Preincisional Dextromethorphan Treatment for Postoperative Pain Management after Upper Abdominal Surgery

Previous studies showed that ketamine, an N-methyl-d-aspartate (NMDA) receptor antagonist, provides a preemptive analgesic effect and preemptive analgesia improves postoperative pain management. The aim of this study was to examine whether premedication with dextromethorphan (DM) improves postoperative pain management after upper abdominal surgery. Sixty (American Society of Anesthesiologists class 1 and 2 of either gender) patients scheduled for upper abdominal surgery were included in the study. Patients were randomly assigned to one of four groups: control, DM-10, DM-20, and DM-40. In the control group, chlorpheniramine maleate (CPM, 20 mg) was injected immediately before induction of anesthesia intramuscularly (IM). In the DM-10, DM-20, and DM-40 groups, patients were premedicated with DM 10 mg, 20 mg, and 40 mg IM, respectively. After operation, patient-controlled analgesia (PCA) with morphine was given for pain relief. The time to the first PCA trigger, morphine consumption, pain scores, and analgesic-related side effects were recorded at 1, 2, 4, 24, 48, and 72 hours after surgery. The time to first PCA trigger for the control group was 17.8 ± 1.4 minutes, for group DM-10 20.2 ± 1.6 minutes, for group DM-20 32.4 ± 1.9 minutes, and for DM-40 77.9 ± 6.5 minutes. The morphine delivered and PCA triggering frequency were 5.5 ± 0.5/11.3 ± 0.8 times for the controls, 5.5 ± 0.4/14.1 ± 1.3 times for DM-10, 3.1 ± 0.3/6.3 ± 1.2 times for DM-20, and 0.2 ± 0.1/0.3 ± 0.2 times for DM-40 during the first hour after operation. For the first day, the figures are 19.9 ± 1.2/23.9 ± 1.4 for the controls, 15.6 ± 1.2/17.3 ± 2.4 for DM-10, 12.6 ± 0.7/15.9 ± 1.6 for DM-20, and 5.0 ± 0.21/5.6 ± 0.9 for DM-40. On the first day, the cough pain scores were 6.67 ± 0.23, 6.53 ± 0.16, 6.67 ± 0.23, and 5.73 ± 0.18 for the controls, DM-10, DM-20, and DM-40 groups, respectively. All data showed dose-dependent better pain relief in DM-premedicated patients. We conclude that DM premedication offers preemptive analgesia and reduces postoperative pain and morphine requirement.     

Postoperative Pain Treatment after Upper Abdominal Surgery with Epidural Morphine at Thoracic or Lumbar Level

Thirty patients undergoing upper laparotomy were entered into a randomized trial, comparing the effect of midthoracic (T) and lumbar (L) epidural morphine on postoperative pain and pulmonary function. Five mg morphine was injected through the catheter at the end of the operation, and subsequently three times a day. Six, 30 and 54 h postoperatively, the following tests were performed: linear analogue pain score, arterial gas tensions (PaO2, PaCO2 and pH), forced ventilatory capacity (FVC), forced expiratory volume in 1s (FEV1) and peak expiratory flow rate (PEF). The changes in pain score (increase of the median): T: 21, 6, 5, and L: 24, 15, 8 per cent of full scale), PaO2 (decrease of the tension: T: 1.7, 2.1, 2.4, and L: 2.0, 2.8, 2.0 kPa), PaCO2, pH, FVC (decrease of the volume: T: 1.3, 1.1, 0.9, and L: 1.3, 1.3, 1.21), FEV1 and PEF from the preoperative tests were not significantly different. It is concluded that the clinical effect of epidural morphine for postoperative pain treatment is the same or little different whether the administration takes place at the thoracic or lumbar level.     

Early Postoperative Pain After Keyless Abdominal Rope-Lifting Surgery

Methods:During a 20-month period, 77 women underwent surgery for a benign ovarian cyst. Keyless abdominal rope-lifting surgery and conventional carbon dioxide laparoscopy techniques were used for the operations in 32 women and 45 women, respectively. The 2 operative techniques were compared with regard to demographic characteristics; preoperative, intraoperative, and postoperative data including early postoperative pain scores; and frequency of shoulder pain and analgesic requirements.Results:Data regarding demographic characteristics, preoperative findings, cyst diameters and rupture rates, intra-abdominal adhesions, intraoperative blood loss, and postoperative hospital stay did not differ between groups (P > .05). However, the mean operative and abdominal access times were significantly longer in the keyless abdominal rope-lifting surgery group (P < .05). Visual analog scale pain scores at initially and at the second, fourth, and 24th hours of the postoperative period were significantly lower in the keyless abdominal rope-lifting surgery group (P < .05). Similarly, keyless abdominal rope-lifting surgery caused significantly less shoulder pain and additional analgesic use (P < .05).Conclusion:Keyless abdominal rope-lifting surgery seems to cause less pain in the management of benign ovarian cysts in comparison with conventional carbon dioxide laparoscopy.     

Comparison of Intravenous or Epidural Patient-controlled Analgesia in the Elderly after Major Abdominal Surgery

Background: Patient-controlled analgesia (PCA) with intravenous morphine and patient-controlled epidural analgesia (PCEA), using an opioid either alone or in combination with a local anesthetic, are two major advances in the management of pain after major surgery. However, these techniques have been evaluated poorly in elderly people. This prospective, randomized study compared the effectiveness on postoperative pain and safety of PCEA and PCA after major abdominal surgery in the elderly patient.

Methods: Seventy patients older than 70 yr of age and undergoing major abdominal surgery were assigned randomly to receive either combined epidural analgesia and general anesthesia followed by postoperative PCEA, using a mixture of 0.125% bupivacaine and sufentanil (PCEA group), or general anesthesia followed by PCA with intravenous morphine (PCA group). Pain intensity was tested three times daily using a visual analog scale. Postoperative evaluation included mental status, cardiorespiratory and gastrointestinal functions, and patient satisfaction scores.

Results: Pain relief was better at rest (P = 0.001) and after coughing (P = 0.002) in the PCEA group during the 5 postoperative days. Satisfaction scores were better in the PCEA group. Although incidence of delirium was comparable in the PCA and PCEA groups (24%vs. 26%, respectively), mental status was improved on the fourth and fifth postoperative days in the PCEA group. The PCEA group recovered bowel function more quickly than did the PCA group. Cardiopulmonary complications were similar in the two groups.     

Effect of Prophylactic Epidural Morphine or Bupivacaine on Postoperative Pain after Upper Abdominal Surgery

Morphine 2 mg and 4 mg or bupivacaine 50 mg (another 50 mg 4 h later) was administered into the epidural space prior to general anaesthesia of 40 patients undergoing upper abdominal surgery. During anaesthesia, additional analgesics were not given. In the recovery room (4 h) the pain score (0–10) was lowest in the bupivacaine group (mean 2.4) followed by the 4 mg-morphine group (4.1), 2 mg-morphine group (5.3) and control group (5.7). Half of the patients of the bupivacaine group and those of the 4 mg-morphine group needed no analgesics in the recovery room. Later, in the ward (until next morning 7 am), only morphine patients (5/20) managed without postoperative analgesics. The mean number of requests for analgesics during that time was: 4 mg-morphine 1.3, 2 mg-morphine 1.9, bupivacaine 2.7, and control 2.9. Episodes of hypotension and nausea were most frequent in the bupivacaine group. No serious respiratory complications occurred; 4 h after anaesthesia three patients in the 4 mg-morphine group and two in the bupivacaine group had capillary Pco₂ values above 6.65 kPa (50 mmHg), the highest being 7.1 kPa. In two additional patients with choledochal drainage (T-tube), the intracholedochal pressure was shown to rise about 2 kPa (15 mmHg) and 2.7 kPa after epidural injection of 2 mg and 4 mg, respectively. A pressure peak was reached within 10 min and at 75 min the pressure was still 0.7-1.3 kPa above the initial level.     

舒芬太尼用于腹部手术后静脉自控镇痛的临床观察

目的观察舒芬太尼用于腹部手术后患者静脉自控镇痛(patient controlled intravenous an-algesia,PCIA)的临床效果。方法60例择期全麻下行腹部手术患者,ASAⅠ~Ⅱ级,随机分为舒芬太尼组(SF组)、芬太尼组(F组)和对照组(C组),每组20例。SF组和F组术后行PCIA,镇痛药物配方:SF组为舒芬太尼100μg+生理盐水至100 ml,F组为芬太尼1 mg+生理盐水至100 ml,镇痛泵负荷剂量2.5 ml,背景剂量2 ml/h持续输注,自控剂量1.0 ml,锁定时间20 min;C组根据需要间断肌注哌替啶镇痛。监测术前、手术结束、术后24 h、48 h的HR、SBP、DBP,记录术后8、12、24、48 h疼痛视觉模拟评分(visual analogue scale,VAS)。结果组间比较,三组术后8、12、24及48 h各时点的静息VAS均有显著差异(P0.01或P0.05),C组VAS分值最高,F组次之,SF组最低;SF组、F组在手术结束及术后24 h时SBP、DBP及HR均低于C组(P0.05),但SF组与F组间无统计学差异(P0.05)。结论腹部手术后患者采用舒芬太尼行PCIA,镇痛效果确切,血流动力学稳定,可安全用于临床。     

Perioperative Factors Predicting Prolonged Postoperative Ileus After Major Abdominal Surgery

Background

Prolonged postoperative ileus (PPOI) is among the common complications adversely affecting postoperative outcomes. Predictors of PPOI after major abdominal surgery remain unclear, although various PPOI predictors have been reported in patients undergoing colorectal surgery. This study aimed to devise a model for stratifying the probability of PPOI in patients undergoing abdominal surgery.

Methods

Between 2012 and 2013, 841 patients underwent major abdominal surgery after excluding patients who underwent less-invasive abdominal surgery, ileus-associated surgery, and emergency surgery. Postoperative managements were generally based on enhanced recovery after surgery (ERAS) program. The definition of PPOI was based on nausea, no oral diet, flatus absence, abdominal distension, and radiographic findings. A nomogram was devised by evaluating predictive factors for PPOI.

Results

Of the 841 patients, 73 (8.8%) developed PPOI. Multivariable logistic regression analysis revealed smoking history (P = 0.025), colorectal surgery (P = 0.004), and an open surgical approach (P = 0.002) to all be independent predictive factors for PPOI. A nomogram was devised by employing these three significant predictive factors. The prediction model showed relatively good discrimination performance, the concordance index of which was 0.71 (95%CI 0.66–0.77). The probability of PPOI in patients with a smoking history who underwent open colorectal surgery was calculated to be 19.6%.

Conclusions

Colorectal surgery, open abdominal surgery, and smoking history were found to be independent predictive factors for PPOI in patients who underwent major abdominal surgery. A nomogram based on these factors was shown to be useful for identifying patients with a high probability of developing PPOI.

     

Quality of Postoperative Pain Using an Intraoperatively Placed Epidural Catheter after Major Lumbar Spinal Surgery

Background: Major spinal surgery is associated with high postoperative pain scores and opioid requirement. The aim of the current prospective, randomized, placebo-controlled, double-blind study was to assess the reduction of opioid requirement and pain scores using an intraoperatively placed epidural catheter with infusion of 0.1% ropivacaine during the postoperative period.

Methods: Thirty patients undergoing major lumbar spinal surgery from a dorsal approach were included in this study. Before wound closure, the orthopedic surgeon inserted an epidural catheter. Postoperatively, patients were randomly assigned to receive an infusion of 12 ml/h ropivacaine, 0.1% (group R), or 12 ml/h saline (group N) after an initial bolus of 10 ml of the respective study solution. Additional pain relief was provided using an intravenous patient-controlled analgesia pump with the opioid piritramide. Patients were assessed with respect to pain scores (visual analog scale of 0-100), cumulative opioid requirement, side effects, and satisfaction with pain management.

Results: Demographic data, duration of surgery, and type of surgery were comparable between groups. Pain scores were assessed as follows (group R vs. group N: 6 h: 24 +/- 20 vs. 51 +/- 20, P = 0.002; 24 h: 33 +/- 19 vs. 53 +/- 27, P = 0.04; 48 h: 21 +/- 17 vs. 40 +/- 26, P = 0.04; 72 h: 14 +/- 13 vs. 38 +/- 25, P = 0.02). The cumulative piritramide requirement after 72 h was 97 +/- 23 mg in group R and 157 +/- 72 mg in group N (P = 0.03). The incidence of side effects was comparable between groups, and patient satisfaction was always higher in group R (P < 0.05).     

Postoperative Pulmonary Function in Obese Patients after Upper Abdominal Surgery

The pulmonary course after jejuno-ileal by-pass operation in six massively obese patients (mean weight 130.2 kg) was followed for the first 5 postoperative days by means of arterial blood gas analysis and measurements of forced vital capacity (FVC), forced expired volume in the first second (FEV_1.0) and peak expiratory flow rate (PEFR). The patients were extubated in the operating room and were breathing spontaneously in the postoperative period. Pa_o2 and FVC reached their minimum values in the first 24 postoperative hours (respectively, 74% and 45% of their preoperative values), but were almost restored in 5 days. PEFR had at this time reached 77% of its preoperative value. FEV_1.0% (FEV_1.0 in per cent of FVC) did not change from the pre- to the postoperative period, but remained about 70%.     

帕瑞昔布用于妇科腹腔镜术后镇痛的观察

目的：观察围术期应用帕瑞昔布对妇科腹腔镜术后疼痛的影响。 方法：前瞻性、随机、双盲、安慰剂对照不,平行分组研究,选择ASA,Ⅰ或Ⅱ级的择期全麻下行妇科腹腔镜手术病人40例,年龄25－45岁,随机分为帕瑞普布组和安慰剂组,每组20列,帕瑞普布组于切皮前10min、切皮后12h分别静注帕瑞普布40mg,安慰剂组于切皮前10min,切皮后12h和24h分别静注生理盐水5ml,用视觉模拟评分法（Visual Analogue Scaie ;VAS）观察术后2h 、4h、 6h、 12h、 24h的疼痛度和病人对镇痛的落单度。结果：与安慰剂组相比,帕瑞普布组的术后2h 、4h、 6h、 12h和24h的VAS评分明显降低（P〈0.05）,手术后24h镇痛满意度明显提高（P〈0.05）。结论：静注帕瑞普布用于妇科腹腔镜手术,能有效缓解术后疼痛,提主病人术后镇痛质量。     

Efficacy and Safety of Intravenous Parecoxib Sodium in Relieving Acute Postoperative Pain following Gynecologic Laparotomy Surgery

Background: This study tested the hypothesis that an injectable cyclooxygenase (COX)-2-specific inhibitor will be at least as effective and well tolerated as a COX-nonspecific conventional nonsteroidal antiinflammatory drug (NSAID) by comparing the analgesic efficacy and tolerability of one intravenous dose of parecoxib sodium, an injectable prodrug of the novel COX-2-specific inhibitor, valdecoxib, with ketorolac and placebo in postoperative laparotomy surgery patients. Intravenous morphine, 4 mg, was studied as a positive analgesic control.

Methods: In this multicenter, double-blinded, placebo-controlled study, women experiencing moderate-to-severe pain on the first day after abdominal hysterectomy or myomectomy received one intravenous dose of parecoxib sodium, 20 or 40 mg, ketorolac, 30 mg, morphine, 4 mg, or placebo. Analgesic efficacy and tolerability were evaluated for 24 h postdose or until patients, whose pain was not adequately controlled, opted to receive rescue analgesia.

Results: Two hundred two patients were enrolled. All treatment groups had comparable demographics and baseline pain status. All active treatments had an equally rapid time to onset of analgesia (10-23 min). Overall, each parecoxib sodium dose and ketorolac were significantly superior to morphine and placebo for most measures of analgesic efficacy at most time points, including a significantly longer (two- to threefold) time to rescue analgesia (P <= 0.05). All treatments were well tolerated.     

Automatic CPAP Compared with Conventional Treatment for Episodic Hypoxemia and Sleep Disturbance after Major Abdominal Surgery

Background: After major surgery, analgesia with opioids can cause obstructive apnea and intermittent hypoxemia, probably from loss of upper airway control. Since this resembles the obstructive sleep apnea syndrome, we tested the possibility that nasal continuous positive airway pressure (nCPAP) would reduce episodes of reduced oxygen saturation and sleep disruption. Because oxygen therapy is frequent after surgery, we also assessed the effect of oxygen on sleep disruption.

Methods: We recruited 48 patients about to have major abdominal surgery. We present data for 34 patients: 27 who received patient-controlled intravenous morphine and 7 who received epidural opioid. Treatment was randomized to either nCPAP or conventional therapy with an oxygen mask. Alternate periods of administration of air and 35% oxygen were used in both groups. If the oxygen saturation as measured by pulse oximetry was consistently <90% on air, the patient was withdrawn from the study. We measured sleep, arousals, oxygenation, episodes of desaturation, and disturbances of respiration. Values are given as median and quartiles.

Results: The median proportion of time awake was 65% (45-79%) among control patients and 74% (55-87%) among those undergoing nCPAP. Oxygen administration did not affect the sleep pattern. The median frequency of arousals per hour of sleep was very similar in each group: during air breathing from nCPAP, 125 (76-187), and during air breathing by mask, 116 (84-187). Oxygen therapy had no effect. Oxygenation and hypoxemic events were not improved by nCPAP. Oxygen therapy improved oxygenation and reduced but did not eliminate episodes of desaturation.     

术后硬膜外病人自控镇痛的临床研究

采用硬膜外病人自控镇痛（ＰＣＥＡ）技术研究负荷剂量的临床效应，并与传统硬膜外工物镇痛（ＥＤＡ）进行比较，１００例（ＡＳＡＩ～Ⅱ级）手术病例随机分成为４组，Ａ组（ｎ＝３０），用０．２５％布比卡因＋０．００１５％丁丙诺啡，负荷剂量＋ＰＣＥＡ；Ｂ组（ｎ＝３０），Ａ组溶液中加０．００５％吗啡，用法同Ａ组：Ｃ组（ｎ＝２０），ＰＣＥＡ的药液同Ａ组，不同负荷剂量；Ｄ组（ｎ＝２０），药液同Ａ组，单次ＥＤＡ５ｍｌ。     

Can Postoperative Pulmonary Conditions be Improved by Treatment with the Bartlett-Edwards Incentive Spirometer after Upper Abdominal Surgery?

During the immediate postoperative course after upper abdominal surgery, pulmonary complications often occur, caused, inter alia, by reduced regional ventilation and by atelectases as a result of: (1) narrowing of the small peripheral bronchi, and (2) impaired respiratory function. Based on these pathophysiological mechanisms, an instrument (Bartlett-Edwards Incentive Spirometer) has been devised, which aims at giving the patient an opportunity of sustained maximal inspiration under standardized and controlled conditions. The use of this instrument has been followed by reports of a considerable reduction in postoperative pulmonary complications. In a controlled clinical investigation of the pre- and postoperative condition of the lungs, we were unable to show any beneficial effect of the instrument. In general, we have a low frequency of severe postoperative pulmonary complications, as compared with the results reported in the literature. We ascribe this to our very effective pre- and postoperative respiratory therapy.     

Splanchnic Vasoregulation After Major Abdominal Surgery in Pigs

Background  

Unrecognized reduction of blood supply to intestinal organs is associated with significant postoperative morbidity in abdominal surgery. The aim of this study was to determine whether—in the absence of hypovolemia—intestinal hypoperfusion as a result of blood flow redistribution occurs after abdominal surgery.     

Acetazolamide Reduces Referred Postoperative Pain after Laparoscopic Surgery with Carbon Dioxide Insufflation

Background: Carbon dioxide is the preferred insufflating gas for laparoscopy because of greater safety in the event of intravenous embolism, but it causes abdominal and referred pain. Acidification of the peritoneum by carbonic acid may be the major cause of pain from carbon dioxide insufflation. Carbonic anhydrase is an enzyme that increases the rate of carbonic acid formation from carbon dioxide. Because acetazolamide inhibits carbonic anhydrase, the authors hypothesized that the pain caused by carbon dioxide insufflation may be decreased by the administration of acetazolamide.

Methods: A prospective, randomized, double-blind study of 38 patients undergoing laparoscopic surgery during general anesthesia was performed. Acetazolamide (5 mg/kg) or a saline placebo was administered intravenously during surgery. Pain was rated on a visual analog scale (0-10) at four times: when first awake, at discharge from the recovery room, when discharged from the hospital, and on the day after surgery. The site and quality of pain were recorded, as were medications and side effects.

Results: Initial referred pain scores were lower after acetazolamide (1.00 +/- 1.98; n = 18) than after placebo (3.40 +/- 3.48; n = 20; P = 0.014), and 78% of patients in the acetazolamide group had no referred pain; however, only 45% patients in the placebo group had no referred pain. Incisional pain scores were not statistically different, and referred pain scores were similar at later times.     

Postoperative Pain Therapy After Lumbar Disc Surgery

Summary  Object. This study was undertaken to determine whether a special postoperative pain administration of tramadol and diclofenac provides any benefits in patients who underwent microsurgical lumbar discectomy.  Methods. The study consisted of 60 patients undergoing microsurgical lumbar discectomy. Patients were randomly divided into two groups based on the postoperative pain management: 1) Group A (n=30): no standardized pain therapy; these patients received on demand different analgesics and at variable dosages which were selected by the neurosurgeons; 2) Group B (n=30): standardized pain therapy with specific dosages of tramadol and diclofenac in regular time intervals during the first 48 hours after surgery. After surgery follow-up data from a special standardized questionnaire were obtained for all 60 patients during the first 48–72 postoperative hours. The patients were asked for course and intensity of pain as well as about some specific circumstances of clinical therapy after surgery.  The postoperative pain intensity of patients treated with the special combination of tramadol and diclofenac was significantly diminished (24 hours after surgery: p=0.0002, 48 h: p=0.0047, 72 h: p=0.0034) in relation to the group without standardized pain therapy. Similarly, the frequency of breakthrough pain was significantly reduced (24 h: p=0.0001, 48 h: p=0.003, 72 h: p=0.004).  Conclusions. The results suggest that the application of tramadol and diclofenac during the first 48 hours after lumbar microdiscectomy results in a reduction in postoperative pain without complications. We suggest that the use of this combination can be a beneficial adjunct to lumbar disc surgery.