David Olsfanger

Residual pneumoperitoneum: a cause of postoperative pain after laparoscopic cholecystectomy.

After laparoscopic cholecystectomy, residual gas is inevitably retained in the peritoneal cavity. An active attempt is not always made to remove it. Using a double-blind prospective protocol in 40 healthy patients, we evaluated the effect of residual pneumoperitoneum on post-laparoscopic cholecystectomy pain intensity. On completion of surgery, prior to removal of the surgical instruments, the patients were randomly divided into two groups: in the active aspiration (AA) group an active attempt was made to remove as much gas as possible from the peritoneal cavity, while in the nonactive aspiration (NAA) group no such effort was made. Postoperative pain was assessed hourly over a 4-h period with a visual analog scale (VAS) and a patient-controlled analgesia (PCA) device. During the first postoperative hour, the NAA patients made significantly (P < 0.05) more demands (mean ± SD) for morphine than those in the AA group (31.3 ± 26.2 VS 15.3 ± 15.7) and also received a borderline significantly (P = 0.056) larger dose (mean ± SD) of PCA morphine (3.9 ± 1.9 mg VS 2.7 ± 1.3 mg). The VAS scores (mean ± SD) over the 4-h study period were similar in both groups, being high during the first postoperative hour (AA = 5.1 ± 2.1 VS NAA = 6.1 ± 2.2) and then decreasing. We conclude that residual pneumoperitoneum is a contributing factor in the etiology of postoperative pain after laparoscopic cholecystectomy.

The opioid-sparing effect of diclofenac sodium in outpatient extracorporeal shock wave lithotripsy (ESWL)

STUDY OBJECTIVE To evaluate the opioid-sparing and analgesic effect of diclofenac sodium in ambulatory nonimmersion extracorporeal shock wave lithotripsy (ESWL). DESIGN Randomized, double-blind, placebo-controlled study. SETTING Large referral hospital. PATIENTS Twenty-seven ASA physical status I and II patients with upper renal tract nephrolithiasis. INTERVENTIONS ESWL was performed with a sedative-analgesic technique. Diclofenac sodium 75 mg or an equal volume of saline was given intramuscularly 45 minutes prior to the procedure. Fentanyl and midazolam were added to maintain adequate sedation and analgesia. MEASUREMENTS AND MAIN RESULTS Demographically, both groups were comparable. In the diclofenac sodium group, heart rate was slightly higher, treatment time was shorter, more shock waves were administered (p < 0.02), and less fentanyl was required (p < 0.02). Mean arterial pressure was lower and arterial oxygen saturation by pulse oximeter was higher in the diclofenac sodium group. There were no differences between the groups in voltage, stone size, fragmentation, dose of midazolam administered, or overall assessment by both the doctors and patients. CONCLUSIONS Patients administered diclofenac sodium received a greater number of shock waves, required less fentanyl, and showed a marginal improvement in hemodynamic stability and oxygenation during ambulatory nonimmersion ESWL.

The induction, maintenance, and recovery characteristics of spinal versus general anesthesia in elderly patients

STUDY OBJECTIVE To compare the induction and recovery profiles of three combinations of general anesthesia when used as an alternative to spinal anesthesia for elderly patients. DESIGN Randomized, prospective, open-label study. SETTING Large referral hospital. PATIENTS 100 [ASA physical status I, II, and III] patients over 60 years of age undergoing brief transurethral surgery. INTERVENTIONS In Groups Propofol-Propofol (P-P), Propofol-Isoflurane (P-I), and Propofol-Desflurane (P-D), anesthesia was induced with fentanyl (1 to 2 micrograms/kg i.v.) and propofol (1.0 to 2.0 mg/kg i.v.) and maintained with 70% nitrous oxide in oxygen and either a propofol infusion (75 to 150 micrograms/kg/min) or isoflurane (end-tidal 0.7% to 1.2%) or desflurane (end-tidal 1% to 4%), respectively. After induction, a laryngeal mask airway was placed and spontaneous ventilation was maintained. In Group Spinal (S), 1.5 ml 4% lidocaine (60 mg), in an equal volume of 10% dextrose, was administered intrathecally. MEASUREMENTS AND MAIN RESULTS Induction and recovery characteristics were compared. Induction with propofol was technically easier and significantly (medp < 0.0001) faster (4.6 +/- 1.7 min, 4.7 +/- 2.2 min, and 3.8 +/- 1.4 min for Groups P-P, P-I, and P-D, respectively) than induction of spinal anesthesia (9.3 +/- 3.4 min). During the induction period, mean arterial blood pressure and heart rate were significantly higher in Group S. Emergence, extubation, and orientation times were similar among the general anesthesia treatment groups. In Group S, patient-generated pain scores were lower (p < 0.05) and recovery room admission longer (p < 0.001). Time to return to baseline digit symbol substitution test (DSST) scores was marginally improved in Groups P-P and P-D when compared to Group P-I. Postoperative nausea, sleepiness, anxiety, and coordination were unaffected by the treatment modality. CONCLUSION General anesthesia with propofol and desflurane facilitates shorter induction and recovery times without adversely affecting patient comfort. Therefore, this technique may be preferable to spinal anesthesia for elderly patients undergoing short transurethral surgical procedures.

Ketorolac does not decrease postoperative pain in elderly men after transvesical prostatectomy

PurposeTo assess the postoperative analgesic efficacy and morphine-sparing effect of ketorolac in elderly patients.MethodsSixty ASA-physical status I to III men, aged 60–88 yr, undergoing transvesical prostatectomy were studied according to a randomized, placebo controlled, double-blind study protocol. A standard general anaesthetic was administered. Thirty minutes before concluding the surgical procedure either ketorolac 60 mg or an equal volume of saline was administered, im. Postoperative pain was assessed hourly for six hours using a 100 mm visual analog score (VAS) and a patient-controlled analgesia (PCA) device.ResultsHourly PCA-demands, actual morphine delivered, and patient generated VAS pain scores were unaffected by the treatment modality. On conclusion of the study the total PCA morphine delivered was 11.9 mg ± 1.38 and 10.8 mg ± 1.52 for the saline and ketorolac groups, respectively.ConclusionThe intraoperative administration of ketorolac, 60 mg, im, was not associated with postoperative morphinesparing or improved analgesia in this elderly population.RésuméObjectifEvaluer l’efficacité analgésique postopératoire et l’effet d’épargne du kétorolac sur la morphine chez les patients âgés.MéthodesSoixante patients du sexe masculin ASA I à III âgés de 60 à 88 ans, soumis à une prostatectomie transvésicale ont fait l’objet d’une étude aléatoire, contrôlée avec placebo et en double aveugle. Une anesthésie générale standardisée a été administrée. Trente minutes avant la fin de l’intervention, du kétorolac 60 mg ou une volume égal de soluté physiologique ont été administré i.m. La douleur postopératoire a été évaluée à toutes les heures pour six heures sur une échelle visuelle analogique de 100 mm (EVA) et à l’aide d’un dispositif d’analgésie autocontrôlée (PCA).RésultaisLa demande horaire sur PCA. la quantité de morphine administrée et le score sur l’EVA fourni par le patient n’ont pas été affectés par le mode de traitement. A la fin de l’étude, la morphine totale administrée était de 11,9 mg ± 1,38 et de 10,8 mg ± 1,52 respectivement pour le groupe soluté physiologique et pour le groupe kétorolac.ConclusionL’administration peropératoire de kélorolac 60 mg im n’est pas associée à un effet d’épargne sur la morphine ou à une amélioration de l’analgésie chez ces patients âgés.

Delivery room analgesia: an analysis of maternal satisfaction

On the first post-partum day, 324 mothers completed a questionnaire designed to assess maternal perception of delivery room experience. Antenatal pain expectation, actual pain severity, analgesia received, as well as maternal satisfaction and choice of analgesia for future deliveries were recorded. Forty-five percent of primiparae and 36% of multiparae reported that they anticipated suffering extreme pain during delivery. The incidence of unbearable pain was similar among patients who received no analgesia or intravenous pethidine but significantly (P<0.0001) higher when compared to epidural analgesia. During the first stage of labour, continuous epidural analgesia was associated with severe or unbearable pain in 51% and 58% of primiparae and multiparae, respectively. The incidence of severe or unbearable pain during the second stage of labour was 43% and 46% for primiparae and multiparae, respectively. Patient satisfaction with epidural analgesia did not correlate with subjective pain scores. Among mothers who received continuous epidural analgesia 70% described their experience as good or excellent and 65.8% indicated that they would request similar pain relief in the future. Despite advances in obstetric analgesia, women anticipate and actually experience severe pain during childbirth. However, due to psychological and cultural factors, as well as possible post-partum euphoria, satisfaction with the delivery room experience is high.

Alternating patient position following the induction of obstetric epidural analgesia does not affect local anaesthetic spread

To assess the influence of gravity on epidural-induced sensory blockade during the first stage of labour, 60 parturients were recruited to a randomized, controlled, single-blinded study. In all cases an epidural catheter was placed with the patient in the left lateral position. Thereafter, patients were randomized to one of three groups. In group supine (S), the epidural injection was performed in the supine position with a 15-20 degrees right flank elevation and the patient remained supine. In group left (L) patients remained in the left lateral position for 10 min after injection. In group left and right (L+R) patients remained in the left lateral position for 5 min and then assumed the right lateral position for 5 min. Thereafter, in groups L and L+R patients lay supine with a 15-20 degrees right flank elevation. All patients received 50 microg fentanyl in 10 ml of 0.125% bupivacaine. Ten minutes after injection loss of pinprick and temperature sensation were assessed and pain scores measured. Height of sensory deficit 10 min after injection and after maximal blockade were unaffected by patient position. In all cases maximal blockade reached T8 or higher. Time to maximal block was 14.7 +/- 2.3 min, 14.1 +/- 1.6 min and 13.9 +/- 1.5 min for groups L, L+R and S respectively. After maximal blockade, pain scores were significantly (P<0.0001) decreased in all groups, with no differences between them. We conclude that position immediately following local anaesthetic drug administration has little effect on onset and distribution of epidural analgesia.

Effect of spinal versus general anesthesia on bladder compliance and intraabdominal pressure during transurethral procedures

STUDY OBJECTIVE To evaluate the influence of spinal versus general anesthesia on bladder compliance and intraabdominal pressure in elderly males undergoing elective transurethral resection of the prostate. DESIGN Prospective, randomized, open-label study. SETTING Teaching hospital. PATIENTS 21 ASA physical status I, II, and III patients at least 18 years of age, undergoing transurethral surgery. INTERVENTIONS According to a computer-generated randomization schedule, patients were allocated to one of two groups. In Group Spinal (S), 10 mg of hyperbaric tetracaine was administered intrathecally. In Group General Anesthesia (GA), patients received, fentanyl intravenous (i.v. 1 to 2 micrograms/kg and propofol i.v. 1.0 to 2.0 mg/kg for induction of anesthesia. Thereafter, a laryngeal mask airway was inserted and, with spontaneous ventilation, anesthesia was maintained by administering isoflurane (end-tidal 0.7% to 1.2%) and 70% nitrous oxide (N2O) in oxygen. Intraabdominal pressure and bladder compliance were recorded prior to the induction of anesthesia and immediately before the onset of the surgical procedure. MEASUREMENTS AND MAIN RESULTS The two groups were demographically comparable. In Group S, mean bladder compliance was significantly (p = 0.003) higher and mean intraabdominal pressure significantly lower (p = 0.007) when compared to baseline preanesthetic values. In Group GA, mean intraabdominal pressure significantly (p = 0.006) decreased when compared to baseline preanesthetic recordings. Following the induction of general anesthesia, a small change in bladder compliance was noted. However, statistical significance was not reached. Data were analyzed and compared using Students t-test (p < 0.05 was considered statistically significant). CONCLUSION Both spinal and general anesthesia induced a significant decrease in intraabdominal pressure. While both techniques were associated with an increase in bladder compliance, statistical significance was demonstrated only in the spinal anesthesia treatment group.

Anaesthesia for caesarean delivery: low-dose epidural bupivacaine plus fentanyl.

To determine the acceptability of epidural bupivacaine-induced sixth thoracic (T6) sensory blockade and the analgesic efficacy of epidural fentanyl 50 microg, 24 parturients undergoing elective caesarean section were given a test dose of lidocaine 60 mg plus epinephrine followed by 10 ml of either 0.5 % bupivacaine (control group) or 0.5 % bupivacaine plus 50 microg fentanyl (fentanyl group) in a randomized double-blind manner. Fifteen minutes later loss of pinprick sensation was determined. Additional local anaesthetic was titrated to achieve T6 sensory blockade. Intraoperative pain intensity was assessed using a 10 cm visual analogue scale (VAS); total dose of bupivacaine and need for i.v. rescue fentanyl were recorded. The incidence of intraoperative respiratory depression, nausea, vomiting and pruritus were documented. Mean (+/- SD) volume of bupivacaine was 14.1 +/- 3.05 ml versus 13 +/- 1.48 ml for the control and fentanyl groups respectively. The most severe intraoperative VAS for pain was significantly (P=0.023) lower in the fentanyl group (0.4 +/- 0.08 cm) than in the control group (3.1 +/- 0.3 cm). Rescue fentanyl was administered in 40% and 0% of patients in the control and fentanyl groups respectively. The incidence of side-effects was unaffected by treatment group. Apgar scores were similar in the two groups. We conclude that following administration of 10-15 ml 0.5% bupivacaine plus fentanyl 50 microg, T6 sensory blockade is associated with good intraoperative analgesia without obvious maternal or neonatal respiratory depression.

Anaesthesia for Transthoracic Endoscopic Sympathectomy in the Treatment of Upper Limb Hyperhidrosis

Renewed interest has been shown in transthoracic endoscopic sympathectomy (TES) for the treatment of upper limb hyperhidrosis. We review our experience and discuss the anaesthetic technique and perioperative problems encountered in 58 patients undergoing TES for hyperhidrosis. Patients were monitored for arterial pressure, heart rate, ECG, pulse oximetry (SpO2), end-tidal carbon dioxide concentration, peak inspired airway pressure and skin temperature. General anaesthesia, with a double-lumen endobronchial tube, enabled the lungs to be collapsed alternately, thereby ensuring easy and clear access to the sympathetic chain. Controlled ventilation with 100% inspired oxygen was necessary to obviate hypoxaemia. In two patients, severe hypotension and bradycardia occurred during insufflation of carbon dioxide into the chest cavity. Four patients required underwater drainage of the pleural cavity for treatment of pneumothorax or haemothorax. The success and safety of the procedure depends on a scrupulous anaesthetic technique.