Geertrui Dewinter

Systemic Lidocaine Fails to Improve Postoperative Pain, But Reduces Time to Discharge Readiness in Patients Undergoing Laparoscopic Sterilization in Day-Case Surgery: A Double-Blind, Randomized, Placebo-Controlled Trial.

Background and Objectives Perioperative systemic lidocaine provides postoperative analgesia, decreases opioid consumption, and facilitates rehabilitation in abdominal surgery. We hypothesized that systemic lidocaine has analgesic effects in women undergoing day-case laparoscopic sterilization. Methods Eighty women were randomized in this prospective, double-blind trial to receive either lidocaine (intravenous bolus of 1.5 mg/kg at induction of anesthesia, followed by an infusion of 1.5 mg · kg−1 · h−1, which was continued until 30 minutes after arrival at the postanesthesia care unit [PACU]) or placebo. The primary end point was the proportion of patients with a numeric rating scale (NRS) of greater than 3, 30 minutes after arrival at the PACU. Secondary outcomes included total opioid consumption, postoperative pain scores, incidence of postoperative nausea and vomiting, and time to readiness for discharge. This clinical trial was registered (Eudra CT 2011-001315-31). Results Thirty minutes after PACU admission, the proportion of patients with an NRS score of greater than 3 did not differ between the groups (lidocaine group: 59% vs placebo group: 58%). The postoperative NRS for pain over the entire observation period was not significantly different between lidocaine and placebo groups (mean, 3.1 [SD, 0.7] vs 2.8 [SD, 0.6]; P = 0.4). Groups did not differ with respect to perioperative opioid consumption. Patients in the placebo group suffered significantly less from nausea (NRS: 0.1 [SD, 0.1] [placebo] vs 0.3 [SD, 0.1] [lidocaine]; P = 0.02) and required less postoperative nausea and vomiting rescue medication (1 patient in the placebo group vs 7 in the lidocaine group; P = 0.03). The time to meet hospital discharge criteria was significantly lower in the lidocaine group (median, 177 minutes [range, 96–408 minutes] vs 221 minutes [range, 121–420 minutes]; P = 0.02). The mean lidocaine plasma levels at the end of IV lidocaine infusion was 2.5 (SD, 1.1) &mgr;g/mL. Conclusions In laparoscopic sterilization, systemic lidocaine reduces time to readiness for hospital discharge.

Transversus abdominis plane block versus perioperative intravenous lidocaine versus patient-controlled intravenous morphine for postoperative pain control after laparoscopic colorectal surgery: study protocol for a prospective, randomized, double-blind controlled clinical trial

BackgroundDespite the laparoscopic approach becoming the standard in colorectal surgery, postoperative pain management for minimally invasive surgery is still mainly based on strategies that have been established for open surgical procedures. Patient-controlled epidural and intravenous analgesia are considered standard postoperative analgesia regimens in colorectal surgery. Epidural analgesia provides excellent analgesia, but is increasingly scrutinized in laparoscopic surgery since postoperative pain after the laparoscopic approach is significantly reduced. Moreover, epidural analgesia can be associated with numerous complications. Therefore, epidural analgesia is no longer recommended for the management of postoperative pain in laparoscopic colorectal surgery. Likewise, patient-controlled intravenous analgesia is subject to significant side effects. Given these important limitations of the traditional strategies for postoperative analgesia, effective and efficient alternatives in patients undergoing laparoscopic colorectal surgery are needed. Both the transversus abdominis plane block and systemically administered lidocaine have already been reported to effectively reduce pain after laparoscopic colorectal surgery. We hypothesize that the transversus abdominis plane block is superior to perioperative intravenous lidocaine.Methods/designOne hundred and twenty five patients undergoing laparoscopic colorectal surgery will be included in this prospective, randomized, double-blind controlled clinical trial. Patients will be randomly allocated to three different postoperative strategies: postoperative patient-controlled intravenous analgesia with morphine (control group, n = 25), a transversus abdominis plane block with ropivacaine 0.375% at the end of surgery plus postoperative patient-controlled intravenous analgesia with morphine (TAP group, n = 50), or perioperative intravenous lidocaine plus postoperative patient-controlled intravenous analgesia with morphine (LIDO group, n = 50). As the primary outcome parameter, we will evaluate the opioid consumption during the first 24 postoperative hours. Secondary endpoints include the Numeric Rating Scale, time to return of intestinal function, time to mobilization, inflammatory response, incidence of postoperative nausea and vomiting, length of hospital stay and postoperative morbidity as assessed with the Clavien-Dindo classification.DiscussionRecognizing the importance of a multimodal approach for perioperative pain management, we aim to investigate whether a transversus abdominis plane block delivers superior pain control in comparison to perioperative intravenous lidocaine and patient-controlled intravenous analgesia with morphine alone.Trial registrationEudraCT Identifier: 2014-001499-73; 31 July 2014.

Alizapride and ondansetron for the prevention of postoperative nausea and vomiting in patients undergoing laparoscopic gynaecological surgery: A double-blind, randomised, placebo-controlled noninferiority study.

BACKGROUND Postoperative nausea and vomiting (PONV) can be prevented. Alizapride is an established antiemetic that may be effective in this role. OBJECTIVE Our primary objective was to test the hypothesis that alizapride is noninferior to ondansetron for the prophylaxis of PONV. DESIGN A randomised, placebo-controlled, double-blinded noninferiority study. SETTING University hospitals of Leuven, Belgium, from November 2008 to July 2011. PATIENTS A total of 523 patients undergoing laparoscopic gynaecological surgery were included in the study. Reasons for exclusion were American Society of Anesthesiologists (ASA) greater than 2, hypersensitivity to the study medication, pregnancy, mental disorders, psychiatric illness or consumption of antiemetic drugs within 24 h before initiation of the study. INTERVENTION Patients received either alizapride 100 mg, ondansetron 4 mg or placebo intravenously 30 min before the end of surgery. MAIN OUTCOME MEASURES The main outcome measures included the incidences of postoperative nausea (PON) and postoperative vomiting (POV) during the stay in the postanaesthetic care unit (PACU), with noninferiority testing for alizapride versus ondansetron. The region of noninferiority was defined as a relative difference in incidence of 25%. Secondary outcome was the incidence of PONV in the PACU and after 24 h. RESULTS In the alizapride group, 32% of the patients experienced PON during the PACU stay, compared with 28% in the ondansetron group [relative risk 1.13, 90% confidence interval (CI) 0.87 to 1.46], exceeding the predefined margin of noninferiority. With respect to the incidences of POV during the PACU stay, 12.8% of the patients randomised to receive alizapride experienced POV, compared with 7.7% of who received ondansetron (relative risk 1.67, 90% CI 1.00 to 2.87). The incidences of PON and POV in the placebo group during the PACU stay were 34.2 and 9.8%, respectively. The 24-h incidences of PONV were lower than expected in this high-risk group of patients and were similar at 39.3, 36.8 and 31.5% in the placebo, alizapride and ondansetron groups, respectively (&khgr;2, P = 0.36). Patients treated with ondansetron required significantly less rescue medication than placebo-treated patients (P = 0.035). Due to the lower than expected incidences of PONV in this study, the power to conclude any noninferiority of alizapride was reduced to only 41%. CONCLUSION We found no evidence to support the noninferiority of alizapride 100 mg when compared with ondansetron 4 mg for the intraoperative prophylaxis of PONV. However, the lower than expected incidences of PONV reduced the power of this study to conclude noninferiority or confirm significant beneficial effects for either antiemetic for PON and POV during the PACU stay. TRIAL REGISTRATION Eudra CT 2008-004789-20

Simplified algorithm for the prevention of postoperative nausea and vomiting: a before-and-after study

Background: Poor adherence to guidelines aimed at reducing the incidence of postoperative nausea and vomiting (PONV) is well known. In a before‐and‐after study, we tested the effectiveness of a simplified algorithm for PONV prophylaxis on the incidence of PONV. Methods: In the first audit, we examined the adherence to our institutional guidelines for PONV prevention. In response to the results of this audit, we introduced a simplified algorithm for PONV prevention [female patients receiving triple prophylaxis (dexamethasone and ondansetron plus either a target‐controlled infusion with propofol or droperidol) and male patients receiving double prophylaxis, dexamethasone, and ondansetron]. The impact of the simplification of the PONV algorithm was evaluated in a second audit. In both audits, we reviewed the medical records of all adult patients undergoing elective non‐cardiac non‐day‐case surgery under general anaesthesia and being admitted to our post‐anaesthesia care unit during two arbitrarily chosen weeks. We assessed the incidence of nausea, vomiting, and PONV after 1 and 24 h, and the compliance with the departmental algorithm for PONV prophylaxis. Results: After simplification of the PONV algorithm, the overall incidence of PONV within 24 h after surgery was significantly lower than before the implementation of the simplified PONV algorithm (22% vs 33%, P=0.02). The PONV incidence within 1 h was comparable between the audits (11% vs 14%, P=0.45). The adherence to departmental guidelines for PONV prophylaxis was significantly higher after the implementation of the simplified PONV algorithm (46% vs 18%, P=0.0001). Conclusions: A simplified algorithm for PONV prophylaxis resulted in a significant reduction in the PONV incidence and better compliance with the PONV algorithm.

Systemic lidocaine fails to improve postoperative morphine consumption, postoperative recovery and quality of life in patients undergoing posterior spinal arthrodesis. A double-blind, randomized, placebo-controlled trial

Background. It is inconclusive whether the perioperative administration of systemic lidocaine provides effective postoperative analgesia and enhances recovery in major orthopaedic surgery. We hypothesised that in adolescent and adult patients undergoing posterior spinal arthrodesis, a perioperative lidocaine infusion would reduce opioid requirements during the first 24 postoperative h. Methods. 70 patients undergoing posterior arthrodesis were enrolled in this prospective, randomised, double-blind, placebo-controlled clinical trial. Patients received total i.v. anaesthesia with propofol and remifentanil and were randomized to an adjuvant therapy with either lidocaine [i.v.-bolus injection of 1.5 mg kg -1 at induction of anaesthesia, followed by an infusion of 1.5 mg kg -1 h -1 which was continued until six h after arrival at the post-anaesthesia care unit] or placebo (equal volumes of saline). Postoperative pain was treated with patient-controlled i.v. morphine. Primary endpoints of this study were morphine requirements in the first postoperative 24 h. Results. Systemic lidocaine did not decrease morphine requirements in the first 24 postoperative h [lidocaine-group: 48 (23) mg (mean( sd )) vs placebo-group: 51(19) mg, P  = 0.22]. Likewise, groups were not different with respect to the severity of postoperative pain, morphine consumption after 48 and 72 h, incidence of postoperative nausea and vomiting, perioperative inflammation, time to recovery of intestinal function, hospital length of stay, and quality of life (assessed preoperatively and one month postoperatively using the SF-12 physical and mental composite scores). Conclusions. In our study, systemic lidocaine had no analgesic benefits in posterior arthrodesis when added to an opioid-based anaesthetic regimen. Clinical trial registration. Eudra CT 2012-005264-98.