Pregabalin reduces postoperative opioid consumption and pain for 1 week after hospital discharge, but does not affect function at 6 weeks or 3 months after total hip arthroplasty.

BACKGROUND: This study examined whether a perioperative regimen of pregabalin added to celecoxib improved pain scores and functional outcomes postdischarge up to 3 months after total hip arthroplasty (primary outcome) and acute postoperative pain and adverse effects (secondary outcomes). METHODS: One hundred and eighty-four patients were enrolled in a randomized, double-blind, placebo-controlled study. Two hours before receiving a spinal anaesthetic and undergoing surgery, patients received celecoxib 400 mg p.o. and were randomly assigned to receive either pregabalin 150 mg p.o. or placebo p.o. After surgery, patients received pregabalin 75 mg or placebo twice daily in hospital and for 7 days after discharge. Patients also received celecoxib 200 mg every 12 h for 72 h and morphine i.v. patient-controlled analgesia for 24 h. Pain and function were assessed at baseline, 6 weeks, and 3 months after surgery. RESULTS: There was no difference between groups in physical function or incidence and intensity of chronic pain 3 months after total hip arthroplasty. The pregabalin group used less morphine [mean (sd): 39.85 (28.1) mg] than the placebo group [54.01 (31.2) mg] in the first 24 h after surgery (P<0.01). Pain scores were significantly lower in the pregabalin group vs the placebo group on days 1-7 after hospital discharge, and the pregabalin group required less adjunctive opioid medication (Percocet) 1 week after hospital discharge (P<0.05). CONCLUSIONS: Perioperative administration of pregabalin did not improve pain or physical function at 6 weeks or 3 months after total hip arthroplasty. Perioperative administration of pregabalin decreased opioid consumption in hospital and reduced daily pain scores and adjunct opioid consumption for 1 week after discharge.

Perioperative gabapentin reduces 24 h opioid consumption and improves in-hospital rehabilitation but not post-discharge outcomes after total knee arthroplasty with peripheral nerve block.

BACKGROUND: This study was designed to determine whether a 4 day perioperative regimen of gabapentin added to celecoxib improves in-hospital rehabilitation and physical function on postoperative day 4 and 6 weeks and 3 months after total knee arthroplasty (TKA). METHODS: After Research Ethics Board approval and informed consent, 212 patients were enrolled in a randomized, double-blinded, placebo-controlled study. Two hours before surgery, patients received celecoxib 400 mg p.o. and were randomly assigned to receive either gabapentin 600 mg or placebo p.o. Two hours later, patients received femoral, sciatic nerve blocks, and spinal anaesthesia. After operation, patients received gabapentin 200 mg or placebo three times per day (TID) for 4 days. All patients also received celecoxib 200 mg q12 h for 72 h and i.v. patient-controlled analgesia for 24 h. Pain and function were assessed at baseline, during hospitalization, on postoperative day 4 (POD4), and 6 weeks and 3 months after surgery. RESULTS: The gabapentin group used less morphine in the first 24 h after surgery [G=38.3 (29.5 mg), P=48.2 (29.4 mg)] (P<0.0125) and had increased knee range of motion compared with the placebo group in-hospital (P<0.05). There were no differences between groups in favour of the gabapentin group for pain or physical function on POD 4 [95% confidence interval (CI): pain: -1.4, 0.5; function: -6.3, 2.0], 6 weeks (95% CI: pain: 0.1, 1.9; function: -0.2, 6.5) or 3 months (95% CI: pain: -0.2, 1.7; function: -2.2, 4.3) after TKA. CONCLUSIONS: In the context of celecoxib, spinal anaesthesia, femoral and sciatic nerve blocks, a dose of gabapentin 600 mg before operation followed by 4 days of gabapentin 200 mg TID decreased postoperative analgesic requirements and improved knee range of motion after TKA. Gabapentin provided no improvement in pain or physical function on POD4 and 6 weeks or 3 months after surgery.

Ultrasound reduces the minimum effective local anaesthetic volume compared with peripheral nerve stimulation for interscalene block.

BACKGROUND: Previous studies have demonstrated that lower local anaesthetic (LA) volumes can be used for ultrasound (US)-guided interscalene brachial plexus block (ISB). However, no study has examined whether US can reduce the volume required when compared with nerve stimulation (NS) for ISB. Our aim was to do this by comparing the minimum effective analgesic volumes (MEAVs). METHODS: After ethics approval and informed consent, patients undergoing shoulder surgery were recruited to this randomized, double-blind, up-down sequential allocation study. The volume used for both US and NS was dependent upon the success or failure of the previous block. Success was defined as a verbal rating score of 0/10, 30 min after surgery. Ten needle passes were allowed before defaulting to the opposite group. Patients received general anaesthesia. Pain scores and analgesic consumption were assessed by a blinded observer. Statistical comparisons of continuous variables were performed using Student's t-test and Mann-Whitney U-test as appropriate. Categorical variables were analysed using χ² test. MEAV values were estimated using log-transformed up-down independent pairs analysis and probit regression. Significance was assumed at P<0.05 (two-sided). RESULTS: The MEAV required to provide effective analgesia was significantly (P=0.034) reduced to 0.9 ml [95% confidence interval (CI) 0.3-2.8] in the US group from 5.4 ml (95% CI 3.4-8.6) in the NS group. Fewer needle passes were needed to identify the brachial plexus with US (1 vs 3; P<0.0001) and patients had less pain at 30 min after surgery (P=0.03). CONCLUSIONS: US reduces the number of attempts, LA volume, and postoperative pain when compared with NS for ISB.

Brain death and organ donation: an audit in the Irish National Transplantation and Neurosurgical Centre.

We set out to identify the reasons why potential organ donors (PODs) fail to become actual donors and the causes of under-utilization of organs offered for donation. We audited 354 patients who died in the intensive Care Unit over 18 months. Of 155 PODs, 78 (50%) did not undergo brain stem testing (BST) because of (i) unavoidable death from non-CNS causes before BST (n = 50), (ii) treatment withdrawal without BST (n = 17) and (iii) preconditions for BST were not fulfilled (n = 11). Brain death was confirmed in 75 patients. Relatives refused consent for donation in 25 patients organ donation was not discussed with the family in 6, and medical contraindications to organ donation prevented donation in 5. Thirty seven (24% of all PODs) became organ donors who provided a total of 216 organ. All donated kidneys were utilized but unsuitability and logistic issues prevented utilization of 20% and 13% of all donated organs respectively. The commonest reason for failure to utilise potential organ donors was failure to perform BST. In most cases this was because BSTs were not possible but more aggressive management of and the routine performance of BST in all PODs could increase the number of donors. Not approaching relatives to ask consent for organ donation and a high rate of refusal by relatives also led to loss of organ donors.

Amniotic fluid embolism and isolated coagulopathy: atypical presentation of amniotic fluid embolism.

A 41-year-old multigravida presented at 32 weeks of gestation with polyhydramnios and an anencephalic fetus. Abnormal bleeding as a result of disseminated intravascular coagulation complicated an emergency Caesarean section for severe abdominal pain thought to be due to uterine rupture. Massive transfusion with blood products was necessary and the abdomen packed to control bleeding. The patient was transferred to the intensive care unit where she made a slow but complete recovery. Amniotic fluid embolism with atypical presentation of isolated coagulopathy is the likely diagnosis in this case. The case serves to demonstrate that amniotic fluid embolism may present with symptoms and signs other than the classical pattern of dyspnoea, cyanosis and hypotension.

Analgesia during radial artery cannulation: comparison of the effects of lidocaine applied by local injection or iontophoresis.

We compared the effect of lidocaine injection with lidocaine iontophoresis for pain relief during radial artery cannulation prior to induction of anaesthesia. Patients were allocated randomly to one of two groups. Group 1 (n = 15) received iontophoresis for 10 min prior to cannulation, using 4% lidocaine 4 ml. Group 2 (n = 15) received local infiltration of 1% lidocaine 1 ml using a 25G needle. Pain scores were recorded immediately after cannulation using a 10-cm visual analogue scale (VAS). There was no difference in mean (SD) pain scores [group 1: 2.2 (1.5) cm; group 2: 2.3 (2.7) cm; 95% CI of difference -1.8 to 1.5 cm]. Lidocaine delivered by iontophoresis is an effective and painless method of providing analgesia for radial artery cannulation.

Unplanned hospital admission in children undergoing day-case surgery.

BACKGROUND AND OBJECTIVE: Unplanned hospital admission is a measure of quality of care in the setting of day-case surgery. We set out to identify the incidence and causes of unplanned hospital admission in a paediatric day-case unit. METHODS: A retrospective survey to determine the incidence and causes of unplanned hospital admissions in children undergoing day-case surgery. The survey covered the period from January 1996 until December 1999 inclusive in a university affiliated children's hospital. This hospital is the second largest paediatric referral centre in Ireland with total admissions across all specialities during the study period of 42 738. RESULTS: During the study period 10 772 children underwent day-case surgery, of whom 242 (2.2%) experienced unplanned hospital admission. The reasons for admission were surgical 146 (54%), anaesthetic 44 (16%), social 38 (14%), medical 31 (11%) and unclassified 10 (4%). Pain, surgical complications and/or further management, admission for observation, extensive surgery and oozing were the commonest surgical reasons. Postoperative nausea and vomiting, anaesthetic-related complication and somnolence were the commonest anaesthetic causes responsible for admission. Surgery performed after 15:00 h was an important factor associated with admission for social reasons. Orthopaedic surgery accounted for the largest absolute number of unplanned admissions with 61 (25%), followed by urology with 46 (19%) and general surgery with 46 (19%). However, measured as percentage of caseload, urology had the highest proportion of unplanned hospital admissions. CONCLUSION: This study demonstrated that the incidence and causes of unplanned hospital admission following day-case surgery in children are similar to those for adults.