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.

Early and late outcome after single step dilatational tracheostomy versus the guide wire dilating forceps technique: a prospective randomized clinical trial.

PURPOSE: Percutaneous tracheostomy is frequently performed in long-term ventilated patients in the intensive care unit (ICU). Unfortunately, despite many years of experience, the optimal technique is still unknown, especially considering the occurrence of late complications. The purpose of this study was to determine which of the two most frequently used percutaneous tracheostomy techniques performs best with the emphasis on late complications. METHODS: This prospective randomized trial involved 120 patients, comparing two techniques of percutaneous tracheostomy, the guide wire dilating forceps (GWDF) and the single step dilatational tracheostomy (SSDT) technique. RESULTS: Sixty patients in each group underwent a percutaneous tracheostomy and were followed for up to 3 months after decannulation. The majority of complications in both groups were minor (58.3% in the GWDF group and 61.7% in the SSDT group). We found a trend towards more major perioperative complications in the GWDF group versus the SSDT group, 10.0 versus 1.7% (p = 0.06). One patient in the SSDT group developed a significant tracheal stenosis. However, this may also have been related to prolonged translaryngeal intubation. Results of magnetic resonance imaging (MRI) investigations showed only minor tracheal changes. Only 37.5% of patients in the GWDF group and 31.8% in the SSDT group had no complaints after their percutaneous tracheostomy. CONCLUSION: Compared with the GWDF, the SSDT shows a trend toward less major perioperative complications with a comparable long-term outcome.

Comparison of two percutaneous tracheostomy techniques, guide wire dilating forceps and Ciaglia Blue Rhino: a sequential cohort study.

INTRODUCTION: To evaluate and compare the peri-operative and postoperative complications of the two most frequently used percutaneous tracheostomy techniques, namely guide wire dilating forceps (GWDF) and Ciaglia Blue Rhino (CBR). METHODS: A sequential cohort study with comparison of short-term and long-term peri-operative and postoperative complications was performed in the intensive care unit of the University Medical Centre in Nijmegen, The Netherlands. In the period 1997-2000, 171 patients underwent a tracheostomy with the GWDF technique and, in the period 2000-2003, a further 171 patients with the CBR technique. All complications were prospectively registered on a standard form. RESULTS: There was no significant difference in major complications, either peri-operative or postoperative. We found a significant difference in minor peri-operative complications (P < 0.01) and minor late complications (P < 0.05). CONCLUSION: Despite a difference in minor complications between GWDF and CBR, both techniques seem equally reliable.