RESUMO
Over the past few decades, obesity rates in the United States have risen drastically, and with this, there has been a rising demand for bariatric surgery. As such, anesthesiologists need to be familiar with the challenges presented by patients seeking bariatric surgery. Obesity causes pathophysiologic changes which may affect decision-making during the management of these patients. Patients seeking bariatric surgery also have a long, prescribed preoperative course that offers anesthesiologists the opportunity to be involved earlier during the pre-surgical evaluation and optimization process.
Assuntos
Cirurgia Bariátrica , Obesidade Mórbida , Humanos , Estados Unidos , Obesidade , Cuidados Pré-Operatórios , Assistência Perioperatória , Anestesiologistas , Obesidade Mórbida/cirurgiaRESUMO
BACKGROUND: We aimed to describe the financial implications of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) in the USA. MATERIALS AND METHODS: We conducted a retrospective cost analysis of 100 CRS/HIPEC procedures to examine the impact of patient and procedural factors on hospital costs and reimbursement. A comparison of surgeons' work relative value units (wRVUs) between CRS/HIPEC and a representative sample of complex surgical oncology procedures was made to assess the physicians' compensation rate. Univariable and multivariable backward logistic regression was used to analyze the association between perioperative variables and high direct cost (HDCs). RESULTS: The median direct cost per CRS/HIPEC procedure was US $44,770. The median hospital reimbursement was US $43,066, while professional reimbursement was US $8608, resulting in a positive contribution margin of US $7493/procedure. However, the contribution margin significantly varied with the payer mix. Privately insured patients had a positive median contribution margin of US $23,033, whereas Medicare-insured patients had a negative contribution margin of US $13,034. Length of stay (LOS) had the most significant association with HDC, and major complications had the most significant association with LOS. Finally, CRS/HIPEC procedures generated a median of 13 wRVU/h, which is significantly lower than the wRVU/h generated by open pancreatoduodenectomies, open gastrectomies, and hepatectomies. However, higher operation complexity and multiple visceral resections help compensate for the relatively low wRVU/h. CONCLUSIONS: CRS/HIPEC is an expensive operation, and prolonged LOS has the most significant impact on the total cost of the procedure. High-quality care is essential to improve patient outcomes and maintain the economic sustainability of the procedure.
Assuntos
Hipertermia Induzida , Neoplasias Peritoneais , Humanos , Idoso , Estados Unidos , Neoplasias Peritoneais/patologia , Estudos Retrospectivos , Medicare , Hipertermia Induzida/métodos , Custos e Análise de Custo , Procedimentos Cirúrgicos de Citorredução/métodos , Terapia Combinada , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Taxa de SobrevidaRESUMO
BACKGROUND: Enhanced recovery protocols have been developed to improve perioperative outcomes; however, there is ongoing concern for aspiration with recent oral intake in patients with obesity, who may be predisposed to impaired gastrointestinal motility and greater gastric volumes. We aim to study the safety of a 300-mL preoperative carbohydrate-loading drink preceding bariatric surgery. STUDY DESIGN: Data were collected prospectively from patients undergoing primary bariatric surgery. All bariatric patients at our institution are prescribed a proton pump inhibitor for 4 weeks before surgery and undergo a screening preoperative esophagogastroduodenoscopy (EGD) before surgery with a traditional 8-hour fast (NOCARB), followed by an intraoperative day-of-operation EGD with carbohydrate loading (CARB) 2 to 4 hours before incision. Gastric volumes and pH are measured after being endoscopically suctioned via direct visualization during both settings. RESULTS: We identified 203 patients: 94 patients (46.3%) in the CARB group and 109 patients (53.7%) in the NOCARB group. The patients were 82.3% female with a mean age of 42.8 years and average BMI of 41.7 kg/m 2 . There was no difference in gastric volume between NOCARB and CARB (17.0 vs 16.1 mL, p = 0.59). The NOCARB group had lower pH values than the CARB group (2.8 vs 3.8, p = 0.001). Subset analysis of 23 patients who had measurements on both screening and intraoperative EGD revealed lower gastric volumes in CARB patients (13.3 vs 18.3, p < 0.0001). CONCLUSIONS: When included in an enhanced recovery protocol, proton pump inhibitor use and preoperative carbohydrate loading 2 to 4 hours before bariatric surgery does not increase aspiration risk based on gastric volumes and pH and should be strongly considered in all eligible bariatric patients.
Assuntos
Cirurgia Bariátrica , Obesidade Mórbida , Humanos , Feminino , Adulto , Masculino , Dieta da Carga de Carboidratos , Inibidores da Bomba de Prótons/uso terapêutico , Cirurgia Bariátrica/métodos , Cuidados Pré-Operatórios/métodos , Obesidade Mórbida/cirurgiaRESUMO
Enhanced recovery pathways (ERPs) and recommendations have become widely accepted for metabolic and bariatric surgery, including recommendations for preoperative carbohydrate loading and duration of fasting status. There is still a lack of consensus regarding such protocols and the underlying issues of gastric emptying time, resting gastric volume and pH, and risk of aspiration in patients with severe obesity and in patients undergoing bariatric surgery. The goal of this position statement by the International Society for the Perioperative Care of Patients with Obesity (ISPCOP) is to provide an analysis of available data on preoperative fasting and loading with oral complex clear carbohydrate drinks as well its potential effects on perioperative risk of aspiration in the context of Enhanced Recovery Pathways for Metabolic and Bariatric Surgery (ERAMBS).
Assuntos
Cirurgia Bariátrica , Dieta da Carga de Carboidratos , Humanos , Assistência Perioperatória , Obesidade , JejumRESUMO
BACKGROUND: This is the second updated Enhanced Recovery After Surgery (ERAS®) Society guideline, presenting a consensus for optimal perioperative care in bariatric surgery and providing recommendations for each ERAS item within the ERAS® protocol. METHODS: A principal literature search was performed utilizing the Pubmed, EMBASE, Cochrane databases and ClinicalTrials.gov through December 2020, with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. After critical appraisal of these studies, the group of authors reached consensus regarding recommendations. RESULTS: The quality of evidence for many ERAS interventions remains relatively low in a bariatric setting and evidence-based practices may need to be extrapolated from other surgeries. CONCLUSION: A comprehensive, updated evidence-based consensus was reached and is presented in this review by the ERAS® Society.
Assuntos
Cirurgia Bariátrica , Recuperação Pós-Cirúrgica Melhorada , Consenso , Humanos , Assistência Perioperatória/métodos , Estudos ProspectivosRESUMO
BACKGROUND: Enhanced recovery after surgery (ERAS) pathways have been shown to considerably reduce complications, length of stay and costs after most of surgical procedures by standardised application of best evidence-based perioperative care. The aim was to elaborate dedicated recommendations for cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC) in a two-part series of guidelines based on expert consensus. The present part I of the guidelines highlights preoperative and intraoperative management. METHODS: The core group assembled a multidisciplinary panel of 24 experts involved in peritoneal surface malignancy surgery representing the fields of general surgery (n = 12), gynaecological surgery (n = 6), and anaesthesia (n = 6). Experts systematically reviewed and summarized the available evidence on 72 identified perioperative care items, following the GRADE (grading of recommendations, assessment, development, evaluation) system. Final consensus (defined as ≥50%, or ≥70% of weak/strong recommendations combined) was reached by a standardised 2-round Delphi process, regarding the strength of recommendations. RESULTS: Response rates were 100% for both Delphi rounds. Quality of evidence was evaluated high, moderate low and very low, for 15 (21%), 26 (36%), 29 (40%) and 2 items, respectively. Consensus was reached for 71/72(98.6%) items. Strong recommendations were defined for 37 items, No consensus could be reached regarding the preemptive use of fresh frozen plasma. CONCLUSION: The present ERAS recommendations for CRS±HIPEC are based on a standardised expert consensus process providing clinicians with valuable guidance. There is an urgent need to produce high quality studies for CRS±HIPEC and to prospectively evaluate recommendations in clinical practice.
Assuntos
Procedimentos Cirúrgicos de Citorredução/métodos , Recuperação Pós-Cirúrgica Melhorada , Quimioterapia Intraperitoneal Hipertérmica/métodos , Cuidados Intraoperatórios/métodos , Neoplasias Peritoneais/terapia , Cuidados Pré-Operatórios/métodos , Técnica Delphi , Humanos , Assistência PerioperatóriaRESUMO
BACKGROUND: Enhanced recovery after surgery (ERAS) pathways have been shown to considerably reduce complications, length of stay and costs after most of surgical procedures by standardised application of best evidence-based perioperative care. The aim was to elaborate dedicated recommendations for cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC) in a two-part series of guidelines based on expert consensus. The present part II of the guidelines highlights postoperative management and special considerations. METHODS: The core group assembled a multidisciplinary panel of 24 experts involved in peritoneal surface malignancy surgery representing the fields of general surgery (n = 12), gynaecological surgery (n = 6), and anaesthesia (n = 6). Experts systematically reviewed and summarized the available evidence on 72 identified perioperative care items, following the GRADE (grading of recommendations, assessment, development, evaluation) system. Final consensus (defined as ≥50%, or ≥70% of weak/strong recommendations combined) was reached by a standardised 2-round Delphi process, regarding the strength of recommendations. RESULTS: Response rates were 100% for both Delphi rounds. Quality of evidence was evaluated high, moderate low and very low, for 15 (21%), 26 (36%), 29 (40%) and 2 items, respectively. Consensus was reached for 71/72(98.6%) items. Strong recommendations were defined for 37 items. No consensus could be reached regarding the preemptive use of fresh frozen plasma. CONCLUSION: The present ERAS recommendations for CRS ± HIPEC are based on a standardised expert consensus process providing clinicians with valuable guidance. There is an urgent need to produce high quality studies for CRS ± HIPEC and to prospectively evaluate recommendations in clinical practice.
Assuntos
Procedimentos Cirúrgicos de Citorredução , Recuperação Pós-Cirúrgica Melhorada/normas , Quimioterapia Intraperitoneal Hipertérmica , Neoplasias Peritoneais/terapia , Cuidados Pós-Operatórios/normas , Terapia Combinada , Procedimentos Cirúrgicos de Citorredução/efeitos adversos , Procedimentos Cirúrgicos de Citorredução/normas , Técnica Delphi , Humanos , Quimioterapia Intraperitoneal Hipertérmica/efeitos adversos , Quimioterapia Intraperitoneal Hipertérmica/normas , Neoplasias Peritoneais/cirurgia , Complicações Pós-Operatórias/prevenção & controle , Período Pós-OperatórioRESUMO
Postoperative nausea and vomiting (PONV) is a frequent side effect in patients undergoing bariatric procedures. The simplified Apfel score is an attractive and frequently used tool to assess PONV risk in the general surgical population. Despite applying the recommendations based on the Apfel risk prediction score, several studies show that up to 82% of patients undergoing metabolic and bariatric surgery suffer from PONV in the PACU. A combination of multiple antiemetic drugs of different pharmacologic classes targeting a variety of receptors in addition to an intraoperative opioid-free TIVA technique should be considered in high-risk patients.
Assuntos
Antieméticos , Cirurgia Bariátrica , Obesidade Mórbida , Analgésicos Opioides/uso terapêutico , Antieméticos/uso terapêutico , Cirurgia Bariátrica/efeitos adversos , Humanos , Obesidade Mórbida/cirurgia , Náusea e Vômito Pós-Operatórios/prevenção & controleRESUMO
BACKGROUND: Prolonged storage of packed red blood cells (PRBCs) may increase morbidity and mortality, and patients having massive transfusion might be especially susceptible. We therefore tested the hypothesis that prolonged storage increases mortality in patients receiving massive transfusion after trauma or nontrauma surgery. Secondarily, we considered the extent to which storage effects differ for trauma and nontrauma surgery. METHODS: We considered surgical patients given more than 10 units of PRBC within 24 hours and evaluated the relationship between mean PRBC storage duration and in-hospital mortality using multivariable logistic regression. Potential nonlinearities in the relationship were assessed via restricted cubic splines. The secondary hypothesis was evaluated by considering whether there was an interaction between the type of surgery (trauma versus nontrauma) and the effect of storage duration on outcomes. RESULTS: 305 patients were given a total of 8,046 units of PRBCs, with duration ranging from 8 to 36 days (mean ± SD: 22 ± 6 days). The odds ratio [95% confidence interval (CI)] for in-hospital mortality corresponding to a one-day in mean PRBC storage duration was 0.99 (0.95, 1.03, P = 0.77). The relationship did not differ for trauma and nontrauma patients (P = 0.75). Results were similar after adjusting for multiple potential confounders. CONCLUSIONS: Mortality after massive blood transfusion was no worse in patients transfused with PRBC stored for long periods. Trauma and nontrauma patients did not differ in their susceptibility to prolonged PRBC storage.
Assuntos
Preservação de Sangue , Bases de Dados Factuais , Transfusão de Eritrócitos , Eritrócitos , Ferimentos e Lesões/mortalidade , Ferimentos e Lesões/cirurgia , Adulto , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de TempoRESUMO
BACKGROUND: Lung isolation skills, such as correct insertion of double lumen endobronchial tube and bronchial blocker, are essential in anesthesia training; however, how to teach novices these skills is underexplored. Our aims were to determine (1) if novices can be trained to a basic proficiency level of lung isolation skills, (2) whether video-didactic and simulation-based trainings are comparable in teaching lung isolation basic skills, and (3) whether novice learners' lung isolation skills decay over time without practice. METHODS: First, five board certified anesthesiologist with experience of more than 100 successful lung isolations were tested on Human Airway Anatomy Simulator (HAAS) to establish Expert proficiency skill level. Thirty senior medical students, who were naive to bronchoscopy and lung isolation techniques (Novice) were randomized to video-didactic and simulation-based trainings to learn lung isolation skills. Before and after training, Novices' performances were scored for correct placement using pass/fail scoring and a 5-point Global Rating Scale (GRS); and time of insertion was recorded. Fourteen novices were retested 2 months later to assess skill decay. RESULTS: Experts' and novices' double lumen endobronchial tube and bronchial blocker passing rates showed similar success rates after training (P >0.99). There were no differences between the video-didactic and simulation-based methods. Novices' time of insertion decayed within 2 months without practice. CONCLUSION: Novices could be trained to basic skill proficiency level of lung isolation. Video-didactic and simulation-based methods we utilized were found equally successful in training novices for lung isolation skills. Acquired skills partially decayed without practice.
Assuntos
Anestesiologia/educação , Broncoscopia/educação , Competência Clínica/normas , Simulação por Computador , Docentes de Medicina/normas , Estudantes de Medicina , Anestesiologia/métodos , Broncoscopia/métodos , Humanos , PulmãoRESUMO
PURPOSE: Generally, novices are taught fiberoptic intubation on patients by attending anesthesiologists; however, this approach raises patient safety concerns. Patient safety should improve if novice learners are trained for basic skills on simulators. In this educational study, we assessed the time and number of attempts required to train novices in fiberoptic bronchoscopy and fiberoptic intubation on simulators. Because decay in skills is inevitable, we also assessed fiberoptic bronchoscopy and fiberoptic intubation skill decay and the amount of effort required to regain fiberoptic bronchoscopy skill. METHODS: First, we established attempt- and duration-based quantitative norms for reaching skill proficiency for fiberoptic bronchoscopy and fiberoptic intubation by experienced anesthesiologists (n = 8) and prepared an 11-step checklist and a 5-point global rating scale for assessment. Novice learners (n = 15) were trained to reach the established skill proficiency in a Virtual Reality simulator for fiberoptic bronchoscopy skills and a Human Airway Anatomy Simulator for fiberoptic intubation skills. Two months later, novices were reassessed to determine decay in learned skills and the required time to retrain them to fiberoptic bronchoscopy proficiency level. RESULTS: Proficiency in fiberoptic bronchoscopy skill level was achieved with 11 ± 5 attempts and after 658 ± 351 s. After 2 months without practice, the time taken by the novices to successful fiberoptic bronchoscopy on the Virtual Reality simulator increased from 41 ± 8 to 68 ± 31 s (P = 0.0138). Time and attempts required to retrain them were 424 ± 230 s and 9.1 ± 4.6 attempts, respectively. CONCLUSION: Novices were successfully trained to proficiency skill level. Although fiberoptic bronchoscopy skills started to decay within 2 months, the re-training time was shorter.
Assuntos
Broncoscopia/educação , Tecnologia de Fibra Óptica/educação , Intubação Intratraqueal/métodos , Simulação por Computador , Humanos , AprendizagemRESUMO
BACKGROUND: Morbidly obese patients are at high risk for perioperative complications, including surgical site infections. Baseline arterial oxygenation is low in the morbidly obese, leading to low tissue oxygenation, which in turn is a primary determinant of infection risk. We therefore tested the hypothesis that extending intraoperative supplemental oxygen 12 to 16 hours into the postoperative period reduces the risk of surgical site infection and healing-related complications. METHODS: Morbidly obese patients having open or laparoscopic bariatric surgery were given 80% inspired oxygen intraoperatively. Postoperatively, patients were randomly assigned to either 2 L/min of oxygen via nasal cannula or approximately 80% supplemental inspired oxygen after tracheal extubation until the first postoperative morning. The risks of surgical site infection and of major healing-related complications were evaluated 60 days after surgery. RESULTS: In a preplanned interim analysis based on the initial 400 patients, the overall observed incidence of the collapsed composite of major complications was 13.3%; the observed incidence of components of the composite outcome ranged from 0% (peritonitis) to 8.5% (surgical wound infection). The estimated relative risk of any ≥1 major complications occurring within the first 60 days after surgery, adjusting for study site, was 0.94 (95% confidence interval, 0.52-1.68) (P = 0.80, Cochran-Mantel-Haenszel). The Executive Committee thus stopped the trial for futility. CONCLUSIONS: Supplemental postoperative oxygen does not reduce the risk of surgical site infection rate and healing-related postoperative complications in patients having gastric bypass surgery.
Assuntos
Derivação Gástrica/efeitos adversos , Laparoscopia/efeitos adversos , Obesidade Mórbida/cirurgia , Oxigenoterapia , Infecção da Ferida Cirúrgica/prevenção & controle , Cicatrização , Adulto , Término Precoce de Ensaios Clínicos , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/diagnóstico , Ohio/epidemiologia , Cuidados Pós-Operatórios , Fatores de Risco , Infecção da Ferida Cirúrgica/diagnóstico , Infecção da Ferida Cirúrgica/epidemiologia , Fatores de Tempo , Resultado do TratamentoRESUMO
Postoperative isolated injury of the musculocutaneous nerve is a rare disorder and complication. Reported cases are claimed to present with loss of biceps and brachialis power without neuropathic pain. When injury occurs to one of the terminal branches of the brachial plexus, the lateral cutaneous nerve of the forearm, pain is the major symptom and it typically radiates along the radial aspect of the forearm. In the literature, isolated lesions of the musculocutaneous nerve have been attributed to repeated microtrauma, indirect trauma or direct trauma to the nerve. It may also occur due to strenuous extension of the forearm for prolonged periods.
Assuntos
Nervo Musculocutâneo/lesões , Complicações Pós-Operatórias/diagnóstico , Tireoidectomia/efeitos adversos , Traumatismos do Sistema Nervoso/diagnóstico , Adulto , Diagnóstico Diferencial , Feminino , Antebraço/inervação , Humanos , Complicações Pós-Operatórias/etiologia , Traumatismos do Sistema Nervoso/etiologiaRESUMO
BACKGROUND: It remains unclear whether local anesthetic concentration or total drug dose is the primary determinant of continuous peripheral nerve block effects. The only previous investigation, involving continuous popliteal-sciatic nerve blocks, specifically addressing this issue reported that insensate limbs were far more common with higher volumes of relatively dilute ropivacaine compared with lower volumes of relatively concentrated ropivacaine. However, it remains unknown if this relationship is specific to the sciatic nerve in the popliteal fossa or whether it varies depending on anatomic location. We therefore tested the null hypothesis that providing ropivacaine at different concentrations and rates, but at an equal total basal dose, produces comparable effects when used in a continuous infraclavicular brachial plexus block. METHODS: Preoperatively, an infraclavicular catheter was inserted using the coracoid approach in patients undergoing moderately painful orthopedic surgery distal to the elbow. Patients were randomly assigned to receive a postoperative perineural ropivacaine infusion of either 0.2% (basal 8 mL/h, bolus 4 mL) or 0.4% (basal 4 mL/h, bolus 2 mL) through the second postoperative day. Both groups, therefore, received 16 mg of ropivacaine each hour with a possible addition of 8 mg every 30 min via a patient-controlled bolus dose. Our primary end point was the incidence of an insensate limb during the 24-h period beginning the morning after surgery. Secondary end points included analgesia and patient satisfaction. RESULTS: Patients given 0.4% ropivacaine (n = 27) experienced an insensate limb, a mean (sd) of 1.8 (1.6) times, compared with 0.6 (0.9) times for subjects receiving 0.2% ropivacaine (n = 23; estimated difference = 1.2 episodes, 95% confidence interval, 0.5-1.9 episodes; P = 0.001). Satisfaction with postoperative analgesia (scale 0-10, 10 = highest) was scored a median (25th-75th percentiles) of 10.0 (8.0-10.0) in Group 0.2% and 7.0 (5.3-8.9) in Group 0.4% (P = 0.018). Analgesia was similar in each group. CONCLUSIONS: For continuous infraclavicular nerve blocks, local anesthetic concentration and volume influence perineural infusion effects in addition to the total mass of local anesthetic administered. Insensate limbs were far more common with smaller volumes of relatively concentrated ropivacaine. This is the opposite of the relationship previously reported for continuous popliteal-sciatic nerve blocks. The interaction between local anesthetic concentration and volume is thus complex and varies among catheter locations.
Assuntos
Amidas/administração & dosagem , Anestésicos Locais/administração & dosagem , Plexo Braquial/efeitos dos fármacos , Clavícula/inervação , Bloqueio Nervoso/métodos , Procedimentos Ortopédicos/efeitos adversos , Dor Pós-Operatória/prevenção & controle , Adulto , Amidas/efeitos adversos , Anestésicos Locais/efeitos adversos , Relação Dose-Resposta a Droga , Esquema de Medicação , Feminino , Humanos , Bombas de Infusão , Infusões Parenterais , Masculino , Pessoa de Meia-Idade , Ontário , Medição da Dor , Limiar da Dor/efeitos dos fármacos , Dor Pós-Operatória/etiologia , Satisfação do Paciente , Ropivacaina , Método Simples-Cego , Tato/efeitos dos fármacos , Estados UnidosRESUMO
BACKGROUND: It remains unknown whether local anesthetic concentration, or simply total drug dose, is the primary determinant of continuous peripheral nerve block effects. We therefore tested the null hypothesis that providing different concentrations and rates of ropivacaine, but at equal total doses, produces comparable effects when used in a continuous sciatic nerve block in the popliteal fossa. METHODS: Preoperatively, a perineural catheter was inserted adjacent to the sciatic nerve using a posterior popliteal approach in patients undergoing moderately painful orthopedic surgery at or distal to the ankle. Postoperatively, patients were randomly assigned to receive a perineural ropivacaine infusion of either 0.2% (basal 8 mL/h, bolus 4 mL) or 0.4% (basal 4 mL/h, bolus 2 mL) through the second postoperative day. Therefore, both groups received 16 mg of ropivacaine each hour with a possible addition of 8 mg every 30 min via a patient-controlled bolus dose. The primary end point was the incidence of an insensate limb, considered undesirable, during the 24-h period beginning the morning after surgery. Secondary end points included analgesia and patient satisfaction. RESULTS: Patients given 0.2% ropivacaine (n = 25) experienced an insensate limb with a mean (sd) of 1.8 (1.8) times, compared with 0.6 (1.1) times for subjects receiving 0.4% ropivacaine (n = 25; estimated difference = 1.2 episodes, 95% confidence interval, 0.3-2.0 episodes; P = 0.009). In contrast, analgesia and satisfaction were similar in each group. CONCLUSIONS: For continuous popliteal-sciatic nerve blocks, local anesthetic concentration and volume influence block characteristics. Insensate limbs were far more common with larger volumes of relatively dilute ropivacaine. During continuous sciatic nerve block in the popliteal fossa, a relatively concentrated solution in smaller volume thus appears preferable.
Assuntos
Amidas/administração & dosagem , Anestésicos Locais/administração & dosagem , Bombas de Infusão , Bloqueio Nervoso , Dor Pós-Operatória/prevenção & controle , Nervo Isquiático , Adulto , Idoso , Procedimentos Cirúrgicos Ambulatórios , Analgesia Controlada pelo Paciente , Analgésicos Opioides/uso terapêutico , Feminino , Pé/cirurgia , Serviços Hospitalares de Assistência Domiciliar , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Ortopédicos , Medição da Dor , Dor Pós-Operatória/tratamento farmacológico , Satisfação do Paciente , RopivacainaRESUMO
BACKGROUND AND OBJECTIVES: It is currently unknown if the primary determinant of continuous peripheral nerve block effects is simply total drug dose, or whether local anesthetic concentration and/or volume have an influence. We therefore tested the null hypothesis that providing ropivacaine at different concentrations and rates--but at an equal total basal dose--produces similar effects when used in a continuous interscalene nerve block. METHODS: Preoperatively, an anterolateral interscalene perineural catheter was inserted using the anterolateral approach in patients undergoing moderately painful shoulder surgery. Subjects were randomly assigned to receive a postoperative perineural infusion of either 0.2% ropivacaine (basal 8 mL/h, bolus 4 mL) or 0.4% ropivacaine (basal 4 mL/h, bolus 2 mL) through the second postoperative day. Our primary endpoint was the incidence of an insensate hand/finger during the 24 hours beginning the morning following surgery. RESULTS: The incidence of an insensate hand/finger did not differ between the treatment groups (n = 50) to a statistically significant degree (0.2% ropivacaine, mean [SD] of 0.8 [1.3] times; 0.4% ropivacaine, mean 0.3 [0.6] times; estimated difference = 0.5 episodes, 95% confidence interval, -0.1 to 1.1 episodes; P = .080). However, this is statistically inconclusive given the confidence interval. In contrast, pain (P = .020) and dissatisfaction (P = .011) were greater in patients given 0.4% ropivacaine. CONCLUSIONS: For continuous interscalene nerve blocks, given the statistically inconclusive primary endpoint results and design limitations of the current study, further research on this topic is warranted. In contrast, providing a lower concentration of local anesthetic at a higher basal rate provided superior analgesia.