Aikaterini Melemeni

Multimodal analgesia with gabapentin and local anesthetics prevents acute and chronic pain after breast surgery for cancer

We evaluated the effect of multimodal analgesia on acute and chronic pain after breast surgery for cancer. Fifty patients scheduled for breast cancer surgery were blindly randomized to receive gabapentin, eutectic mixture of local anesthetics cream, and ropivacaine in the wound or three placebos. Pain (visual analog scale) and analgesics were recorded in the postanesthesia care unit (PACU) 3, 6, and 9 h and 8 days after surgery. Three and 6 mo later, patients were assessed for chronic pain. The treatment group consumed less paracetamol in the PACU (469 versus 991 mg; P < 0.002) and less Lonalgal® (1.0 versus 4.4 tablets; P = 0.003) than the controls, exhibited lower visual analog scale scores at rest in the PACU (P = 0.001) and on postoperative Days 1, 3, and 5 (P = 0.040, P = 0.015, and P = 0.045, respectively), and after movement in the PACU (P = 0.001) and on postoperative Days 2, 4, and 8 (P = 0.028, P = 0.007, and P = 0.032, respectively). Three and 6 mo after surgery, 18 of 22 (82%) and 12 of 21 (57%) of the controls reported chronic pain versus 10 of 22 (45%) and 6 of 20 (30%) in the treatment group (P = 0.028 and P = 0.424, respectively); 5 of 22 and 4 of 21 of the controls required analgesics versus 0 of 22 and 0 of 20 of those treated (P = 0.048 and P = 0.107, respectively). Multimodal analgesia reduced acute and chronic pain after breast surgery for cancer.

EMLA reduces acute and chronic pain after breast surgery for cancer.

Background and Objectives A significant percentage of women undergoing breast surgery for cancer may develop neuropathic pain in the chest, and/or ipsilateral axilla and/or upper medial arm, with impairment in performing daily occupational activities. We designed this study to determine if the perioperative application of EMLA (eutectic mixture of local anesthetics; AstraZeneca) cream in the breast and axilla area reduces analgesic requirements, as well as the acute and chronic pain after breast surgery. Methods Forty-six female patients scheduled for breast surgery received randomly 5 g of EMLA or placebo on the sternal area 5 minutes before surgery, and 15 g on the supraclavicular area and axilla at the end of the operation. Treatment with EMLA cream (20 g) or placebo was also applied daily on the 4 days after surgery. In the postanesthesia care unit (PACU), 3, 6, 9, and 24 hours after surgery, and on the second to sixth day postoperatively, pain was assessed by visual analogue scale (VAS) at rest and after movement, and postoperative analgesic requirements were recorded. Three months later, patients were asked if they had pain in the chest wall, axilla and/or medial upper arm, decreased sensation, if they required analgesics at home, and for the intensity of pain. Results Acute pain at rest and with movement did not differ between the EMLA and control groups, and the analgesics consumed during the first 24 hours were the same for the EMLA and control groups. However, time to the first analgesia requirement was longer (P = .04), and codeine and paracetamol consumption during the second to fifth days was less (P = .001, and P = .004, respectively) in the EMLA versus the control group. Three months postoperatively, pain in the chest wall, axilla, and the total incidence and the intensity of chronic pain were significantly less in the EMLA versus the control group (P = .004, P = .025, P = .002 and P = .003, respectively). The use of analgesics at home and abnormal sensations did not differ between the 2 groups. Conclusions The application of EMLA to patients undergoing breast surgery for cancer reduced the postoperative analgesic requirements and the incidence and intensity of chronic pain.

Postoperative Pain and Analgesic Requirements After Anesthesia with Sevoflurane, Desflurane or Propofol

BACKGROUND: General anesthetics may have nociceptive actions that affect postoperative pain. In studies evaluating postoperative pain, the effect of general anesthetics on analgesic requirements has not been considered except for one recent study suggesting that propofol anesthesia provides better analgesia after surgery than isoflurane. METHODS: In this prospective, blind, randomized trial we recorded postoperative analgesic requirements (mg of morphine) and pain scores (visual analog scale in mm) 2, 4, 8, and 24 h postoperatively in patients undergoing abdominal hysterectomy or myomectomy under sevoflurane, desflurane or propofol anesthesia, titrated to maintain Bispectral Index values between 35 and 45. Pain scores were also recorded immediately after transfer to the postanesthesia care unit. RESULTS: Cumulative morphine consumption did not differ among the three groups 2, 4, 8, or 24 h postoperatively (P = 0.50). The morphine consumed within 24 h postoperatively was 28 ± 13.8 mg in the sevoflurane group, 25 ± 11.7 mg in the desflurane group and 27 ± 16.1 mg in the propofol group. The visual analog scale values at rest or after cough immediately after patient transport to the postanesthesia care unit and 2, 4, 8, and 24 h after surgery did not differ among the three groups (P = 0.40, 0.39, 0.50, 0.47, 0.06 at rest and P = 0.67, 0.45, 0.22, 0.26, 0.29 after cough respectively). CONCLUSION: Morphine consumption and pain 24 h postoperatively did not differ among the sevoflurane, desflurane, and propofol groups.

Regional block and mexiletine: The effect on pain after cancer breast surgery

Background and Objectives Breast surgery for cancer is associated with chronic pain and sensory abnormalities. The present study investigates the effect of regional block, oral mexiletine, and the combination of both, on acute and chronic pain associated with cancer breast surgery. Methods One hundred patients scheduled for cancer breast surgery received either regional block with 18 mL of 1% ropivacaine intraoperatively and oral mexiletine for the first 6 postoperative days (R + M group), or regional block and placebo (R + PL), or normal saline instead of ropivacaine and mexiletine (PL + M), or normal saline and placebo (PL + PL). Postoperative analgesic requirements were recorded daily. Pain was assessed 0, 3, 6, 9, and 24 hours in the postanesthesia care unit (PACU) and on the second to sixth day postoperatively, at rest, and after movement using the visual analog scale (VAS). Three months after surgery, patients were interviewed for the presence and intensity of pain, abnormal sensations, and analgesic requirements. Results Regional block reduced the number of intramuscular (IM) injections required the first 24 hours (P = .05), the R + PL group requiring less injections versus the PL + M group (P = .037). Lonarid tablet (paracetamol and codeine) consumption from the second to the fifth postoperative day differed among the 4 groups (P = .0304), the R + M group requiring fewer tablets than the PL + PL group (P = .009). Three hours postoperatively, the R + PL group had less pain at rest when compared with all other groups (P < .05 for all comparisons). On the second postoperative day, VAS at rest and after movement was less in the R + M versus the R + PL group (P < .01 and P < .05, respectively). Three months after surgery, the 4 groups were similar with regard to incidence or intensity of pain or analgesic requirements. The R + PL group had a lower incidence (77%) of reduced or absent sensation (P = .016). Conclusions Regional block reduced the analgesic requirements in the early postoperative period, while mexiletine combined with regional block reduced the total analgesic requirements during the next 5 postoperative days. Although chronic pain was not affected by these treatments late-abnormal sensation may be diminished by combination of these treatments.

A combination of gabapentin and local anaesthetics attenuates acute and late pain after abdominal hysterectomy

Background and objective: Gabapentin and local anaesthetics may decrease postoperative pain and analgesic needs. The aim of the study was to investigate the effect of the combination of these drugs on the analgesic needs as well as on acute and late pain after abdominal hysterectomy. Methods: Sixty patients undergoing abdominal hysterectomy were randomly assigned to receive postoperatively oral gabapentin 400 mg 6 hourly for 7 days plus continuous wound infusion of ropivacaine 0.75% for 30 h or placebo capsules identical to those of gabapentin for 7 days and continuous wound infusion of normal saline for 30 h. Morphine consumption (PCA) for 48 h, paracetamol 500 mg plus codeine 30 mg (Lonalgal® tablets) intake on days 3–7, visual analogue pain scores at rest and after cough during the first 7 postoperative days, the need for analgesics at home and the presence and incidence of pain after 1 month were recorded. Results: The treatment group consumed less cumulative morphine over the first 48 h (31 ± 13.2 mg vs. 50 ± 20.5 mg in controls, P < 0.001) and less Lonalgal® tablets on days 3–7 (z = 2.54, P = 0.011). The visual analogue score values at rest and after cough did not differ between the groups during the first 7 postoperative days. One month postoperatively, fewer patients in the treatment group experienced pain due to surgery than in the control group (17/27 vs. 21/24, P = 0.045). Conclusion: Gabapentin and continuous wound infusion with ropivacaine 0.75% decreased analgesic needs and late pain in patients undergoing abdominal hysterectomy.

Perioperative pregabalin for acute and chronic pain after abdominal hysterectomy or myomectomy: a randomised controlled trial.

Context The antiepileptics gabapentin and pregabalin are used as adjuvants to control postoperative pain. Objective The aim of the present study was to investigate the effect of perioperative administration of pregabalin on postoperative acute and chronic pain and analgesic requirements. Setting Department of Anaesthesiology, Aretaieio University Hospital, Athens, Greece. Patients Eighty patients scheduled for abdominal hysterectomy or myomectomy were randomly assigned to the pregabalin or to the control group. Intervention The pregabalin group received 150 mg of pregabalin 8-hourly, starting on the afternoon before surgery and continued until the fifth postoperative day. The control group was similarly treated, but received placebo capsules instead. Measurements Postoperative intravenous morphine and Lonalgal (30 mg codeine with 500 mg paracetamol) tablet consumption, visual analogue pain scores at rest and on coughing, sedation, anxiety, dizziness, ataxia, blurred vision and diplopia were recorded. One and 3 months postoperatively patients were interviewed for the presence of pain and analgesic needs due to surgery. Results The pregabalin-treated patients consumed less morphine during the first 48 h postoperatively (P = 0.0001). However, consumption of Lonalgal tablets and visual analogue scores for pain at rest and on coughing did not differ between the groups. No difference was found in sedation and anxiety scores between the patients who received placebo or pregabalin. Patients in the control group had lower incidences of dizziness (29 versus 58%, P = 0.015), ataxia (0 versus 18%, P = 0.011), blurred vision (6 versus 26%, P = 0.028) and diplopia (0 versus 16%, P = 0.023). Presence of pain, analgesic intake due to surgery and decreased or absent sensation around the wound did not differ between the groups 1 and 3 months postoperatively. Conclusion Pregabalin in the doses given decreased morphine requirements for the first 48 h postoperatively, but neither altered the analgesic requirements beyond 48 h nor had any effect on acute, late or chronic pain.

Pregabalin Vs. Opioids for the Treatment of Neuropathic Cancer Pain: A Prospective, Head-to-Head, Randomized, Open-Label Study

Neuropathic cancer pain (NCP) is a common manifestation of cancer and/or its treatment. Treatment following the WHO analgesic ladder provides relief for the majority of cancer pain patients; however, concern remains that opioids may be less efficacious for neuropathic pain (NP) compared with nociceptive pain, often necessitating the use of higher doses. Adjuvants, such as pregabalin, have shown to be efficacious for the treatment of NP, although data come mostly from noncancer studies. The comparative efficacy and safety of opioids versus adjuvants has not been studied for NCP. The aim of this study was to directly compare pregabalin versus a strong opioid for the treatment of NCP.

Academic anesthesiologists' views on the importance of the impact factor of scientific journals: a North American and European survey.

Purpose1b investigate the views of North American and European anesthesiologists on the value of the impact factor (IF).MethodFour hundred thirty-eight anesthesiologists in Canada, the United States of America (USA), and Europe were polled about the importance of the IF regarding hiring, promotions, funding of research and to express their personal views.ResultsIF of a candidate’s publications is a criterion in 38% of academic appointments in Canada and USA vs 81% in Europe (P < 0.000l). The importance of IF to obtain funding is greater in Europe (46%) than in North America (17%) (P < 0.0001). Twenty-three percent and 50% of Canadian and American anesthesiologists respectively believe that IF affects financial support (P = 0.0389). European anesthesiologists value the IF more than the North Americans (67% vs 31%,P < 0.000l). Forty-five percent, 67%, and 56% of the Canadian, American and European anesthesiologists respectively estimate that IF reflects journal quality. Sixty-four percent of anesthesiologists in North America vs 81 % in Europe (P = 0.0175) pursue to publish in high IF journals. Eighty-six percent, 85% and 90% of the Canadian, American and European anesthesiologists believe that the IF of ajournai can be manipulated. Finally, 79%, 67%, and 81% of the Canadian, American, and European anesthesiologists believe that IF should be improved but 33%, 35%, and 30% believe that it should be abandoned.ConclusionsIF for academic appointments and funding is more important in Europe than in North America. More than 50% of anesthesiologists agree that IF needs to be improved.ObjectifObtenir l’opinion des anesthésiologistes nord-américains et européens sur la valeur du facteur d’impact (FI).MéthodeQuatre cent trente-huit anesthésiologistes du Canada, des États-Unis et d’Europe ont répondu á un sondage sur l’importance du FI en regard de l’embauche, des promotions, du financement de la recherche et de leurs opinions personnelles.RésultatsLe FI des publications d’un candidat sert de critère dans 38 % des nominations au Canada et aux É-Uvs 81 % en Europe (P < 0,0001). L’importance du FI pour l’obtention de financement est plus marquée en Europe (46 %) quén Amérique du Nord (17 %) (P < 0,0001). Vingt-trois pour cent et 50 % des anesthésiologistes canadiens et américains, respectivement, croient que le FI influence le soutien financier (P = 0,0389). Les anesthésiologistes européens accordent plus de valeur au FI que les nord-américains (67 %vs 31 %,P < 0,0001). Quarante-cinq pour cent, 67 % et 56 % des anesthésiologistes canadiens, américains et européens, respectivement, estiment que le FI reflète la qualité de la revue. Soixante-quatre pour cent des anesthésiologistes d’Amérique du Nordvs 81 % d’Europe (P = 0,0175) cherchent á publier dans des revues á FI important. Quatrevingt-six pour cent, 85 % et 90 % des anesthésiologistes canadiens, américains et européens croient que le FI d’une revue peut être manipulée. Enfin, 79 %, 67 % et 81 % des anesthésiologistes canadiens, américains et européens pensent que le FI devrait être amélioré, mais 33 %, 35 % et 30 % voudraient qu’on l’abandonne.ConclusionsLe FI est plus important en Europe quén Amérique du Nord quant aux nominations universitaires et au financement de la recherche. Plus de 50 % des anesthésiologistes pensent que le FI devrait être amélioré.

Pharmacology of Sedation Agents and Reversal Agents

Sedation for gastrointestinal endoscopies is obtained by opioids, benzodiazepines, propofol, ketamine and/or droperidol. The pharmacokinetic profile of some sedatives/anesthetics renders them advantageous over others. Opioids, mainly pethidine and fentanyl, are the most popular. Though newer opioids provide a faster recovery, fentanyl is safe and advantageous due to its lower cost. Remifentanil, due to its pharmacokinetic profile (elimination half-life: 9 min), is advantageous for ambulatory patients, though it is not known whether the high cost compensates the benefits. Midazolam is the benzodiazepine of choice as it has a shorter duration of action and a better pharmacokinetic profile than diazepam. Propofol, an intravenous anesthetic, has become very popular for gastrointestinal endoscopies in sedative doses. The opioid and benzodiazepine antagonists, naloxone and flumazenil, are indicated only in particular circumstances, like deep sedation with threatening respiratory depression. Ketamine and droperidol are not popular agents for sedation in the modern endoscopic practice.

Systemic ondansetron antagonizes the sensory block produced by intrathecal lidocaine

In this prospective randomized, double-blind study, we investigated the effect of ondansetron on the lidocaine subarachnoid block. Fifty-four male patients scheduled for transurethral surgery under subarachnoid anesthesia received oral ondansetron 4 mg the evening before surgery and 4 mg IV 15 min before subarachnoid anesthesia (ondansetron group) or placebo (placebo group). Two milliliters of 5% hyperbaric lidocaine was administered intrathecally. Sensory block was assessed 20, 25, and 30 min and motor block 30, 60, and 90 min after lidocaine injection. In two patients in the control group and five in the ondansetron group, sensory block was not assessed for technical reasons. In the ondansetron group, sensory block values differed significantly over the 30-min period of assessments (P = 0.048). Fifteen, 20, 25, and 30 min after subarachnoid lidocaine, the level of sensory block was at T11, T12, T12, and T12 in the control group and T12, T12, T12, and L1 in the ondansetron group and differed between groups at 30 min (P = 0.019). Motor block did not differ between the two groups at any study time. We conclude that, under the conditions of our study, ondansetron antagonizes the sensory block produced by lidocaine.