Lucas J. Castro-Alves

Continuous catheter-infused local anesthetic for lower extremity revascularization

Dear Editor, We read with great interest the article of Shutze et al. in a recent issue of Vascular. The authors performed a retrospective case–control study on 153 patients undergoing lower extremity revascularization and concluded that the continuous catheter-infused local anesthetic group showed better cumulative average pain scores, better high pain scores on postoperative days 1–3, and better average pain scores on postoperative days 2–3. The authors should be congratulated for performing a well-designed study in an important topic (e.g. acute pain) in patients undergoing surgery. Moreover, the current emphasis on the need to reduce the use of postoperative opioids by using multimodal analgesic strategies makes the topic very relevant in perioperative medicine. Although the study of Shutze et al. was well conducted, there are some questions regarding the study that need to be clarified in order to determine the validity of the results. First, it is unclear if the authors standardized the intraoperative and postoperative analgesic interventions, and this can alter the study outcomes. Second, the authors evaluated multiple outcomes at multiple time points but did not adjust their analysis to avoid type I error. Last, it remains to be determined if continuous catheters improve analgesia outcomes when compared to a simple single shot peripheral nerve block. We would welcome some comments to address the aforementioned issues as they were not discussed by the authors. This would help to further validate the findings of this important study.

Sugamadex para prevenir náusea e vômito no pós-operatório?

. Oliveira Filho GR de, Garcia JHS, Goldschimidt R, et al. Fatores de previsão de hipotensão arterial precoce em anestesia subaracnóidea. Rev Bras Anestesiol. 2001;51: 298--304. . Pena SDJ, Bortolini MC. Pode a genética definir quem deve se beneficiar das cotas universitárias e demais ações afirmativas? Estud Av. 2004;18:31--50. . Turan A, Memiş D, Karamanlioğlu B, et al. Intravenous regional anesthesia using lidocaine and magnesium. Anesth Analg. 2005;100:1189--92. . Narang S, Dali JS, Agarwal M, et al. Evaluation of the efficacy of magnesium sulphate as an adjuvant to lignocaine for intravenous regional anaesthesia for upper limb surgery. Anaesth Intensive Care. 2008;36:840--4. . Galgon RE, Strube P, Heier J, et al. Magnesium sulfate with lidocaine for preventing propofol injection pain: a ranFabricio Tavares Mendonçaa,∗, Catia Sousa Goveiab

Thoracic epidural analgesia in donor hepatectomy: An analysis

We read with great interest the article of Koul et al. in a recent issue of Liver Transplantation. The authors performed a retrospective analysis of 104 patients who received thoracic epidural anesthesia (TEA) for right lobe donor hepatectomy and concluded that vigilant use of TEA appears to be safe during donor hepatectomy. The authors should be congratulated for performing a welldesigned study in an important topic (eg, acute pain strategy) in patients undergoing hepatectomy surgery. The current emphasis on the need to use regional anesthesia to improve postoperative outcomes makes the topic very relevant in perioperative medicine. Although the study of Koul et al. was well conducted, there are some questions regarding the study that need to be clarified by the authors. First, the small sample size does not allow the authors to exclude potential complications. The upper limit of the confidence interval for complications can still be on the vicinity of 10% even if no complications were observed. Second, it is unclear if the intraoperative analgesic regimen was standardized for all patients because this can influence some of the outcomes (eg, pain). Lastly, other analgesic strategies (eg, transversus abdominis plane block, long-acting local anesthetic formulations) have been shown to be effective to improve postoperative analgesia, and they do not have the same risk profile as thoracic epidurals. We would welcome some comments by the authors because this would help to further validate the findings of this important clinical trial.

Should ondansetron be used as a routine prophylaxis agent for postoperative nausea and vomiting

recent issue of the Journal. The authors performed a randomized controlled trial in 100 female patients who underwent laparoscopic cholecystectomy. A preinduction dose of 5 mg of dexamethasone plus intraoperative 30 ml/kg Ringer’s lactate solution reported a decrease in the occurrences of postoperative nausea and vomiting (PONV) and pain during the first 24 h after surgery as compared with 5 mg of dexamethasone alone. The authors should be commended for addressing an important topic in perioperative medicine that remains to be relevant to the practice of anesthesiologists [2]. Although the study of Ismail et al. was well designed and conducted, we have a few questions to further confirm the validity of the authors’ findings. First, it was interesting to note that the authors did not standardize the postoperative pain regimen, as this (particularly the use of multimodal agents) can significantly alter the primary outcome of the study [3,4]. In addition, it is not clear why the authors did not use ondansetron as a prophylactic agent because this drug has uncommon side effects (e.g., dizziness, headache) and has been recommended by recent PONV guidelines developed by panel members of the Society of Ambulatory Anesthesia [5]. The guidelines provide information about strategies that health care providers can implement to prevent and treat PONV in adults and children undergoing surgery. Lastly, it is unclear why the author did not use a patient-centered outcome to evaluate the clinical impact of their findings. We would welcome comments from the authors regarding the aforementioned issues to further strengthen the findings of this important study.

Pain outcomes and recovery after robotic laparoscopic transabdominal preperitoneal inguinal hernia repair

We read with great interest the article of Iraniha et al. in a recent issue of the journal [1]. The authors evaluated 82 consecutive patients undergoing robotic laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair and concluded that robotic-assisted TAPP inguinal hernia repair appears to be a technically feasible, with low chronic pain and high health-related quality of life in the long term. The authors should be congratulated for performing a welldesigned study in an important topic (e.g. quality of recovery) in patients undergoing robotic inguinal hernia repair [2, 3]. In addition, the current growth in robotic surgical procedures across different surgical specialties makes the topic timely in perioperative medicine [4, 5]. Although the study of Iraniha et al. was well conducted, there are some questions regarding the study that need to be clarified to determine the validity of the results. First, it is unclear if the authors standardized the intraoperative analgesic management for these patients as this can alter some of the studied outcomes [6]. Second, it is important to determine if he authors recruited the study patients consecutively or if the study results are vulnerable to selection bias. Finally, the data presentation in Table 1 would benefit from 95% confidence interval estimates rather than just mean scores, so the readers could have a better estimation of postoperative pain outcomes [1]. We would welcome some comments to address the aforementioned issues. This would help to further corroborate the findings of this important clinical study. Funding No funding was sought.

Postoperative Pain and Opioid Consumption in the Acute Postoperative Period after Laparoscopic Gastrectomy

To the Editor, We read with great interest the article of Na et al. in a recent issue of the journal. The authors performed a randomized study on 60 patients undergoing laparoscopic gastrectomy and concluded that intraoperative nefopam decreased postoperative pain and opioid consumption in the acute postoperative period after laparoscopic gastrectomy. The authors should be congratulated for performing a well-designed study in an important topic (e.g., acute pain) in patients undergoing gastrointestinal surgery. The current emphasis on the need to use multimodal analgesics to improve postsurgical pain and reduce opioid intake makes the study very relevant in perioperative medicine. Although the study of Na et al. was well conducted, there are some questions regarding the study that need to be clarified. First, it is not clear if any local anesthetics were used in the surgical incision as this can substantially alter the study outcomes. Secondly, the authors evaluated multiple primary and secondary outcomes at various postoperative time periods; however, they did not adjust their statistical analysis to prevent Type I errors. Lastly, the improvements in postoperative analgesia were not accompanied by improvements in opioid-related adverse outcomes. It remains to be determined, therefore, if the authors’ findings are clinically important. We would welcome some comments by the authors as this would help to further support the findings of this important clinical trial. Compliance with Ethical Standards

Does local factors alter discharge times after surgery

We read with great interest the article of Nishida et al. [1] in a recent issue of the journal. The authors evaluated patients < 18 years of age who underwent pediatric ambulatory surgery under general anesthesia and concluded that increased time spent in a hospital was affected by the type of regional block, surgery, and intraoperative fluid volume. The authors should be congratulated for performing a well-designed trial in an important topic in pediatric patients [2]. Moreover, current emphasis on fluid management and regional blocks as a part of enhanced recovery protocols makes the topic more relevant [3]. There are some questions that need to be clarified to determine the validity of the results. First, the authors arbitrarily defined prolonged stay as within 8 h at the end of anesthesia. It would be important to perform a sensitivity analysis to demonstrate if their results differ when other time cutoffs are utilized (e.g., 6 and 4 h). Second, it is unclear how frequent patients were assessed using the PADSS instrument and if the results can be affected by bias on unstandardized discharge evaluations. Last, most studies examining discharge times demonstrate < 3 h. One could argue that the discharge time in this study is driven by practice characteristics and therefore, poor generalizability to other centers.

Comment to: Pre-peritoneal local anaesthetic does not reduce post-operative pain in laparoscopic total extra-peritoneal inguinal hernia repair: double-blinded randomized controlled trial. Kulasegaran S, Rohan M, Pearless L, Hulme-Moir M

We read with great interest the article of Kulasegaranet al. [1] in a recent issue of the journal. The authors evaluated one hundred patients undergoing laparoscopic total preperitoneal hernia repair and concluded that pre-peritoneal local anaesthetic instillation does not offer any advantage in pain scores at 4 and 24 h after surgery. The authors should be congratulated for performing a well-designed study in an important topic (e.g. acute pain) in patients undergoing hernia repair [2, 3]. Moreover, local anesthetic instillation has become the current emphasis on many studies evaluating acute pain [4, 5]. Although the study of Kulasegaran et al. was well conducted, there are some concerns regarding the trial that needs to be clarified to determine the validity of the results. First, it is not clear if intraoperative analgesic administration was standardized using a specific criterion as this can alter the primary outcome [6]. Secondly, as fentanyl was used to treat postoperative pain, it is expected that patients were treated to keep low postoperative pain. One could argue that this is the reason for the lack of analgesic benefit demonstrated by the study. Lastly, the authors performed a presurgical versus post-surgical analysis in Table 2. It would be important to demonstrate a simple pain analysis by study groups since the P value for the preand post-analyses was almost statistically significant (P = 0.06). We would welcome some comments to address the aforementioned issues. This would help to further substantiate the findings of this important study.

Imbalances in intraoperative opioid administration can affect the study outcomes

We read with great interest the article of Tammachote et al. [1] in a recent issue of the journal. The authors performed a double-blinded randomized controlled trial in sixty-four osteoarthritic patients who underwent primary total knee arthroplasty and concluded that multimodal drug injection decreases pain level, reduces morphine consumption in the early postoperative period and prolongs the analgesic effect compared to single anesthetic drug. The authors should be congratulated for performing a well-designed study in an important topic (e.g., acute pain) in patients undergoing total knee arthroplasty [2, 3]. The current emphasis on the use of multimodal analgesics to enhance recovery across many orthopedic procedures makes the topic timely in perioperative medicine [4, 5]. Although the study of Tammachote et al. was well conducted, there are some questions regarding the study that need to be clarified. First, it is unclear if the intraoperative consumption of opioids was similar between the groups. It is important for the authors to clarify this aspect of the study since imbalances in intraoperative opioid administration can affect the study outcomes. Secondly, since most patients received spinal anesthesia, it is important to know if all patients received a standardized intrathecal anesthetic solution. The use of intrathecal opioids can also be an important confounding variable affecting the outcome of interest. We would welcome some comments to address our concerns as this would help to further support the findings of this important clinical trial.

Anesthesia Technique for Cosmetic Breast Augmentation: Does One Size Fit All?

We read with great interest the article of Pang et al. [1] in a recent issue of the journal. The authors evaluated 1200 patients undergoing simple cosmetic breast augmentation and concluded that a tumescent anesthetic technique can be used for immediate postoperative ambulation and a 4.7-min home discharge readiness without a decrease in anesthesia quality and safety. The authors should be congratulated for performing a well-designed study in an important topic (e.g., anesthesia technique) in patients undergoing ambulatory surgery [2, 3]. Moreover, current economic pressures in health care make the reduction in discharge times the emphasis of many studies across multiple surgical procedures in outpatient surgery [4, 5]. Although the study of Pang et al. was well conducted, there are some concerns regarding the study that need to be clarified to determine the validity of the results. First, although the authors state that their intention was not general anesthesia, the propofol dose used by Pang et al. is compatible with general anesthesia used in other studies [6, 7]. The fact that the authors did not use muscle relaxants or an airway device does disqualify their technique as general anesthesia. Secondly, the authors did not utilize a validated instrument to measure home readiness and this questions the validity of this outcome. Lastly, it is unclear whether the authors examined patients consecutively or whether patients were selected for this report. This needs to be clarified as this may represent selection bias and limit the generalizability of the study results. We would welcome some comments to address the aforementioned issues. This would help to further support the findings of this important investigation.