Postoperative pain reduction by pre-emptive N-acetylcysteine: an exploratory randomized controlled clinical trial.

BACKGROUND: A new potential target for multimodal pain management is the group-II metabotropic glutamate receptor subtypes, which can be activated by N-acetylcysteine. We investigated whether pre-emptive administration of N-acetylcysteine leads to a reduction in postoperative pain after laparoscopic inguinal hernia repair. METHODS: Sixty American Society of Anesthesiologists I-II patients scheduled for elective inguinal hernia repair were randomized to receive either N-acetylcysteine (150 mg/kg) or placebo intravenously 1 hour before surgery. The primary outcome was the visual analogue score during movement in the morning (approximately 24 hours) after surgery. Among secondary outcomes were postoperative opioid consumption and safety of intravenous N-acetylcysteine. RESULTS: In total, 23 patients were analyzed per group. Pain scores were similar at all timepoints with a 24 hours median score of 34 (IQR of 19.0 to 42.5) in the N-acetylcysteine group and a median score of 26 (16.0 to 50.0) in the placebo group. The percentage of patients using opioids after surgery was 22% versus 39% day 1 (p=0.63); 9% versus 26% day 2 (p=0.14); 9% versus 17% day 3 (p=0.35) in the N-acetylcysteine group compared with placebo group. Side effects resembling anaphylactoid reactions in response to the administration of N-acetylcysteine were present in more than half of the patients. CONCLUSIONS: Without finding important differences between N-acetylcysteine and placebo group in pain scores postoperatively, but with a high percentage of bothersome side effects for the N-acetylcysteine group, we would not recommend the use of pre-emptive intravenous N-acetylcysteine to reduce postoperative pain in laparoscopic inguinal hernia repair patients based on this study. TRIAL REGISTRATION NUMBER: NCT03354572.

Peri-operative swelling of fingers: A prospective observational study.

BACKGROUND: In most Dutch hospitals, because of putative peri-operative swelling of the fingers, patients must remove rings before entering the operating theatre. If this proves impossible, destructive methods for removal may be required. For some patients, this might be too radical, as the risk of wearing rings may not be in proportion to the economic and emotional damage to the patient. OBJECTIVE: The objective of this study was to determine whether peri-operative swelling of fingers occurs in elective surgery patients. DESIGN: A prospective observational study. SETTING: University Medical Centre. PATIENTS: Five groups of patients: major cardiothoracic surgery, major noncardiothoracic surgery, nonmajor surgery with a minimum of one overnight stay, nonmajor surgery without overnight stay and surgery under intrathecal anaesthesia. MAIN OUTCOME MEASURE: Finger swelling, as measured by the circumference of the first phalanx of the middle and ring fingers of both hands, pre-operatively and at 3, 24 and 48 h postsurgery, using a roller tape with one winding and 20-g weights in a custom-made frame. RESULTS: One hundred and forty-eight patients were enrolled. Peri-operative swelling reached statistical significance in all groups and was most prominent in major cardiothoracic and noncardiothoracic surgery (maximum increases in circumference were 10.6 and 7.3%, respectively). In all groups, maximal swelling was observed 24 h postsurgery. CONCLUSION: Peri-operative swelling of fingers is a common phenomenon, which is related to the extent of the surgical procedure. TRIAL REGISTRATION: Netherlands Trial Register NL8066.

Shared decision-making for postoperative analgesia: A semistructured qualitative study.

BACKGROUND: Shared decision-making (SDM) and decision-support tools have attracted broad support in healthcare as they improve medical decision-making. Experts disagree on how these can help patients evaluate their present situation and possible outcomes of therapy, and how they might reduce decisional conflict. Little is known about their implementation, especially in anaesthesiology. OBJECTIVE: To obtain a more fundamental understanding of pre-operative SDM and evaluate the use of a decision-support tool for postoperative analgesia after major thoracic and abdominal surgery. DESIGN: A qualitative study with semistructured, in-depth interviews of patients and professionals. SETTING: Patient recruitment took place at the Radboud University Medical Centre in Nijmegen and the Canisius Wilhelmina Hospital in Nijmegen, a nonacademic teaching centre. Professionals of the Radboud University Medical Centre were invited to participate in the interviews. PARTICIPANTS: Interviews were performed with 10 individual patients and two focus groups both consisting of eight different professionals. MAIN OUTCOME MEASURES: To gain insight into the provision of pre-operative information, decision-making processes and the clarity and usability of a prototype decision-support tool. RESULTS: Professionals seemed to provide their patients with information directed towards the application of epidural analgesia, providing little attention to its negative effects. For many patients, the information was not tailored to their needs. Patients' involvement in decision-making was minimal, but they did not feel a need for more involvement. They were positive about the decision-support tool, although they indicated that it would not have influenced their treatment decision. Professionals expressed their doubt about the capacity of their patients to fully understand the decisions involved and about the clinical usability of the decision-support tool, because patients might misinterpret the information provided. CONCLUSION: The results of this study suggest that both patients and professionals did not adhere to some 'self-evident' principles of SDM when postoperative analgesia after major thoracic and abdominal surgery was discussed.

Preoperative use of anxiolytic-sedative agents; are we on the right track?

STUDY OBJECTIVE: Although anxiolytic-sedative agents are used preoperatively since the advent of anesthesia, many aspects of this treatment, including the intended effects among which anxiolysis, effectiveness, and optimal agents, remain unclear. The objective of this study was to provide insight into the preoperative use of anxiolytic-sedative agents in the Netherlands and to relate the administration of these agents to the anxiolytic-sedative state of patients. DESIGN: Questionnaire study. SETTING: University, general, and specialized hospitals in the Netherlands. PATIENTS: One anesthesiologist in each hospital was asked for details about premedication in all elective procedures, except cardiothoracic surgery, in normal weighted adults in good to fair clinical condition. INTERVENTIONS: None. MEASUREMENTS: Estimated percentage of patients receiving anxiolytic-sedative premedication, type, dose, route of administration and timing of these agents, and anxiolytic state of patients when arriving at the holding area. MAIN RESULTS: All 8 university hospitals, 69 of 82 general hospitals and 2 of 3 specialized hospitals participated in this study (response rate, 84.9%). The estimated percentage of patients that received anxiolytic-sedative agents was 46.8% for in-patients and 30.4% for day care patients (P<.0001), with large between-hospital variation. Midazolam (62.7%), oxazepam (20.2%), and temazepam (7.8%) were most frequently used and were virtually always orally administered 1 hour preoperatively. There was no relationship between use of anxiolytic-sedative agents and reduction of perceived anxiety (r=-0.09, P=.46 and r=-0.01, P=.91 for clinical and day care patients, respectively). CONCLUSIONS: Anxiolytic-sedative agents are used preoperatively in a substantial number of patients in the Netherlands, and the pharmacokinetic characteristics of many agents are not optimal of their intended use. In addition, we found no relationship with reduced anxiety. This study stresses the need for clear guidelines on preoperative use of anxiolytic-sedative agents.

[The 'paper-based' preoperative evaluation: sometimes, a suitable alternative]. / Het preoperatieve 'papieren consult': soms een prima alternatief.

In the Netherlands, the majority of elective-surgery patients are evaluated by the anaesthesiologist at the preoperative assessment clinic. We believe that this visit can be omitted in selected patients as it has only minimal benefit, whereas its disadvantages can be substantial. Alternatively, the initial screening could be performed by the completion of a questionnaire via the telephone, via internet, by a nurse or by the surgeon. These data can then be evaluated by the anaesthesiologist; this is called the 'paper-based' preoperative evaluation. This method does require the conscientious cooperation between anaesthesiologists and surgeons; it should be clear which patients are eligible, what type of anaesthetic technique should be used, how the patient should be informed and how the informed consent is obtained. In our opinion, this paper-based evaluation combines safety and efficiency with patient-friendliness. It should be anchored in current guidelines to ensure quality.