Low-concentration distal nerve blocks with 0.125% levobupivacaine versus systemic analgesia for ambulatory trapeziectomy performed under axillary block: a randomized controlled trial.

BACKGROUND: Trapeziectomy is one of the most painful procedures in ambulatory surgery. This prospective randomized trial aimed to compare postoperative pain control using distal peripheral nerve blocks (dPNB) with a low concentration of a long-acting local anesthetic versus conventional systemic analgesia. METHODS: Fifty-two patients undergoing trapeziectomy were randomized to receive levobupivacaine 0.125% 5 mL on radial and median nerves at the elbow (dNB group), or not to receive these blocks (control group). In both groups, surgery was performed under axillary block (mepivacaine 1% 20 mL) and the same analgesic regimen was prescribed at discharge. The primary outcome was postoperative pain at 24 and 48 hours after surgery and maximum pain score on the first and second postoperative day. Secondary outcomes were duration of dPNB, rescue analgesia requirements, opioid-related side effects, consumption and effectiveness of antiemetic therapy, and upper limb motor block. RESULTS: Fifty patients were analyzed. Maximum pain intensity was moderate to severe (dPNB vs. control) in 33.3% vs. 92.3% (P=0.002) on the first day after surgery and 20.8% vs. 80.8% (P<0.001) on the second day. The average duration of analgesia after dPNB was 10 hours and no patient reported motor block. dPNB reduced rescue analgesia requirements and the incidence of postoperative nausea and vomiting (PONV). CONCLUSIONS: dPNB on target nerves provided better analgesia than systemic analgesia after trapeziectomy performed under axillary block. Opioid consumption and the incidence of PONV were lower in the dPNB group.

Perioperative aspirin and clonidine and risk of acute kidney injury: a randomized clinical trial.

IMPORTANCE: Acute kidney injury, a common complication of surgery, is associated with poor outcomes and high health care costs. Some studies suggest aspirin or clonidine administered during the perioperative period reduces the risk of acute kidney injury; however, these effects are uncertain and each intervention has the potential for harm. OBJECTIVE: To determine whether aspirin compared with placebo, and clonidine compared with placebo, alters the risk of perioperative acute kidney injury. DESIGN, SETTING, AND PARTICIPANTS: A 2 × 2 factorial randomized, blinded, clinical trial of 6905 patients undergoing noncardiac surgery from 88 centers in 22 countries with consecutive patients enrolled between January 2011 and December 2013. INTERVENTIONS: Patients were assigned to take aspirin (200 mg) or placebo 2 to 4 hours before surgery and then aspirin (100 mg) or placebo daily up to 30 days after surgery, and were assigned to take oral clonidine (0.2 mg) or placebo 2 to 4 hours before surgery, and then a transdermal clonidine patch (which provided clonidine at 0.2 mg/d) or placebo patch that remained until 72 hours after surgery. MAIN OUTCOMES AND MEASURES: Acute kidney injury was primarily defined as an increase in serum creatinine concentration from the preoperative concentration by either an increase of 0.3 mg/dL or greater (≥26.5 µmol/L) within 48 hours of surgery or an increase of 50% or greater within 7 days of surgery. RESULTS: Aspirin (n = 3443) vs placebo (n = 3462) did not alter the risk of acute kidney injury (13.4% vs 12.3%, respectively; adjusted relative risk, 1.10; 95% CI, 0.96-1.25). Clonidine (n = 3453) vs placebo (n = 3452) did not alter the risk of acute kidney injury (13.0% vs 12.7%, respectively; adjusted relative risk, 1.03; 95% CI, 0.90-1.18). Aspirin increased the risk of major bleeding. In a post hoc analysis, major bleeding was associated with a greater risk of subsequent acute kidney injury (23.3% when bleeding was present vs 12.3% when bleeding was absent; adjusted hazard ratio, 2.20; 95% CI, 1.72-2.83). Similarly, clonidine increased the risk of clinically important hypotension. In a post hoc analysis, clinically important hypotension was associated with a greater risk of subsequent acute kidney injury (14.3% when hypotension was present vs 11.8% when hypotension was absent; adjusted hazard ratio, 1.34; 95% CI, 1.14-1.58). CONCLUSIONS AND RELEVANCE: Among patients undergoing major noncardiac surgery, neither aspirin nor clonidine administered perioperatively reduced the risk of acute kidney injury. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01082874.