Robert Jedeikin

The Analgesic Efficacy of Patient-controlled Ropivacaine Instillation After Cesarean Delivery

To assess the efficacy and safety of wound instillation of ropivacaine, when administered via a patient-controlled elastometric pump, 50 term parturients undergoing cesarean delivery were enrolled into this prospective, placebo-controlled, double-blinded study. In all cases, a standard spinal anesthetic was administered. After the surgery, a multihole 20-gauge epidural catheter (B. Braun, Melsungen, Germany) was placed above the fascia such that the tip was sited at the point that demarcated 50% of the length of the surgical wound. Thereafter, the catheter was connected to the elastometric pump. According to a computer-generated randomization schedule, the pump was filled with either ropivacaine 0.2% (Ropivacaine Group) or an equal volume of sterile water (Control Group). Postoperatively, patient-controlled analgesia was administered via the elastometric pump. During the first 6 postoperative hours, a coinvestigator administered “rescue” morphine (2 mg, IV). Thereafter, “rescue” dipyrone (1 g) was administered on patient request. In a subset of 10 patients, blood ropivacaine levels were assessed. Compared with the Control Group, significantly fewer patients in the Ropivacaine Group received “rescue” morphine (92% vs 48%, respectively) (P < 0.01). The total “rescue” morphine administered during the first 6 postoperative hours was 2 ± 3 mg vs 10 ± 5 mg (P < 0.01) for the Ropivacaine and Control Groups, respectively. Patient-generated resting pain scores were similar between the groups. However, pain scores generated after coughing and leg raise were significantly (P < 0.04) less in the Ropivacaine Group. More patients in the Ropivacaine Group than in the Control Group described their analgesia as good or excellent. In the subset of patients (n = 10) studied, unbound ropivacaine blood levels were below the toxic threshold (600 ng/mL). However, blood ropivacaine accumulation was noted. All patients stated that the elastometric pump was easy to use. Ropivacaine wound instillation via an elastometric pump is a simple technique that provides safe and effective analgesia after cesarean delivery. Implications Ropivacaine wound instillation via an elastometric pump is a simple technique that provides safe and effective analgesia after cesarean delivery.

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.

Bupivacaine wound instillation via an electronic patient-controlled analgesia device and a double-catheter system does not decrease postoperative pain or opioid requirements after major abdominal surgery.

To assess the analgesic efficacy of patient-controlled bupivacaine wound instillation, 50 patients undergoing major intraabdominal surgery were enrolled into this prospective, placebo-controlled, double-blinded study. In all cases, a standard general anesthetic was administered. On completion of surgery, two multihole 20-gauge epidural catheters were tunneled through the proximal and distal apices of the surgical wound and placed above the fascia such that the tips were at the margin of the first and second thirds of the surgical wound, respectively. Postoperatively, a patient-controlled analgesia (PCA) device was connected to the instillation system. Either bupivacaine 0.25% (Bupivacaine Group) or an equal volume of sterile water (Control Group) was administered. The PCA device was programmed to deliver 9.0 mL with a 60-min lockout interval and no basal infusion. During the first six postoperative hours, a coinvestigator administered “rescue” morphine (2 mg IV). Thereafter, meperidine 1 mg/kg IM was administered on patient request for additional analgesia. Instillation attempts and actual number of injections were similar between the groups. The mean number of pump infusions and the mean “rescue” opioid requirements during the 24-h study period were similar between the groups. The total “rescue” morphine administered during the first six postoperative hours was 16 ± 17 mg vs 18 ± 14 mg for the Bupivacaine and Control Groups, respectively. The total meperidine administered during this period was 1.6 ± 1.4 mg/kg and 2 ± 1.2 mg/kg for the Bupivacaine and Control Groups, respectively. Preoperatively, hourly for the first six postoperative hours, and on removal of the instillation catheter, patient-generated visual analog scales for pain were similar at rest, on coughing, and after leg raise. In conclusion, bupivacaine wound instillation via an electronic PCA device and a double-catheter system does not decrease postoperative opioid requirements after surgery performed through a midline incision. Implications After major abdominal surgery performed through a 20-cm incision, repeated 0.25% bupivacaine wound instillation via an electronic patient-controlled analgesia device and a double-catheter system does not decrease postoperative pain or opioid requirements.

The analgesic efficacy of patient-controlled bupivacaine wound instillation after total abdominal hysterectomy with bilateral salpingo-oophorectomy.

To assess the effect of local anesthetic wound instillation on visceral and somatic pain, we studied 36 patients undergoing total abdominal hysterectomy and bilateral salpingo-oophorectomy. A standard general anesthetic was administered. On completion of the operation, a multiorifice 20-gauge epidural catheter was placed above the superficial abdominal fascia such that the tip was at the midpoint of the surgical wound. After surgery, either bupivacaine 0.25% (Bupivacaine group) or sterile water (Control group) was administered via a patient-controlled analgesia device programmed to deliver 9.0 mL with a 60-min lockout interval. During the first 6 h after surgery, rescue IV morphine (2 mg) was administered every 10 min until a visual analog scale score of <30 mm was achieved. Thereafter, on patient request, rescue meperidine 1 mg/kg IM was administered. When compared with the Control group, significantly (P < 0.001) less rescue analgesia was administered to patients in the Bupivacaine group. Rescue morphine administered during the first 6 h after surgery was 6 ± 4 mg versus 12 ± 6 mg (P < 0.001) for the Bupivacaine and Control groups, respectively. Rescue meperidine administered was 29 ± 37 mg versus 95 ± 36 mg (P < 0.001) for the Bupivacaine and Control groups, respectively. Nausea and antiemetic drug administration was significantly (P = 0.003) less in the Bupivacaine group. Pain scores were similar between the groups. Patient satisfaction was significantly (P = 0.04) more in the Bupivacaine group. We conclude that bupivacaine wound instillation decreases opioid requirements and nausea in the first 24 h after total abdominal hysterectomy with bilateral salpingo-oophorectomy.

The effect of tourniquet application, tranexamic acid, and desmopressin on the procoagulant and fibrinolytic systems during total knee replacement

STUDY OBJECTIVE To assess the influence of tourniquet inflation-deflation as well as desmopressin and tranexamic acid (TA) administration on prothrombin fragment 1.2, fibrinogen, plasmin antiplasmin complex, and D-dimer concentrations during total knee replacement. DESIGN Randomized, placebo-controlled study. SETTING Large referral hospital. PATIENTS 30 ASA physical status I, II, and III patients undergoing total knee replacement. INTERVENTIONS Patients were randomized to one of three treatment groups. Patients received either tranexamic acid, desmopressin, or an equal volume of saline, intravenously. MEASUREMENTS AND MAIN RESULTS Cubital blood was drawn immediately before induction of anesthesia, 1 hour after tourniquet application, and 2 and 15 minutes after tourniquet deflation. Fibrinogen and D-dimer levels were measured using the Clauss Method and latex agglutination, respectively. Plasmin antiplasmin complex and prothrombin fragment 1.2 levels were measured by enzyme-linked immunosorbent assay (ELISA). All assays were performed in duplicate, and intra-assay variability was documented. No statistically significant difference in fibrinogen, D-dimer, plasmin antiplasmin complex, or prothrombin fragment 1.2 levels was demonstrated among the groups. Similarly, within each group there were no statistically significant differences in the variables studied. However, despite the lack of statistical significance, when compared with their levels during tourniquet application, an increase in D-dimer and plasmin antiplasmin complex levels was observed in all three groups at 2 and 15 minutes after tourniquet release. In contrast, no increase in prothrombin fragment 1.2 generation was noted. Significantly more allogeneic blood was transfused in the Control and Desmopressin Groups when compared with the tranexamic acid group (p< 0.02). CONCLUSIONS No evidence of tourniquet-induced fibrinolysis or thrombin generation was demonstrated in the systemic circulation. Desmopressin and tranexamic acid had no significant effect on the variables measured.

A comparative study of the postoperative allogeneic blood-sparing effect of tranexamic acid versus acute normovolemic hemodilution after total knee replacement

UNLABELLED Both acute normovolemic hemodilution (NVHD) and tranexamic acid (TA) are potentially useful allogeneic blood conservation strategies after total knee replacement. However, the relative efficacy of these blood-sparing techniques is unknown. Therefore, to compare the postoperative allogeneic blood sparing of NVHD and TA after total knee replacement, we investigated 40 patients in a prospective, single-blinded study protocol. In Group TA, 30 min before deflating the limb tourniquet, an IV infusion of TA, 15 mg/kg, was administered over a 30-min period. Thereafter, a constant IV infusion of 10 mg x kg(-1) x hr(-1) was administered until 12 h after deflation of the limb tourniquet. Before induction of anesthesia, NVHD patients were bled to a target hematocrit of approximately 28%. Intravascular blood volume was maintained with lactated Ringers solution. All autologous blood was transfused at the end of the surgery. Postoperatively, hematocrit was measured daily. In all cases, a hematocrit <27% was the postoperative transfusion trigger. Before discharge, deep vein thrombosis was excluded by Echo Doppler. Three months after surgery, the incidence of delayed thromboembolic events was assessed. The two groups were demographically comparable. In Group NVHD, 843 mL+/-289 of autologous blood was removed. Despite autologous blood transfusion, during the early postoperative period and until the third postoperative day, the NVHD group had significantly (P < 0.01) lower mean hematocrits when compared with the TA group. Thereafter, because of a significantly (P < 0.0008) greater allogeneic blood requirement in the NVHD group, no statistically significant difference in mean hematocrit recordings was noted among the groups. Blood accumulation in the surgical drain 12 h postoperatively, was significantly (P < 0.0008) higher in the NVHD group (259 mL+/-156) when compared with the TA group (110 mL+/-62). Significantly (P < 0.0008) more allogeneic blood was transfused in the NVHD group (19 U/13 patients) when compared with the TA group (2 U/2 patients). No abnormal Echo Doppler studies were reported. During the 3-mo follow-up period, a deep vein thrombosis and pulmonary embolus were documented in one patient in the NVHD group. We conclude that perioperative hemodynamic stability and allogeneic blood sparing is superior after tranexamic acid administration when compared with normovolemic hemodilution. IMPLICATIONS For total knee replacement, when compared with normovolemic hemodilution, tranexamic acid administration is associated with superior perioperative hemodynamic stability and allogeneic blood sparing.

Fast-track eligibility of geriatric patients undergoing short urologic surgery procedures.

Our primary objective was to assess the feasibility of geriatric patients (>65 yr) bypassing the postanesthesia care unit (PACU) after ambulatory surgery. A secondary objective was to compare recovery profiles when using three different maintenance anesthetics. Ninety ASA physical status I–III consenting outpatients (>65 yr) undergoing short urologic procedures were randomly assigned to one of three anesthetic treatment groups. After a standardized induction with fentanyl and propofol, anesthesia was maintained with propofol (75–150 &mgr;g · kg−1 · min−1 IV), isoflurane (0.7%–1.2% end tidal), or desflurane (3%–6% end tidal), in combination with nitrous oxide 70% in oxygen. In all three groups, the primary anesthetic was titrated to maintain an electroencephalographic-bispectral index value of 60–65. Recovery times, postanesthesia recovery scores, and therapeutic interventions in the PACU were recorded. Although emergence times were similar in the three groups, the time to achieve a fast-track discharge score of 14 was significantly shorter in patients receiving desflurane compared with propofol and isoflurane (22 ± 23 vs 33 ± 25 and 44 ± 36 min, respectively). On arrival in the PACU, a significantly larger percentage of patients receiving desflurane were judged to be fast-track eligible compared with those receiving either isoflurane and propofol (73% vs 43% and 44%, respectively). The number of therapeutic interventions in the PACU was also significantly larger in the Isoflurane group when compared with the Propofol and Desflurane groups (21 vs 11 and 7, respectively). In conclusion, use of desflurane for maintenance of anesthesia should facilitate PACU bypass (“fast-tracking”) of geriatric patients undergoing short urologic procedures.

Spinal anesthesia in 62 premature, former-premature or young infants--technical aspects and pitfalls.

PurposeTo highlight technical aspects and pitfalls of spinal anesthesia (SA) in infants.MethodsThe medical history and perioperative course of all infants who underwent SA over a 28-month period were collected (retrospectively in the first 20).ResultsSixty-two infants underwent surgery under SA. Fifty-five were premature and former-premature, postconceptional age 43.3 ± 5.0 weeks, weight 3261 ± 1243 g. Of these, 21 had co-existing disease: cerebral (six), cardiac (nine), pulmonary (11) and urological (six). Hyperbaric tetracaine or bupivacaine 1 mg·kg-1 with adrenaline was administered. Four infants (three premature) required N2O supplementation and three needed general anesthesia. The supplementation rate was similar or lower than in previous studies. Postoperatively, all seven were shown to have lower limb motor and sensory blockade. Complications in premature patients included intraoperative hypoxemia (two), apnea (two) and bradycardia (one). Postoperative complications included bradycardia (three), hypoxemia (one) and apnea and hypoxemia (one). The postoperative complication rate was similar to previous studies.ConclusionSuccessful SA in infants depends on close attention to preoperative assessment, appropriate patient positioning during and after lumbar puncture, drug dosing and intra-and postoperative cardiorespiratory monitoring. A relatively high dose of hyperbaric solution of tetracaine or bupivacaine with adrenaline should be administered.RésuméObjectifMontrer les aspects techniques et les pièges de la rachianesthésie (RA) chez les enfants.MéthodeNous avons noté les antécédents médicaux et le déroulement périopératoire pour tous les enfants qui ont eu une RA au cours de 28 mois (de façon rétrospective pour les 20 premiers).RésultatsDes 62 enfants qui ont subi une opération avec RA, 55 étaient prématurés ou anciens prématurés. L’âge post-fécondation était de 43,3 ±5,0 semaines, le poids de 3261 ± 1243 g. De ces 55 enfants, 21 avaient une maladie concomitante: cérébrale (six), cardiaque (neuf), pulmonaire (onze) et urologique (six). Une dose de 1 mg·kg-1 de tétracaïne ou de bupivacaïne hyperbare, combinée à de l’épinéphrine, a été administrée. Quatre enfants (trois prématurés) ont eu besoin d’un apport complémentaire de N2O et trois, d’anesthésie générale. La fréquence d’administration d’un supplément était comparable ou plus faible que celle d’études antérieures. Les sept enfants ont tous présenté un blocage moteur et sensoriel postopératoire des membres inférieurs. Les complications peropératoires notées chez les patients prématurés sont l’hypoxémie (deux), l’apnée (deux) et la bradycardie (un). Les complications postopératoires sont la bradycardie (trois), l’hypoxémie (un) et, l’apnée et l’hypoxémie (un). Ces dernières se comparent à celles d’études antérieures.ConclusionLe succès de la RA chez un enfant dépend de la qualité de l’évaluation préopératoire, de l’installation appropriée de l’enfant pendant et après la ponction lombaire, du dosage médicamenteux et du monitorage cardio-respiratoire peropératoire et postopératoire. Une dose relativement élevée de tétracaïne ou de bupivacaïne hyperbare, combinée à de l’épinéphrine, devrait être administrée.

Observations on the safety and efficacy of surgical decompression for lumbar spinal stenosis in geriatric patients

Abstract. This retrospective study examines the results of surgical decompression of the lumbar spinal canal in 122 geriatric patients (age range 75–89 years) treated under general anesthesia by the same surgeon between the years 1990 and 1999. Patient demographics, perioperative complications, pain profiles before surgery and at the time of data collection (December 2000), as well as overall mortality were recorded. One hundred and twenty-two patients were studied. The average age at the time of surgery was 78.8 years (range 75–89 years). No perioperative deaths were recorded. The mean time elapsed from surgery until patient follow-up was 45.7 months (range 12–119 months). Fourteen patients had died at the time of patient follow-up (December 2000). When compared to pain experienced before surgery, at the time of the interview a significant (P<0.0001) improvement in low-back and radicular pain as well as in the ability to perform daily activities (dressing, washing, getting out of bed and walking) was described. We conclude that, for geriatric patients rated as physical status I-II (>75 years) under the American Society of Anesthesiologists (ASA) classification, surgical release of lumbar spinal stenosis is a safe and effective treatment option. However, the suitability of ASA III patients requires further investigation.

Video-assisted transthoracic sympathectomy in the treatment of primary hyperhidrosis: friend or foe?

The authors hypothesize that palmar hyperhidrosis is a systemic manifestation of abnormal sudomotor function; consequently, thoracoscopic sympathectomy to alleviate symptoms in the hands may result in heat dissipation because sweating is transferred to other sites. To investigate this phenomenon and to determine whether it adversely affects patient satisfaction, a standard questionnaire was administered to 626 patients who underwent sympathectomy at a university-associated public hospital between 1991 and 1998; only patients treated at least 6 months before questionnaire distribution were included in the study. Replies were received from 336 (53.7%) individuals. The surveyed patients underwent bilateral T2, T3 (palmar sweating), or T3, T4 (axillary sweating) sympathectomy by a standard video-assisted transthoracic technique. Main outcome measures included the incidence of dry hands, compensatory sweating, chest pain, upper-limb muscle weakness, shortness of breath, and gustatory phenomena; in addition, patient perception of the success of the surgical procedure was assessed. After sympathectomy, 97.3% (P < 0.0001) and 29.2% (P < 0.001) of patients reported significant improvement in palmar hyperhidrosis and axillary sweating, respectively. Postsurgery, severe compensatory sweating was experienced in 90% of patients (P < 0.0001). The sites of compensatory sweating were the back (75%), abdomen (51%), feet (23%), groin and thigh (13%), chest (13%), and axillae (8%). Transient whole-body sweating for no apparent reason was experienced in 30% of patients. Thirty-seven patients (11%) regretted having undergone the surgical procedure. In contrast, 25% and 64% of patients were either satisfied or very satisfied with the outcome of the procedure. From the survey results, the authors conclude that palmar hyperhidrosis is a systemic manifestation of abnormal sudomotor function and that thoracic sympathectomy may alleviate symptoms in a large proportion of patients. However, for some individuals, compensatory sweating may prove to be an equally troublesome handicap. Because the occurrence of severe compensatory sweating is unpredictable, a reversible sympathectomy may be desirable.