The Effect of Intraoperative Dexmedetomidine Versus Morphine on Postoperative Morphine Requirements After Laparoscopic Bariatric Surgery.

BACKGROUND: Dexmedetomidine is an α2 receptor agonist with sedative and analgesic properties. During bariatric surgery, its use may reduce postoperative opioid requirements, reduce their side effects, and improve quality of recovery. The aim of this prospective randomized controlled trial was to compare the effect of dexmedetomidine bolus and infusion versus morphine bolus given prior to the end of laparoscopic bariatric surgery. METHODS: Sixty morbidly obese patients (BMI > 40 kg m-2) aged 18 to 60 years, undergoing laparoscopic sleeve gastrectomy, received morphine sulfate (bolus 0.08 mg kg-1 followed by a saline infusion) (group M, n = 30) or dexmedetomidine (loading dose of 1 µg kg-1 followed by 0.5 µg kg-1 h-1) (group D, n = 30) 30 min before the end of surgery. Data collected included morphine consumption in the post-anesthesia care unit (PACU) (primary outcome) and at 24 h, pain intensity, nausea, heart rate, blood pressure, vomiting, sedation, and quality of recovery. RESULTS: There was no significant difference in morphine consumption in the PACU (group D 12.2 ± 5.44 mg, group M 13.28 ± 6.64 mg, P = 0.54) or at 24 h (group D 40.67 ± 24.78 mg, group M 43.28 ± 27.79 mg, P = 0.75); when accounting for intraoperative morphine given group M had significantly higher morphine consumption when compared to group D (23.48 ± 6.22 mg vs. 12.22 ± 5.54 mg, respectively, P < 0.01). Group D patients had more cardiovascular stability. CONCLUSIONS: Dexmedetomidine given prior to end of laparoscopic sleeve gastrectomy provides the same level of postoperative analgesia as morphine with better hemodynamic profile.

Dexamethasone with either granisetron or ondansetron for postoperative nausea and vomiting in laparoscopic surgery.

In a prospective randomized double-blind study, we compared the effectiveness of dexamethasone 8 mg with either granisetron 1 mg or ondansetron 4 mg in the prevention of postoperative nausea and vomiting in patients undergoing laparoscopic surgery. Hundred ASA I and II patients scheduled for laparoscopic surgery were enrolled in the study and 84 patients completed it. Following induction of anesthesia, group I (n=42) received granisetron 1 mg and dexamethasone 8 mg, group II (n=42) received ondansetron 4 mg and dexamethasone 8 mg. Nausea and vomiting episodes, pain scores as well as side effects were recorded during the first hour and subsequently during the first 6 and 24 hours postoperatively. Satisfaction scores were obtained at discharge. There was no statistically significant difference between the 2 groups during the 1st 24 hours following surgery in regards to pain scores, satisfaction and side effects manifestations. At 0-1 hour interval, 100% of patients in group I and 97.6% in group II had no vomiting. Total response (no moderate or severe nausea and no rescue antiemetics) was 83.3% in group I and 80.95% in group II, and metoclopramide was used in 7.1% of patients in both groups. At 1-6 hours interval, 97.6% of patients in group I and 100% in group II had no vomiting. Total response was 92.8% in group I and 90.9% in group II, and metoclopramide was used in 4.76% of patients in group I and 2.38% in group II. At 6-24 hours no vomiting occurred in 97.6% of patients in group I and 100% in group II. Total response was 95.2% in both groups, and metoclopramide was used in 2.38% of patients in both groups. In conclusion, the combination of dexamethasone 8 mg with either granisetron 1 mg or ondansetron 4 mg following induction of anesthesia in patients undergoing laparoscopic surgery showed no statistically significant difference in antiemetic efficacy with minimal side effects and excellent patient satisfaction.

Anesthesia for laparoscopy: a review.

Laparoscopy is the process of inspecting the abdominal cavity through an endoscope. Carbon dioxide is most universally used to insufflate the abdominal cavity to facilitate the view. However, several pathophysiological changes occur after carbon dioxide pneumoperitoneum and extremes of patient positioning. A thorough understanding of these pathophysiological changes is fundamental for optimal anesthetic care. Because expertise and equipment have improved, laparoscopy has become one of the most common surgical procedures performed on an outpatient basis and to sicker patients, rendering anesthesia for laparoscopy technically difficult and challenging. Careful choice of the anesthetic technique must be tailored to the type of surgery. General anesthesia using balanced anesthesia technique including several intravenous and inhalational agents with the use of muscle relaxants showed a rapid recovery and cardiovascular stability. Peripheral nerve blocks and neuraxial anesthesia were both considered as safe alternative to general anesthesia for outpatient pelvic laparoscopy without associated respiratory depression. Local anesthesia infiltration has shown to be effective and safe in microlaparoscopy for limited and precise gynecologic procedures. However, intravenous sedation is sometimes required. This article considers the pathophysiological changes during laparoscopy using carbon dioxide for intra-abdominal insufflation, outlines various anesthetic techniques of general and regional anesthesia, and discusses recovery and postoperative complications after laparoscopic abdominal surgery.

Intraperitoneal and intravenous routes for pain relief in laparoscopic cholecystectomy.

BACKGROUND: Postoperative abdominal and shoulder pain are the most common complaints after elective laparoscopic cholecystectomy. Postoperative pain is multifactorial in origin, and therefore multimodal therapy may be needed to optimize pain relief. METHODS: We conducted a double-blind study where patients were randomly allocated to 1 of 5 groups of 20 patients each. Statistical significance was considered P<0.05. Group 1 received 40 mL bupivacaine 0.25% intraperitoneal spray. Group 2 received 40 mL bupivacaine 0.25% intraperitoneal spray mixed with 200 mg ketoprofen. Group 3 received 40 mL bupivacaine 0.25% intraperitoneal spray and intravenous 200 mg ketoprofen. Group 4 received 200 mg ketoprofen intravenously. Group 5 was the control group. RESULTS: Demographic data were similar in the 5 groups. As compared with the control group, group 1 had significantly lower abdominal pain scores at 6 hours; group 2 at 0, 1, 2, and 6 hours; group 3 at 0, 1, 2, 6, 12, and 24 hours; and group 4 at 2 hours. Group 1 had significantly lower shoulder pain scores at 1 and 6 hours; group 2 at 0 and 6 hours; and groups 3 and 4 at 0, 1, and 6 hours. The number of patients requiring postoperative rescue analgesics and the incidence of postoperative vomiting were significantly lower in group 3 only. CONCLUSIONS: A multimodal approach to pain management following elective laparoscopic cholecystectomy is best achieved with a combination of 40 mL bupivacaine 0.25% intraperitoneal spray and 200 mg intravenous ketoprofen, achieving the least incidence of postoperative vomiting.

A combination of alfentanil-lidocaine-propofol provides better intubating conditions than fentanyl-lidocaine-propofol in the absence of muscle relaxants.

PURPOSE: To compare the ease of tracheal intubation without the use of muscle relaxants following an alfentanil-lidocaine-propofol sequence vs a fentanyl-lidocaine-propofol sequence. CLINICAL FEATURES: In 80 ASA I and II adult patients undergoing elective laparoscopic surgery, we compared the intubating conditions following alfentanil 20 microg x kg(-1), lidocaine 1.5 mg x kg(-1), propofol 3 mg x kg(-1) (Group I; n = 40) vs fentanyl 2 microg x kg(-1), lidocaine 1.5 mg x kg(-1), propofol 3 mg x kg(-1) (Group II; n = 40). The intubating conditions were scored by jaw relaxation, vocal cord position and response to intubation, as well as by blood pressure and heart rate changes. The intubating conditions were good or excellent in 95% of patients in Group I vs 62.5% of patients in Group II (P < 0.05). Blood pressure decreased from a preinduction value of 86 +/- 13 mmHg to 72 +/- 28 mmHg and 74 +/- 19 mmHg in Group I, and from 85 +/- 12 mmHg to 78 +/- 15 mmHg and 78 +/- 12 mmHg in Group II, one and five minutes following intubation (P < 0.05). This drop in blood pressure was not different between the two groups. CONCLUSION: An alfentanil-lidocaine-propofol sequence offers significantly better intubating conditions than a fentanyl-lidocaine-propofol sequence in healthy adult patients.