Pregabalin and dexamethasone improves post-operative pain treatment after tonsillectomy.

BACKGROUND: Post-tonsillectomy pain can be severe. We investigated the analgesic effect from combinations of paracetamol, pregabalin and dexamethasone in adults undergoing tonsillectomy. METHODS: In this randomized double-blind study, 131 patients were assigned to either group A (paracetamol+placebo), group B (paracetamol+pregabalin+placebo) or group C (paracetamol+pregabalin+dexamethasone). Pre-operatively, patients received either paracetamol 1000 mg, pregabalin 300 mg, dexamethasone 8 mg or placebo according to their allocation. Post-operative pain treatment included paracetamol 1000 mg 4× and ketobemidone 2.5 mg p.n. Ketobemidone consumption, pain scores [visual analogue scale (VAS)], nausea, sedation, dizziness, number of vomits and consumption of ondansetron were recorded 2, 4 and 24 h after the operation. P<0.05 was considered statistically significant. RESULTS: The mean 24-h VAS-pain score at rest was reduced in group C (P<0.003) vs. group A. The mean 24-h VAS-pain scores during swallowing were reduced in group B (P=0.009) and group C (P<0.003) vs. group A. Consumption of ketobemidone (1-4 h post-operatively) was lower in group B (P=0.003) and group C (P=0.003) vs. group A. The mean 24-h dizziness score was higher in group B (P<0.003) and C (P=0.003) vs. group A. Other parameters including re-operation for post-tonsillectomy bleeding were not different between groups. CONCLUSION: Pregabalin and pregabalin+dexamethasone reduced post-operative pain scores and consumption of ketobemidone following tonsillectomy. Dizziness was increased with pregabalin.

The effect of gabapentin on post-operative pain following tonsillectomy in adults.

BACKGROUND: The aim of the present study was to investigate whether a combination of rofecoxib and gabapentin could improve pain relief and reduce opioid requirements, compared with rofecoxib alone, during the first 5 days after tonsillectomy. METHODS: In a randomized, double-blind, placebo-controlled study, 49 patients received gabapentin 1200 mg pre-operatively, followed by gabapentin 2 x 600 mg on the day of operation and gabapentin 3 x 600 mg for the next 5 days, or placebo. Both groups were given rofecoxib 50 mg daily. In the post-operative care unit, intravenous morphine was administered in doses of 2.5 mg on request. From 4 h to 5 days post-operatively, ketobemidone was offered as escape drug. Pain at rest and during swallowing, and side-effects, were assessed using a four-point verbal rating scale. RESULTS: As a result of the global withdrawal of rofecoxib, the study had to be terminated prematurely. This report comprises the results from 22 patients in the gabapentin group and 27 patients in the placebo group. Gabapentin reduced ketobemidone requirements during the first 24 h post-operatively [4.5 mg (standard deviation, 3.0 mg) in the placebo group vs. 2.0 mg (standard deviation, 2.0 mg) in the gabapentin group; P < 0.003]. Gabapentin induced more dizziness (P < 0.002), gait disturbance (P < 0.02) and vomiting (P < 0.05) during days 0-5 than placebo. No other statistically significant differences were observed. CONCLUSION: Gabapentin reduced opioid requirements in the first 24 h after tonsillectomy. The benefits of the reduced opioid intake may be overshadowed by the drawbacks of side-effects.

Return hospital visits and morbidity within 60 days after day surgery: a retrospective study of 18,736 day surgical procedures.

BACKGROUND: As day surgery includes more extensive procedures focus should be put on late outcome. The frequency of day surgery-related return visits and the associated morbidity were examined to identify suitable indicators of quality. METHODS: From two centres, 16,048 patients underwent 18,736 day surgery operations including 4,829 surgical abortions. Patients were retrospectively analysed for contacts to Danish hospitals within 60 post-operative days and the associated morbidity and mortality. Data were obtained from the Danish National Patient Registry and the National Causes of Death Registry. Patient records were studied to validate contacts as being definite, likely, possible or not related. RESULTS: Altogether 113 patients (not including the surgical abortions) were readmitted to hospitals with 117 complications definitely or likely related to day surgery. The most common complications were haematomas or haemorrhage (0.40%) and infections (0.29%). Morbidity after the two most common procedures, hernia repair and knee arthroscopy, was observed in 1:39 patients and 1:220 patients, respectively. More serious complications included four patients with septic arthritis of the knee and six patients with venous thromboembolism. After surgical abortion, pelvic inflammation and bleeding were observed in 3.1% and 2.2%, respectively, with centre differences. Altogether no myocardial infarctions, central nervous system deficits, pneumonias or deaths were recorded that could definitely or likely be related to day surgery. CONCLUSION: Day surgery in Denmark is a safe practice. Readmission rates, haematomas and wound infections are likely future indicators of outcome quality after day surgery.

Randomized clinical trial comparing an oral carbohydrate beverage with placebo before laparoscopic cholecystectomy.

BACKGROUND: Preoperative oral carbohydrate can attenuate postoperative insulin resistance and catabolism, and may have the potential to improve postoperative recovery. There are no data from randomized studies on postoperative clinical outcome after specific surgical procedures. This study evaluated the clinical effects of a preoperative carbohydrate beverage in patients undergoing laparoscopic cholecystectomy. METHODS: Ninety-four patients undergoing laparoscopic cholecystectomy were included in a randomized clinical trial. Patients were randomized to receive 800 ml of an iso-osmolar 12.5 per cent carbohydrate-rich beverage the evening before operation (100 g carbohydrate) and another 400 ml (50 g carbohydrate) 2 h before initiation of anaesthesia, or the same volume of a placebo beverage. The primary endpoint was general well-being the day after operation. Patients were evaluated from 5 days before to 5 days after operation. Daily scores of general well-being, fatigue, appetite and pain, computerized measurements of physical activity and sleep (actigraphy), and subjective sleep quality were recorded. Nausea and vomiting were assessed twice within the first 24 h after surgery. RESULTS: Data from 86 patients were available for statistical analysis, 43 in each treatment group. No significant intergroup differences in general well-being or any other outcome variable were found. CONCLUSION: A preoperative carbohydrate beverage did not improve clinical outcome after laparoscopic cholecystectomy.

[Laparoscopic cholecystectomy in outpatient surgery]. / Laparoskopisk kolecystektomi i dagkirurgisk regi.

INTRODUCTION: The aim of the study was to describe the organisation of laparoscopic cholecystectomy in outpatient surgery and to discuss whether the method should be the future treatment of choice. MATERIAL AND METHODS: A retrospective descriptive study was carried out on 133 consecutive patients in the period 1 October 1999 to 30 September 2000. RESULTS: Seventy-seven per cent of the patients were discharged directly from the Department of Outpatient Surgery and 121 (97%) who underwent laparoscopy were discharged within 23 hours of the operation. The postoperative complication rate was 1.5% and the frequency of readmittance was 5%. DISCUSSION: Laparoscopic cholecystectomy is suitable for outpatient surgery and appears to be a recommendable setting for this operation. The method is safe and associated with few complications and readmittances.

[Unexpected cardiac arrest during combined spinal-epidural analgesia]. / Uventet hjertestop under kombineret spinal-epidural analgesi.

A 58-year old man who had combined spinal-epidural anaesthesia for a total knee alloplasty suffered a sudden and unexpected cardiac arrest during an otherwise uncomplicated anaesthesia. The patient was promptly resuscitated by ephedrine i.v. The reason for the cardiac arrest is thought to be relative hypovolaemia. The importance of monitoring the patient, giving proper fluid-treatment and early use of ephedrine is emphasized.

The effect of balanced analgesia on early convalescence after major orthopaedic surgery.

Forty-two patients scheduled for total knee arthroplasty (n = 20) or hip arthroplasty (n = 22) were randomly allocated to receive either continuous epidural bupivacaine/morphine for 48 h postoperatively plus oral piroxicam, or general anaesthesia followed by a conventional intramuscular opioid and acetaminophen regimen. Patients undergoing knee- or hip arthroplasty treated with epidural analgesia had significantly lower pain scores during mobilization under the 48 h epidural infusion compared with patients receiving conventional treatment, while no important differences were observed after cessation of the epidural regimen. However, the achieved pain relief had no impact on postoperative convalescence parameters, such as ambulation, patient activity including need for nursing care, fatigue or hospital stay. Late postoperative pain, fatigue and conservative attitudes and routines in the postoperative care, were the most important reasons limiting mobilization and activity. We conclude that effective early (48 h) postoperative pain relief with balanced analgesia does not per se lead to important improvements in convalescence and hospital stay.

Effects of combined perioperative epidural bupivacaine and morphine, ibuprofen, and incisional bupivacaine on postoperative pain, pulmonary, and endocrine-metabolic function after minilaparotomy cholecystectomy.

BACKGROUND AND OBJECTIVES: The study investigates the effects of combined perioperative continuous epidural bupivacaine and morphine, ibuprofen, and incisional bupivacaine, compared with intermittent systemic morphine, ibuprofen, and incisional bupivacaine, on postoperative pain, respiratory function, and endocrine-metabolic alterations associated with minilaparotomy cholecystectomy. METHODS: Thirty-two patients scheduled for cholecystectomy, performed through a minilaparotomy, were randomized to receive general anesthesia with pre- and postoperative thoracic (T7-9) epidural analgesia with bupivacaine and morphine during 38 hours after the operation, or general anesthesia with morphine intramuscular for pain relief every 6-8 hours after the operation. All patients received ibuprofen before the operation until 6 days after the operation, and preoperative infiltration of the surgical field with bupivacaine. RESULTS: Both regimens almost abolished pain at rest, whereas, addition of epidural bupivacaine and morphine significantly improved analgesia during cough and mobilization (P < .05). This improvement was not sustained beyond the expected pharmacologic effect of the epidural analgesics. The postoperative decrease in pulmonary function was only brief and there were no differences between the study groups. No increase in plasma cortisol or glucose was observed from before to 6 hours after the operation, irrespective of the anesthetic regimen. CONCLUSIONS: Epidural analgesia for minilaparatomy cholecystectomy improves pain relief in the immediate postoperative period, compared to intramuscular morphine. Pulmonary and endocrine-metabolic function is not changed to such degree after minicholecystectomy that epidural analgesia can be demonstrated to have beneficial effects.

Blood pressure and heart rate during orthostatic stress and walking with continuous postoperative thoracic epidural bupivacaine/morphine.

Thirty-one patients scheduled for elective cholecystectomy performed through a mini-laparotomy, were randomized to received either combined thoracic epidural anaesthesia/light general anaesthesia and postoperative balanced analgesia with continuous epidural bupivacaine 10 mg.h-1 and morphine 0.2 mg.h-1 for 38 h after surgery plus systemic ibuprofen 600 mg x 8 h-1 (N = 15) or general anaesthesia and postoperative analgesia with systemic morphine and ibuprofen 600 mg x 8 h-1 (N = 16). During postoperative epidural infusion sensory blockade to pinprick was Th4 to L1, and analgesia at rest and during mobilisation was superior compared to systemic morphine and NSAID. There were no significant differences between groups in haemodynamic responses (BP and heart rate) during rest, orthostatic stress and after walking assessed before, 24 and 48 h after operation except for a clinically unimportant lower heart rate (approximately 10 bpm) 48 h after surgery at rest and during orthostatic stress in the epidural group. There was no significant difference between groups in number of patients with a reduction > 20 mmHg (2.7 kPa) in systolic blood pressure during orthostatic stress (two in each group at 24 h) or in number of episodes of dizziness, nausea or vomiting during rest or mobilisation. These results do not support the common belief that low-dose thoracic epidural bupivacaine/morphine may prevent ambulation due to sympathetic blockade or to impaired cardiovascular adaptation to the upright position.

Effect of piroxicam in addition to continuous thoracic epidural bupivacaine and morphine on postoperative pain and lung function after thoracotomy.

Twenty-eight patients scheduled for lung resection with lateral thoracotomy and postoperative chest drains during combined thoracic epidural bupivacaine plus morphine and general anaesthesia were studied. Postoperative pain treatment was continuous epidural infusion of bupivacaine 0.25% 5 ml h-1 plus morphine 0.2 mg h-1 for 48 h and, in addition, the patients received rectal piroxicam 40 mg randomly and double-blind 12 h and 1 h before surgery and 20 mg 24 h-1 postoperatively or placebo. Pain was evaluated at rest, during cough and mobilisation, together with pulmonary function (FEV1, FVC, PEFR) and sensory level of analgesia repeatedly for 48 h. The results showed efficient pain relief, but without differences in pain scores or need for supplementary analgesics between the two groups. Pulmonary function decreased similarly in the two groups. Thus we were unable to show enhanced analgesia by supplementing an otherwise effective low-dose epidural bupivacaine and morphine treatment with piroxicam after thoracic surgery with chest drains.

Influence of timing on the effect of continuous extradural analgesia with bupivacaine and morphine after major abdominal surgery.

We have studied the effect of continuous extradural analgesia with bupivacaine and morphine, initiated before or after colonic surgery, in a double-blind, randomized study. Thirty-two patients were allocated randomly to receive an identical extradural block initiated 40 min before surgical incision (n = 16) or at closure of the surgical wound (n = 16). The extradural regimen consisted of a bolus of 7 ml of plain bupivacaine 7.5 mg ml-1 plus morphine 2 mg and continuous extradural infusion of a mixture of bupivacaine 7.5 mg ml-1 plus morphine 0.05 mg ml-1, 4 ml h-1 for 2 h, followed by a continuous extradural infusion of a mixture of bupivacaine 2.5 mg ml-1 plus morphine 0.05 mg ml-1, 4 ml h-1, continued for 72 h after operation. In addition, all patients received similar general anaesthesia. There was no significant difference in request for additional morphine and no significant differences between the groups in pain scores (visual analogue scale or verbal) during rest or ambulation at any time of measurement. These results do not suggest that timing of analgesia with a conventional extradural regimen is of major clinical importance in patients undergoing colonic surgery.

Differential analgesic effects of low-dose epidural morphine and morphine-bupivacaine at rest and during mobilization after major abdominal surgery.

In a double-blind, randomized study, epidural infusions of low-dose morphine (0.2 mg/h) combined with low-dose bupivacaine (10 mg/h) were compared with epidural infusions of low-dose morphine (0.2 mg/h) alone for postoperative analgesia at rest and during mobilization and cough in 24 patients after elective major abdominal surgery. All patients in addition received systemic piroxicam (20 mg daily). No significant differences were observed between the groups at any assessment of pain at rest (P greater than 0.05), whereas pain in the morphine/bupivacaine group was significantly reduced during mobilization from the supine into the sitting position 12 and 30 h after surgical incision and during cough 8, 12, and 30 h after surgical incision (P less than 0.05). We conclude, that low-dose epidural bupivacaine potentiates postoperative low-dose epidural morphine analgesia during mobilization and cough. Evaluation of postoperative analgesic regimens should include assessment of pain during various activities as different analgesics may have differential effects on pain at rest and during mobilization.

Effects of lidocaine aerosol on postoperative pain and wound tenderness following minor gynaecological laparotomy.

Twenty-four female patients undergoing sterilization through a minor lower laparotomy received, in a double-blind, randomized study, either lidocaine spray 200 mg or placebo in the surgical wound. Postoperative pain intensity was evaluated on a verbal and a visual analogue scale and wound tenderness with an algometer. During mobilisation from the supine to the sitting position, VAS-score was lower (P less than 0.05) in the lidocaine group 2 h postoperatively, but not 4, 6 and 8 h postoperatively (P greater than 0.05). No significant differences were found in VAS-scores at rest or during cough, or in verbal scale ratings during rest, cough or mobilisation, and postoperative consumption of morphine was similar in the two groups. Pressure pain thresholds were higher (P less than 0.05) 2 h postoperatively in the lidocaine group, but not 4, 6 and 8 h postoperatively. In conclusion, topically applied lidocaine aerosol in the surgical wound leads to very short and clinically insignificant relief of postoperative pain.

[Minicholecystectomy]. / Minikolecystektomi.

Mini-cholecystomectomy was performed in 24 unselected patients with symptomatic gallbladder stones with pain control by intra- and postoperative epidural analgesia. Twenty three patients were discharged on the second postoperative day, while one patient who required re-laparotomy for haemostasis had recovered completely on the third day postoperatively. Median pain score (VAS) was 0 at rest, during coughing and mobilisation. Pulmonary function was not influenced significantly and postoperative fatigue normalized after 48 hours. These preliminary, uncontrolled observations suggest that mini-cholecystectomy is advantageous compared to conventional cholecystectomy, and may represent an alternative to laparoscopic cholecystectomy.

[Sudden unexpected respiratory arrest outside hospital among young patients with asthma]. / Pludseligt, uventet respirationsstop hos unge asthmapatienter uden for hospital.

In a prospective investigation lasting for one year, the medically staffed ambulance in Copenhagen registered patients under the age of 60 years with asthma who developed respiratory arrest outside hospital. The circumstances involved in the acute serious cases were illustrated as far as possible by review of the case records and interviews with the surviving patients. Five patients participated in the investigation. All of these were young with a median age of 24 years (19-28). Two patients had cardiac arrest, four patients survived after tracheal intubation at the site of the onset of illness and subsequent mechanical ventilation. One patient died in hospital on account of anoxic encephalopathy. The common denominators of all of the patients were that the condition had been recognized for many years, that before the attack involved they had been well and without asthmatic symptoms, the attack commenced hyper-acutely and the patients had not taken medicine regularly during a prolonged period. On the basis of these observations, the present authors recommend that young patients with asthma should receive optimal medication and that the necessity of taking the prescribed medicine despite possible good health should be emphasized.

[Emergency prehospitalization treatment of cardiac arrest in the municipality of Copenhagen]. / Akut praehospitalsbehandling af hjertestop i Københavns Kommune.

A retrospective study was performed concerning prehospital cardiac arrest. This revealed that 177 consecutive patients received advanced medical resuscitation by an anaesthesiologist at the site of the accident during the period 01.01.1988-31.12.1988. A total of 61 (35%) were admitted to hospital and 24 of these (14%) survived for more than 30 days. All 24 were discharged to their homes without major cerebral sequelae. After one year, 21 were still alive. Compared with the results of previous studies in Copenhagen, this study reveals that the overall survival rate may have improved and that cerebral function after cardiac arrest seems to have been improved by the introduction of prehospital medically staffed ambulances.

[Treatment of postoperative pain]. / Postoperativ smertebehandling.

Intensive research during recent years concerning treatment of postoperative pain has demonstrated that the majority of operation patients can be rendered free from pain but that this is far from being the case in clinical practice. This article reviews the physiological mechanisms of acute pain and the methods available for treatment of pain related to acute physiology of pain. Postoperative treatment of pain should be aggressive with the object of preventing pain and normalizing the vital functions with the object of reducing the perioperative morbidity and mortality. A series of recommendations are given for treatment of pain after surgical intervention.

[Assessment of early postoperative convalescence by a simple scoring system]. / Vurdering af tidlig postoperativ rekonvalescens ved hjaelp af et simpelt scoringssystem.

Fifty patients in classes 1-2 of the American Society of Anaesthesiologists (ASA) were submitted to major elective abdominal surgery. They were anaesthetised with a balanced technique and were assessed preoperatively and daily until the tenth postoperative day by a simple scoring system based on self-care. The total score fell significantly to a minimum on the first postoperative day and remained significantly decreased but with an increasing tendency until the tenth postoperative day. Patients with wound or respiratory complications had significantly lower scores than patients without complications on the sixth to ninth days. It is concluded that this simple scoring system is useful for monitoring early postoperative morbidity and it may prove of value in future investigations of surgical therapeutic regimes.

Comparison of the effects of extradural clonidine with those of morphine on postoperative pain, stress responses, cardiopulmonary function and motor and sensory block.

We have examined the effects of extradural clonidine 150 micrograms or morphine 4 mg on postoperative pain, stress responses, cardiopulmonary function and motor and sensory block in a double-blind, randomized study in 20 patients undergoing hysterectomy with general anaesthesia. Observations were made for 6 h after each patient's first request for analgesia. Clonidine provided greater pain relief than morphine only for the first 2 h of observation (P less than 0.001). Plasma cortisol concentrations decreased to a greater extent (P less than 0.05) with morphine, while plasma glucose concentration increased by a similar extent in both groups. After clonidine, mean arterial pressure decreased from 100 (SEM 3) mm Hg to 70 (3) mm Hg (P less than 0.05), but there was no change after morphine. There were no significant changes in heart rate, pulmonary function (FEV1), motor function or sensory analgesia to touch, temperature and pinprick in both groups. Additional systemic opioids were required by five and six patients in the clonidine and morphine groups, respectively.

The roles of acute and chronic pain in regression of sensory analgesia during continuous epidural bupivacaine infusion.

The purpose of this study was to investigate whether regression of sensory analgesia during constant epidural bupivacaine infusion was different in postoperative patients with acute pain than in patients with chronic nonsurgical pain. Sensory levels of analgesia (to pinprick) and pain (on a five-point scale) were assessed hourly for 16 hours during continuous epidural infusion of 0.5% plain bupivacaine (8 ml/hr) in 12 patients with chronic nonsurgical pain and in 30 patients after major abdominal surgery performed under combined bupivacaine and halothane--N2O general anesthesia. No opiates were given. If sensory analgesia decreased more than five segments from the initial level or if the pain score reached 2 (moderate pain), the patient was removed from the study. Initial levels of sensory analgesia after loading doses of 21.8 +/- 0.5 and 19.3 +/- 0.8 ml bupivacaine 0.5% were similar (T3.8 +/- 0.3 and T3.8 +/- 0.5) in the surgical and chronic pain patients, respectively (mean +/- SEM). Of the surgical patients, only 4 of the 30 (13%) maintained the initial level of sensory analgesia, and a pain score below 2 throughout the study compared with 7 of the 12 patients with chronic pain (58%) (P less than 0.01). Mean duration of sensory blockade was significantly longer (P less than 0.005) in the patients with chronic pain than in surgical patients (13.1 +/- 1.2 and 8.5 +/- 0.7 hours, respectively). Thus, surgical injury hastens regression of sensory analgesia during continuous epidural bupivacaine infusion. The underlying mechanism remains to be determined.