DHA and DHA-S concentrations did not change in the etomidate group.(ABSTRACT TRUNCATED AT 250 WORDS)     

Ropivacaine in paediatric surgery: preliminary results

In a double blind study 40 patients, aged 1–9 years, undergoing elective minor surgery were examined and randomly divided in two groups (20 children each). After light general anaesthesia Group 1 received caudal injection of bupivacaine 0.25% 2 mg·kg^?1 while Group 2 received 0.2% ropivacaine 2 mg·kg^?1. No differences were observed in demographic data, HR, BP and duration of surgery; the onset time of anaesthesia was 12 min and 9 min in Group 1 and 2 respectively. Ten patients in Group 1 received paracetamol in the first 24 h after surgery while only two children in Group 2 needed analgesic; even the duration of analgesia in the patients requiring paracetamol was superior in group 2 (520 min vs 253 min). No motor block was apparent at awakening in either group and no side effect was noticed. In conclusion ropivacaine seems to be an effective and safe drug in paediatric regional anaesthesia.     

Effect of pre-emptive analgesia on self-reported and biological measures of pain after tonsillectomy

This prospective, double-blind, randomized study assessed effect of pre-emptive peritonsillar block in 30 ASA-I children, aged 6-12 years, of both sexes, scheduled for tonsillectomy. Patients were divided into three groups: those in group I received a sham block, whereas peritonsillar blocks with bupivacaine 0.25% were given to the children before tonsillectomy (group II) or immediately after surgery had been completed (group III). Constant pain, pain on swallowing, blood glucose, serum epinephrine and norepinephrine concentrations were measured immediately after surgery and 4h after operation. Patients in group I experienced more pain (P< 0.05) than those in groups II and III, both in the immediate postoperative period and over the next 4 h. Patients in groups II and III experienced similar pain (P> 0.05). The pain experienced when water was swallowed was similar to that of the constant pain. The rise of serum norepinephrine concentration in group II was significantly less (P< 0.05) compared to groups I and III. We found both pre-emptive and postoperative block to be equally effective in treating postoperative pain, with pre-emptive block being more effective in preventing the rise in norepinephrine concentration.     

The effects of prophylactic dixyrazine on postoperative vomiting after two different anaesthetic methods for squint surgery in children

The incidence of postoperative vomiting after squint surgery was studied for two anaesthetic techniques with and without prophylactic dixyrazine. After induction, anaesthesia was maintained with either fentanyl/pancuronium/nitrous oxide or halothane/nitrous oxide in two randomly selected groups of 58 children each. Half of the children in each group were randomly allocated to receive dixyrazine 0.25 mg kg^-1 i.v. after surgery had been completed but before reversal of muscle relaxants or termination of anaesthesia. With prophylactic dixyrazine the incidence of postoperative vomiting was significantly reduced from 69% (20/29) to 21% (6/29) in the fentanyl group and from 45% (13/29) to 10% (3/29) in the halothane group. Without prophylactic dixyrazine, 20 of 29 children in the fentanyl group vomited compared to 13 of 29 in the halothane group (n.s.). Thus, prophylactic dixyrazine reduced the incidence of vomiting in children given either opioid or halothane anaesthesia for squint surgery. In comparable groups avoidance of opioid anaesthetic technique and use of prophylactic dixyrazine resulted in a greatly reduced incidence of vomiting.     

Changes of blood pressure and cerebral arterio-venous oxygen content differences (AVDo2) with and without bupivacaine scalp infiltration during craniotomy

In 20 patients subjected to craniotomy for supratentorial cerebral tumours, the effect of scalp infiltration with bupivacaine before incision was evaluated by measuring mean arterial blood pressure (MABP) and cerebral arterio-venous oxygen content differences (AVDO2) repeatedly during the operation. All patients were given halothane 0.5% anaesthesia. Ten patients were given bupivacaine 0.25% and ten patients were given normal saline for scalp infiltration prior to incision. The study was performed in a double-blind randomized fashion. Significantly higher values of MABP (P less than 0.0005) after incision were found in the saline group compared to the bupivacaine group. Significantly lower values of AVDO2 (P less than 0.0005) after incision were seen in the saline group compared to the bupivacaine group. The results indicate that the increase in MABP associated with a decrease in AVDO2, suggesting an increase in CBF and cerebral hyperperfusion, is reduced by using bupivacaine scalp infiltration prior to incision.     

Anesthesia for inguinal hernioplasty: a comparison of techniques

New surgical and modern anaesthesia techniques for inguinal hernioplasty have significantly reduced the duration of the procedure and the postoperative length of hospital stay. From 1994 to 1998, 405 patients with a mean age of 54.7 years (range: from 18 to 90) undergoing inguinal hernioplasty were studied. Four different anaesthetic techniques were used: (i) surgical field infiltration (SFI) with 0.5% carbonated lidocaine + 0.125% bupivacaine (193 pts.) in which monitored anaesthesia care was administered with propofol (3 to 4 mg/kg/h) when necessary; (ii) epidural anaesthesia with 2% lidocaine + fentanyl 100 mg (137 pts.); (iii) general anesthesia with isoflurane and fentanyl in N2O:O2 (48 pts.); and (iv) intrathecal anaesthesia with 1% hyperbaric bupivacaine 1-2 ml (25 pts.). Intra- and postoperative complications, intraoperative sedation, postoperative supplemental drugs for analgesia and postoperative length of hospital stay were recorded. The data obtained were analyzed statistically using Student's t-test Anova, Bonferroni post hoc analysis, chi square, and P values less than 0.05 were considered significant. Intraoperative hypotension/brachycardia were observed in 4 patients (2%) in the SFI group and in 6 patients (4%) in the epidural group. Sedation was required in 29.5% of patients in the SFI group and in 15.3% in the epidural group (P < 0.05). Postoperative supplemental analgesic drugs administered and length of hospital stay were similar in the 4 groups. No difference in intra- and postoperative complications was observed among the 4 groups. Patients who required sedation in the SFI group were significantly more numerous than those with epidural anaesthesia. In conclusion, both SFI and epidural anaesthesia are safe and suitable for the inguinal hernioplasty procedure, without intra- or postoperative complications.     

Strabismuschirurgie bei Kindern Einfluß von Paracetamol und Bupivacain

Postoperative vomiting is induced by different mechanisms such as age, anaesthetic technique and medications, postoperative analgesia, and surgical traction on the extra-ocular muscles. The influence of anticholinergic premedication and the use of benzodiazepines as factors affecting the incidence of vomiting is controversial. In a prospective, randomised, single-blind study we examined two different treatments with regard to postoperative pain, vigilance, and vomiting in young children undergoing strabismus repair. Methods. After institutional ethical committee approval, informed written consent was obtained from all parents. The children were randomly assigned to three groups: (1) paracetamol (P) – 17 patients who received 250–500?mg paracetamol rectally (dependent on body weight) immediately after intubation of the trachea; (2) bupivacaine (B) – 17 patients who received two drops 0.5% bupivacaine hydrochloride on the conjunctiva of the eye(s) being corrected following intubation of the trachea and again 10?min after intubation. After the surgeon had exposed the extra-ocular muscle and before readaptation of the conjunctiva, two drops of the same solution were applied again each time directly on the muscle; and (3) controls (C) – 16 patients who received rectal paracetamol after completion of the operation but before extubation. The children were premedicated with 0.05?mg/kg flunitrazepam sublingually. After 0.25?mg atropine i.v., anaesthesia was induced with 0.1?mg/kg vecuronium, 5?mg/kg thiopentone, 1.5 vol% enflurane, and N₂O/O₂ 50:50. When the trachea was intubated anaesthesia was maintained with enflurane as required and 70% N₂O in oxygen. Extubation was performed only if the patient could touch or did not tolerate the tube. Oral diet was allowed 6?h after extubation at the earliest. Examination of vigilance and analgesia. The degrees of vigilance and pain were evaluated preoperatively and after extubation over 24?h using two different scales. Evaluation of the scales was performed during the first 3 postoperative h at 12 different time points (Figs.?1, 2) and 6, 12, and 24?h after extubation. The evaluation was conducted by nursing staff who were blinded to the treatment (single-blind study). Postoperative analgesia consisted of 250–500?mg rectal paracetamol (all patients). Parametric data were expressed as mean± SD, and comparisons were made with the one-way analysis of variance. Fisher's exact test was applied to ordinal data. P<0.05 indicates a statistically significant difference. Results. Two patients (P) were excluded from the study postoperatively because of refusing rectal paracetamol in spite of pain and postoperative infection of the upper airways, which had manifestated on the afternoon of the operative day. No significant differences were found between the three groups in patient characteristics (Table?1). The quantity of enflurane administered, rate, postoperative consumption of rectal paracetamol, and postoperative emesis were highest in the control group (Tables?2, 3), but the incidence of postoperative vomiting ranged only between 13% and 24% (Table?3). Children with preoperative paracetamol needed more time to fulfill the criteria to “stick out the tongue” and “recognising the mother”. Vigilance. The time to postoperative crying or screaming and restlessness was shorter in the control group. The values reached significant difference at 10?min (P) and 25?min (P and B) after extubation compared with the other groups (Fig.?1). Analgesie. At 5, 10, and 150?min after extubation pain was significantly higher in patients in the control group (Fig.?2). Conclusions. Intraoperative administration of rectal paracetamol or topical 0.5% bupivacaine was most effective in the treatment of postoperative pain for strabismus surgery in younger children. Sublingual flunitrazepam and i.v. atropine given as premedication probably decrease postoperative vomiting. Postoperative administration of rectal paracetamol cannot be recommended because peak plasma levels of rectal paracetamol occur after 2 to 4?h. Intraoperative topical 0.5% bupivacaine seems to be an alternative treatment for reducing postoperative pain in squint surgery.     

Catecholamine and Endocrine Response in Children During Halothane and Enflurane Anaesthesia for Adenoidectomy

In 28 children undergoing adenoidectomy, plasma concentrations of catecholamines, ACTH and cortisol were measured. Fourteen children were anaesthetized with halothane (seven non-intubated, seven intubated) and 14 with enflurane (seven non-intubated, seven intubated). During undisturbed anaesthesia, plasma catecholamines were significantly higher with halothane than with enflurane (P less than 0.05). Immediately after surgery, catecholamines were increased up to 300% in the halothane groups. In the enflurane groups, however, the catecholamine concentrations remained unchanged. This difference between the two agents, after surgery, was statistically significant (P less than 0.01 for intubated and P less than 0.001 for non-intubated children). Fifteen minutes postoperatively no difference was found in plasma concentrations between the groups. In all four groups, plasma concentrations of ACTH and cortisol increased similarly during the procedure. It was concluded that plasma catecholamines were higher during halothane than during enflurane anaesthesia in children undergoing adenoidectomy. This difference may be caused by a stimulating effect of halothane on the endogenous catecholamine release. This increased sympathomimetic response during halothane anaesthesia was correlated to the incidence of ventricular arrhythmias previously found with this agent during adenoidectomy.