Postoperative analgesia with continuous wound infusion of local anaesthesia vs saline: a double-blind randomized, controlled trial in colorectal surgery.

AIM: The aim of this prospective double-blind randomized clinical trial was to determine whether preperitoneal continuous wound infusion (CWI) of the local anaesthetic ropivacaine after either laparotomy or video-assisted laparoscopy for colorectal surgery would reduce patient consumption of morphine. METHOD: Patients scheduled for colorectal surgery randomly received a 48-h preperitoneal CWI of either 0.38% ropivacaine or 0.9% saline at rates of 5 ml/h after laparotomy or 2 ml/h after laparoscopy. The primary end-point was total morphine consumption in surgery and afterwards through a patient-controlled analgesia device. Results in the laparotomy and laparoscopy subgroups were also compared. RESULTS: Sixty-seven patients were included, 33 in the ropivacaine CWI group and 34 in the saline group. Median [interquartile range (IQR)] morphine consumption was lower in the ropivacaine group [23.5 mg (11.25-42.75)] than in the saline group [52 mg (24.5-64)] (P = 0.010). Morphine consumption was also lower in the laparotomy subgroup receiving ropivacaine [21.5 (15.6-34.7)] than in the saline group [52.5 (22.5-65) ml] (P = 0.041). Consumption was statistically similar in laparoscopy patients on ropivacaine or saline. No side effects were observed. Sixteen patients had a surgical wound infection (23.9%); 11 (16.4%) presented wound infection and five (7.5%) organ space infection. Forty-six catheter cultures were obtained; 10 (21.7%) were positive, assessed to be due to contamination. CONCLUSION: Preperitoneal CWI of ropivacaine is a good, safe addition to a multimodal analgesia regimen for colorectal surgery. CWI can reduce morphine consumption without increasing adverse effects.

Postoperative respiratory outcomes in laparoscopic bariatric surgery: comparison of a prospective group of patients whose neuromuscular blockade was reverted with sugammadex and a historical one reverted with neostigmine.

PURPOSE: Bariatric surgery patients are at high risk of perioperative respiratory adverse events. We hypothesized that the use of sugammadex to reverse neuromuscular blockade could improve postoperative respiratory outcomes. METHODS: Prospective observational series of consecutive patients scheduled for laparoscopic bariatric surgery in whom neuromuscular blockade was reverted with sugammadex were compared with a historical matched cohort of patients reverted with neostigmines. The necessity of postoperative mechanical ventilation or pathological changes in postoperative chest X-ray were two of the comparisons done. RESULTS: We enrolled 160 patients in each group (Sugammadex - SG and Historical - HG). Two patients (mean, CI 95%), (1.25, 0.34-4.4) in the SG and five patients in the HG (mean, CI 95%), (3.13, 1.34-7.11) required mechanical ventilation immediately after surgery (p=0.38, chi-square test). Significantly less chest X-ray postoperative changes were observed in the SG: 11 patients (6.9%) versus 26 patients (16.3%) in the HG (Odds ratio OR, CI 95%) (0.36, 0.18-0.8). CONCLUSION: Requirement of mechanical ventilation is not associated to the reversal agent employed. Less pathological postoperative chest X-ray changes were found in the group of patients whose neuromuscular blockade was reverted with sugammadex.

[Analysis of difficult intubation factors in bariatric surgery. Influence of the choice of neuromuscular blocker on the availability of sugammadex]. / Análisis de los factores de intubación difícil en cirugía bariátrica. Influencia en la elección del bloqueante neuromuscular de la disponibilidad de sugammadex.

OBJECTIVE: To determine the incidence of difficult tracheal intubation (DTI), as well as predictive factors for DTI and what influences the choice of the neuromuscular blocking agent (succinylcholine or rocuronium). METHODS: This is an observational, prospective study on consecutive bariatric surgery patients. Tracheal intubation was performed by direct laryngoscopy with a preformed tracheal tube. DTI was considered when there was a Cormack-Lehane classification of iii-iv or when it was necessary to apply the DTI algorithm, which consisted in the use of Frova guide, and Airtraq video-laryngoscope as second choice, and finally awaking the patient and sugammadex reversal if rocuronium was the selected neuromuscular blocking agent. Thereafter, tracheal intubation was performed using an awake fibroscopic technique RESULTS: One hundred and sixty six patients were included. In one case, conscious fiberscope tracheal intubation was performed. Succinylcholine was selected for 14 patients, and rocuronium for 151 patients. Fifteen patients had a DTI (9%): in 4 Airtraq was deemed necessary. One patient received sugammadex to reverse neuromuscular blockade. Conscious tracheal intubation represented 1.2% (95% CI; 0.3-4%). DTI was associated with Mallampati score of 3-4 (odds ratio, 3 [95% CI; 1.37-6.8], sensitivity of 33%, specificity of 91%) and with thyromental distance<6cm (odds ratio, 4.8 [95% CI; 1.45-16]; sensitivity of 53%; specificity of 79%). CONCLUSION: Rescue airway protocol with Frova and Airtraq avoided the use of sugammadex, except in one patient.

Rocuronium profile during orthotopic liver transplantation: effect of changing the order of vascular clamp release at reperfusion of the hepatic graft.

BACKGROUND: Clearance of rocuronium in the neohepatic period may be a criterion for graft function during orthotopic liver transplantation (OLT). Our goal was to demonstrate that changes in rocuronium elimination are caused mainly by variations in blood volume at reperfusion. We have explored the influence on rocuronium plasma concentrations of changing the order of vascular unclamping at graft reperfusion. METHODS: Thirty patients were randomized at graft reperfusion: initial arterial revascularization (IAR; n = 14) wherein the hepatic artery was released first, and initial portal revascularization (IPR; n = 16) wherein the portal vein was released first. Tracheal intubation was facilitated by rocuronium (1 mg/kg) with an infusion initiated at 0.25 mg kg(-1) h(-1) to maintain a response to the first stimulus of the train of four <25% of controls. Rocuronium plasma concentrations (RPC) were measured throughout the transplantation. RESULTS: No differences were observed in rocuronium consumption at different stages. RPCs decreased after reperfusion, with primarily portal unclamping responsible. In 6 patients of the IAR group and 5 patients of the IPR group, RPC at 60 minutes after reperfusion was higher than previous values. Indicators of graft dysfunction among those 11 did not differ from the other patients. Two patients in the IPR group required retransplantation without any relation to changes in RPCs. CONCLUSION: The increase of blood flow produced by portal vein unclamping influenced RPCs; no relation was observed between RPCs and graft outcomes.