Vegard Dahl

NON - OPIOID POSTOPERATIVE ANALGESIA

Although significant improvement has been made in the treatment of pain in the postoperative period, many patients still experience unnecessary discomfort resulting in distress, higher morbidity and prolonged stay in hospital. The standard pillar of postoperative treatment of severe pain is the use of opioids. However, adverse reactions to opioids make their use unfavourable. A better understanding of the pathophysiology of pain has helped clinicians to a more balanced approach to postoperative pain treatment. The development of the multimodal approach to postoperative analgesia, with the use of different drugs acting via different routes to give good analgesia, with minimal side-effects, represents a major development in the treatment of postoperative pain. Early, aggressive mobilisation and feeding must follow in order to restore normal conditions quickly. Alternatives to opioids should be used as extensively as possible. Local anaesthesia, used as regional blocks or as wound infiltration, is most beneficial. Paracetamol has good basic analgesic properties, and should probably be used in dosages higher than recommended today. The combination with a NSAID results in better and longer-lasting analgesia. The intravenous form propacetamol will increase the possibilities of its use. The new concept of selective COX-2 inhibiting NSAIDs will result in analgesic and anti-inflammatory drugs with fewer side-effects. The well-known inexpensive group of corticosteroids have good analgesic and anti-emetic properties, and are especially interesting to use in patients who do not tolerate NSAIDs. The alpha2-receptor agonists like clonidine, when administered epidurally or intrathecally, are useful adjuncts, but their adverse effects on sedation and hypotension limit their use. NMDA-receptor antagonists are of limited value in the postoperative period. Adenosine and neostigimine are still on a research level but may lead to new, clinically useful analgesic drugs. In the future, cannabinoids, cholecystokinin-receptor antagonists and neurokinin-1 antagonists may become important analgesic drugs.

Does Ketamine Have Preemptive Effects in Women Undergoing Abdominal Hysterectomy Procedures

Ketamine may produce “preemptive” analgesia when administered before surgically induced trauma. Therefore, we hypothesized that pre- versus postincisional administration of ketamine would improve pain control after abdominal hysterectomy procedures. Eighty-nine patients were randomly assigned to one of three treatment groups according to a placebo-controlled, double-blinded protocol: Group 1 (placebo) received saline 0.04 mL/kg IV immediately before and after surgery; Group 2 (preincision), received ketamine 0.4 mg/kg IV before skin incision and saline at the end of the operation; and Group 3 (postincision), received saline before skin incision, and ketamine 0.4 mg/kg IV was given after skin closure. The general anesthetic technique was standardized in all three treatment groups. During the first postoperative hour, Group 3 experienced significantly less pain than Groups 1 and 2, as assessed by using both visual analog and verbal rating scales. There were no significant differences between Groups 1 and 2 with respect to pain scores, postoperative opioid analgesic requirements, and incidence of postoperative nausea and vomiting. We conclude that a single dose of ketamine 0.4 mg/kg IV fails to produce preemptive analgesic effects. Implications Even though ketamine 0.4 mg/kg IV has short-lasting acute analgesic effects, it failed to produce a preemptive effect when given before abdominal hysterectomy procedures.

Safety and efficacy of sugammadex for the reversal of rocuronium-induced neuromuscular blockade in cardiac patients undergoing noncardiac surgery

Background and objective The present randomized, safety-assessor blinded, placebo-controlled trial was designed to assess safety and efficacy of sugammadex, a novel selective relaxant-binding agent, in patients with underlying cardiovascular disease undergoing noncardiac surgery. Methods Overall, 116 patients (New York Heart Association class II–III) were randomized and received sugammadex 2.0 mg kg−1 (n = 38), sugammadex 4.0 mg kg−1 (n = 38) or placebo (n = 40) for reversal of rocuronium-induced neuromuscular blockade at reappearance of T2. Safety variables included heart rate, blood pressure and electrocardiogram characteristics, including rate-corrected QT (QTc Fridericia and QTc Bazett) interval. Efficacy was evaluated as time to recovery of the T4/T1 ratio to 0.9 after administration of sugammadex or placebo. Results There were no significant differences between groups in terms of QTc (Fridericia) interval. Three serious adverse events, one in each treatment group, considered to be possibly drug-related according to the investigator, were cases of mild QTc (Bazett) interval prolongation. Blood pressure and heart rate decreased after initiation of anaesthesia and remained stable in all groups up to 10 min after administration of study drug. Blood pressure was significantly higher (P < 0.05) in both sugammadex dose groups compared with placebo at 30 min. The decrease in heart rate from baseline (prestudy drug) was significantly greater in the 2.0 mg kg−1 sugammadex group at 2 and 5 min, and, for both sugammadex groups, the increase at 30 min was greater compared with placebo. Both sugammadex doses resulted in considerably shorter time to recovery of the T4/T1 ratio to 0.9 compared with placebo. Conclusion The findings indicate sugammadex 2.0 and 4.0 mg kg−1 can be given safely and effectively for the reversal of rocuronium-induced neuromuscular blockade in patients with cardiovascular disease undergoing noncardiac surgery.

Spinal, epidural or propofol anaesthesia for out–patient knee arthroscopy?

Background: We have compared three different methods of anaesthesia for out–patient knee arthroscopy in terms of perioperative conditions, postoperative pain, time taken and economy.

Pre‐emptive effect of pre‐incisional versus post‐incisional infiltration of local anaesthesia on children undergoing hernioplasty

Background: Although promising in experimental studies of post‐traumatic pain, the concept of pre‐emptive analgesia is still controversial in a clinical setting. Thus, we wanted to compare the clinical efficacy of wound infiltration with local anaesthesia before surgery with wound infiltration after hernioplasty in children.

Anaesthesia for urgent (grade 1) caesarean section.

Purpose of review We describe the different possible anaesthetic techniques for an emergency caesarean section. To choose the right method of anaesthesia may have major implications for mother, child and all involved personnel. The major controversy is whether one have other or better alternatives or both than general anaesthesia, with a rapid sequence induction technique, when the foetus is compromised. Recent findings Recently published studies indicate that a top-up of a well functioning labour epidural is as fast as general anaesthesia, and that the top-up can be performed during preparation and transport. Spinal anaesthesia, when performed by skilled anaesthetists, is as fast or almost as fast as general anaesthesia with a very low failure rate. Combined spinal/epidural may have advantages, especially in high-risk cardiac patients, but is too time-consuming. General anaesthesia still seems to be the method of choice for most anaesthetists in extremely urgent settings. The major disadvantage with general anaesthesia is the risk of failure and the dramatic consequences of a ‘cannot intubate, cannot ventilate’ situation. Awareness is another concern, and the incidence varies from 0.26 to 1% in recent literature. Summary Regional anaesthesia techniques such as a single-shot spinal or a top-up of a well functioning labour epidural analgesia are good alternatives to general anaesthesia in an emergency caesarean setting.

Effect of a single dose of pregabalin on post-operative pain and pre-operative anxiety in patients undergoing discectomy.

Background: Pregabalin acts as a membrane stabilizer and has both analgesic and anxiolytic effects. We hypothesized that one pre‐operative dose of pregabalin would reduce pre‐operative anxiety and post‐operative pain in patients undergoing discectomy.

Management of accidental dural puncture and post-dural puncture headache after labour: a Nordic survey

Background: A major risk with epidural analgesia is accidental dural puncture (ADP), which may result in post‐dural puncture headache (PDPH). This survey was conducted to explore the incidence of ADP, the policy for management of PDPH and the educational practices in epidural analgesia during labour in the Nordic countries.

Does esomeprazole prevent post‐operative nausea and vomiting?

Background:  Esomeprazole is a potent proton pump inhibitor (PPI), reducing acid production as well as gastric juice volume. This study evaluated the possible beneficial effect of esomeprazole on reducing post‐operative nausea and vomiting (PONV).

Regional anaesthesia in ambulatory surgery

Purpose of review The purpose of this review is to present recent research into the clinical use of regional anaesthesia techniques in ambulatory surgery. Further, to put into an ambulatory perspective some of the issues recently discussed on the basis and practice of regional anaesthesia in general. Recent findings Early discharge with long-acting peripheral nerve blockade seems safe, and discharge of patients who have not voided after surgery is possible under specified terms. The spinal anaesthesia technique may be improved in terms of better and faster recovery characteristics if the dose of local anaesthesia is reduced by adding a small dose of opioid. Summary Loco-regional techniques are well suited for ambulatory surgery due to less postoperative nausea and pain and possibly less cognitive dysfunction. The different techniques are continuously being refined in order to provide fast discharge readiness, while still maintaining the benefits.