The impact of orthostatic intolerance on early ambulation following abdominal surgery in an enhanced recovery programme.

BACKGROUND: The prevalence of orthostatic intolerance on the day of surgery is more than 50% after abdominal surgery. The impact of orthostatic intolerance on ambulation on the day of surgery has been little studied. We investigated orthostatic intolerance and walking ability after colorectal and bariatric surgery in an enhanced recovery programme. METHODS: Eighty-two patients (colorectal: n = 46, bariatric n = 36) were included and analysed in this prospective study. Walk tests for 2 min (2-MWT) and 6 min (6-MWT) were performed before and 24 h after surgery, and 3 h after surgery for 2-MWT. Orthostatic intolerance characterised by presyncopal symptoms when rising was recorded at the same time points. Multivariate binary logistic regressions modelling the probability of orthostatic intolerance and walking inability were performed taking into account potential risk factors. RESULTS: Prevalence of orthostatic intolerance and walking inability was, respectively, 65% and 18% 3-hour after surgery. The day after surgery, patients' performance had greatly improved: approximately 20% of the patients experienced orthostatic intolerance, whilst only 5% of the patients were unable to walk. Adjusted binary logistic regressions demonstrated that age (p = .37), sex (p = .39), BMI (p = .74), duration of anaesthesia (p = .71) and type of surgery (p = .71) did not significantly influence walking ability. CONCLUSION: Our study confirms that orthostatic intolerance was frequent (~ 60%) 3-hour after abdominal surgery but prevented a 2-MWT only in ~20% of patients. No risk factors for orthostatic intolerance and walking inability were evidenced.

Impact of non-steroidal anti-inflammatory drugs on the efficiency of enhanced recovery programmes after colorectal surgery: a retrospective study of the GRACE database.

BACKGROUND: Multimodal analgesia is considered a key element of enhanced recovery programmes (ERPs) after colorectal surgery. We investigated the effects of NSAIDs, a major component of multimodal analgesia on adherence to ERP, incidence of postoperative complications, and length of hospital stay (LOS). METHODS: This was a retrospective study of the GRACE database that included 8611 patients scheduled for colorectal surgery with an ERP between February 2016 and November 2019. Primary endpoints were adherence to the postoperative protocol, the rate and type of postoperative complications, and LOS. Data are median [IQR] and number (per cent). Multivariate models were used to assess the effects of NSAIDs on these variables taking into account potential confounding factors. RESULTS: Data from 8258 patients were analysed and classified into four groups according to whether NSAIDs had been given intra- and/or postoperatively or not at all; 4578 patients were given NSAIDs intra- and/or postoperatively and 3680 patients received no NSAIDs. Use of NSAIDs was significantly (P<0.001) associated with improved adherence to the postoperative protocol (4.0 [3.0-4.0] vs. 3.0 [2.0-4.0] items), a reduced incidence of complications (21.1% vs. 29.2%), and a shortened LOS (5.0 [3.0-7.0] vs. 6.0 [4.0-9.0] days) compared to the no-NSAIDs group. Multivariate analyses adjusted for the confounding factors confirmed a significant (P<0.001) beneficial impact of NSAIDs on these three primary endpoints. CONCLUSION: This study suggests that perioperative NSAID use results in better adherence to the postoperative protocol, fewer postoperative in-hospital complications, and shorter LOS after colorectal surgery.

Short message service as a tool to improve perioperative follow-up of surgical outpatients: A before-after study.

BACKGROUND: In outpatient surgery, the patients may be called by phone for detecting and managing perioperative problems. However, phone calls consume time and can waste caregiver's time when the patient is not available. Information and communication technologies could bridge the gap between available resources and need to contact patients. METHODS: In the present before-after study, the before-implementation group was contacted by phone (phone group). The after group was contacted with a SMS or a phone call according to patient's preference (SMS group). The primary outcome was the non-inferiority of the SMS system on the occurrence of preoperative events disturbing the organisation of unit including cancellation of the case related to patient's condition the day before and the day of surgery; non-compliance with fasting rules or requirement of an escort; non-adherence to instructions regarding medication; not reporting to the surgical centre, or a delayed arrival > 30 min. RESULTS: Among 1300 included outpatients (650 per group), 381 (59%) and 542 (83%) patients were successfully contacted in the preoperative period in phone or SMS group, respectively P < 0.0001). Preoperative events were observed in 94 patients of the phone group (14.5% [CI 95% 11.9-17.3]) and in 77 patients of the SMS group (11.8% [CI 95% 9.5-14.6]), meaning that the upper bound 95% CI of the group was within the non-inferiority margin. CONCLUSIONS: In outpatient surgery, implementation of an SMS-based system, supplemented by phone calls for contacting patients is not inferior to a phone-based system in regard to preoperative events.

Bilateral subcostal transversus abdominis plane block does not improve the postoperative analgesia provided by multimodal analgesia after laparoscopic cholecystectomy: A randomised placebo-controlled trial.

BACKGROUND: Laparoscopic cholecystectomy might be considered minor surgery, but it may result in severe postoperative pain. Subcostal transversus abdominis plane (TAP) block, which produces long-lasting supra-umbilical parietal analgesia, might improve analgesia after laparoscopic cholecystectomy. OBJECTIVE: We investigated whether subcostal TAP block would reduce opioid consumption and pain after laparoscopic cholecystectomy in patients provided with multimodal analgesia. DESIGN: A randomised, placebo-controlled, double-blind study. SETTING: The study was conducted at a university teaching hospital from December 2017 to June 2018. PATIENTS: Sixty patients scheduled for laparoscopic cholecystectomy were included. Anaesthesia and postoperative analgesia (etoricoxib, paracetamol, ketamine and dexamethasone) were standardised. INTERVENTION: After induction of anaesthesia, patients were allocated into two groups: ultrasound-guided bilateral subcostal TAP block with 20 ml of levobupivacaine 0.375% and epinephrine 5 µg ml or 0.9% saline with epinephrine 5 µg ml. MAIN OUTCOME MEASURES: Opioid consumption in the recovery room and during the first 24 h after surgery were recorded. Postoperative somatic and visceral pain scores, fatigue and nausea were measured. Intra-operative end-tidal concentrations of sevoflurane (FETSEVO) were also recorded. RESULTS: Twenty-four hour postoperative opioid consumption were similar in both groups: 21.2 mg (95% CI 15.3 to 27.1) vs. 25.2 (95% CI 15.1 to 35.5) oral morphine equivalent in the levobupivacaine and 0.9% saline groups, respectively; P = 0.48. No significant between-group differences were observed with regards to parietal (P = 0.56) and visceral (P = 0.50) pain scores, fatigue and nausea. FETSEVO was slightly lower in the levobupivacaine group (P < 0.01). CONCLUSION: Subcostal TAP block does not improve the analgesia provided by multimodal analgesia after laparoscopic cholecystectomy. It allows for a small reduction in intra-operative sevoflurane requirements. TRIAL REGISTRATION: NCT0339153.

Prevalence, characteristics and risk factors of chronic postsurgical pain after laparoscopic colorectal surgery: Retrospective analysis.

BACKGROUND: The prevalence of chronic postsurgical pain (CPSP) is a critical medical problem with economic implications. Its prevalence after gastrointestinal surgery is not well documented, particularly when a laparoscopic approach is used. OBJECTIVE: The aim of the study was to determine the prevalence, the characteristics and the risk factors for CPSP after laparoscopic colorectal surgery. DESIGN: A retrospective analysis using a postal questionnaire. SETTING: The study was conducted at a university teaching hospital. PATIENTS: Patients who underwent laparoscopic colorectal surgery from April 2008 until December 2011 (n = 260). No epidural analgesia was used. MAIN OUTCOME MEASURES: Postoperative pain intensity, incidence and characteristics of CPSP, and impact on quality of life and sleep. RESULTS: Of 199 responses, 33 patients (17%) reported chronic pain at a median [interquartile range, IQR] of 38 [27 to 55] months after laparoscopic surgery with a median intensity of 4 [3 to 5]. CPSP had a negative impact on the quality of life in 84% of patients and on sleep in 43%. CPSP required regular analgesic(s) intake in 54% patients. Using a backward stepwise multivariate logistic regression model, the following variables were determined as independent risk factors for CPSP: redo surgery for anastomotic leakage (P = 0.01), inflammatory bowel disease (IBD) as the indication for surgery (P = 0.01) and preoperative pain (P = 0.05). CONCLUSION: The incidence of CPSP after laparoscopic colorectal surgery (17%) is similar to those reported in the literature after laparotomy. Risk factors are redo surgery for postoperative peritonitis, IBD and preoperative pain. TRIAL REGISTRATION: EudraCT 2012-005712-25.

Effects of oral preoperative carbohydrate on early postoperative outcome after thyroidectomy.

BACKGROUND: Preoperative carbohydrate (CHO) reduces perioperative insulin resistance and improves preoperative patient comfort. We tested the hypotheses that preoperative CHO reduces the risk of postoperative nausea and vomiting (PONV) and improves early postoperative patient comfort. METHODS: Two hundred women scheduled for thyroidectomy were randomly allocated to drink 50 g CHO in 400 ml of water or 0.5 g aspartam in 100 ml of water 2 h before surgery. The incidence and the severity of PONV, pain scores, and analgesic consumption were recorded postoperatively. Intensity of thirst, hunger, anxiety, fatigue were recorded on 100-mm visual analog scales just before the induction of anesthesia, 2, 6, and 24 h postoperatively. RESULTS: The incidence and severity of PONV were similar in both groups. Patients from the CHO group reported significantly less thirst (P = 0.007), hunger (P = 0.04), and fatigue (P = 0.01) than patients from the control group. Postoperative pain scores did not differ significantly between both groups (P = 0.34). However patients from the CHO group requested less acetaminophen during the first 24 postoperative h: 3 g vs. 2 g (median, P = 0.002). CONCLUSIONS: Oral carbohydrate before thyroidectomy improves pre- and postoperative patient comfort, as well as postoperative analgesia, but has no effect on the PONV.

Ventilatory management during routine general anaesthesia.

Intraoperative hypoxaemia and postoperative respiratory complications remain the challenges of modern anaesthetic practice. Anaesthesia causes both depression of respiratory centres and profound changes of respiratory mechanics. Most anaesthetized patients consequently require mechanical ventilation and supplemental oxygen. Recent data suggest that intraoperative respiratory management of a patient can affect postoperative outcome. In this review, we briefly describe the mechanisms responsible for the impairment of intraoperative gas exchange and provide guidelines to prevent or manage hypoxaemia. Moreover, we discuss several aspects of mechanical ventilation that can be employed to improve patients' outcome.

Effect of adrenergic stimulation on cutaneous microcirculation immediately after surgical adventitiectomy in a rat skin flap model.

Chronic sympathetic denervation leads to the development of supersentivity to adrenergic agents. Free flap surgery results in the disruption of the autonomic nerve fibers running along the anastomosed vessels. We therefore investigated the early effect of surgical sympathectomy on the reactivity of cutaneous microcirculation challenged to adrenergic agents. Two epigastric flaps were elevated and exposed in 15 rats. On the right flap (Side A), a circular adventitiectomy of the feeder vessels was realized to provide surgical sympathectomy. On the left flap (Side N), vessels were kept intact. The following drugs were then given intravenously successively: phenylephrine (10 and 15 microg kg(-1)), norepinephrine (10 microg kg(-1)), prazocin (1 mg kg(-1)) followed by norepinephrine (10 microg kg(-1)). Cutaneous microcirculation was assessed using Laser-Doppler Flowmeters simultaneously on the two flaps after each drug administration. Mean arterial pressure was also measured. On side N, phenylephrine and norepinephrine resulted in a transient increase in cutaneous microcirculation followed by a more prolonged reduction. On side A, only the initial increase was observed, which was greater and longer as compared with side N, and paralleled the increase in mean arterial pressure. After prazocin pre-treatment, norepinephrine produced a transient increase in cutaneous microcirculation similar on both sides, and parallel to the changes in arterial pressure. No decrease in cutaneous microcirculation was observed. Immediately after surgical adventitiectomy, the vasoconstriction produced by alpha-adrenergic agents is prevented. No denervation-induced hypersentivity is observed. Surgical sympathectomy might protect cutaneous flaps from vasoconstriction induced by endogenous catecholamines release.

Pressure-controlled ventilation does not improve gas exchange in morbidly obese patients undergoing abdominal surgery.

BACKGROUND: Morbid obesity results in marked respiratory pathophysiologic changes that may lead to impaired intraoperative gas exchange. The decelerating inspiratory flow and constant inspiratory airway pressure resulting from pressure-controlled ventilation (PCV) may be more adapted to these changes and improve gas exchanges compared with volume-controlled ventilation (VCV). METHODS: Forty morbidly obese patients scheduled for gastric bypass were included in this study. Total intravenous anesthesia was given using the target-controlled infusion technique. During the first intraoperative hour, VCV was used and the tidal volume was adjusted to keep end-tidal PCO(2) around 35 mmHg. After 1 h, patients were randomly allocated to 30-min VCV followed by 30-min PCV or the opposite sequence using a Siemens Servo 300. FiO(2) was 0.6. During PCV, airway pressure was adjusted to provide the same tidal volume as during VCV. Arterial blood was sampled for gas analysis every 15 min. Ventilatory parameters were also recorded. RESULTS: Peak inspiratory airway pressures were significantly lower during PCV than during VCV (P < 0.0001). The other ventilatory parameters were similar during the two periods of ventilation. PaO(2) and PaCO(2) were not significantly different during PCV and VCV. CONCLUSION: PCV does not improve gas exchange in morbidly obese patients undergoing gastric bypass compared to VCV.

Intravenous lidocaine infusion facilitates acute rehabilitation after laparoscopic colectomy.

BACKGROUND: Intravenous infusion of lidocaine decreases postoperative pain and speeds the return of bowel function. The authors therefore tested the hypothesis that perioperative lidocaine infusion facilitates acute rehabilitation protocol in patients undergoing laparoscopic colectomy. METHODS: Forty patients scheduled to undergo laparoscopic colectomy were randomly allocated to receive intravenous lidocaine (bolus injection of 1.5 mg/kg lidocaine at induction of anesthesia, then a continuous infusion of 2 mg.kg.h intraoperatively and 1.33 mg.kg.h for 24 h postoperatively) or an equal volume of saline. All patients received similar intensive postoperative rehabilitation. Postoperative pain scores, opioid consumption, and fatigue scores were measured. Times to first flatus, defecation, and hospital discharge were recorded. Postoperative endocrine (cortisol and catecholamines) and metabolic (leukocytes, C-reactive protein, and glucose) responses were measured for 48 h. Data (presented as median [25-75% interquartile range], lidocaine vs. saline groups) were analyzed using Mann-Whitney tests. P<0.05 was considered statistically significant. RESULTS: Patient demographics were similar in the two groups. Times to first flatus (17 [11-24] vs. 28 [25-33] h; P<0.001), defecation (28 [24-37] vs. 51 [41-70] h; P=0.001), and hospital discharge (2 [2-3] vs. 3 [3-4] days; P=0.001) were significantly shorter in patients who received lidocaine. Lidocaine significantly reduced opioid consumption (8 [5-18] vs. 22 [14-36] mg; P=0.005) and postoperative pain and fatigue scores. In contrast, endocrine and metabolic responses were similar in the two groups. CONCLUSIONS: Intravenous lidocaine improves postoperative analgesia, fatigue, and bowel function after laparoscopic colectomy. These benefits are associated with a significant reduction in hospital stay.

Epidural levobupivacaine 0.1% or ropivacaine 0.1% combined with morphine provides comparable analgesia after abdominal surgery.

UNLABELLED: Ropivacaine appears attractive for epidural analgesia because it produces less motor block than racemic bupivacaine. The potential benefits of levobupivacaine with regard to motor blockade require further investigations. In this study, we compared the efficacy, dose requirements, side effects, and motor block observed with epidural levobupivacaine and ropivacaine when given in combination with small-dose morphine for 60 h after major abdominal surgery. Postoperatively, 50 patients were randomly allocated, in a double-blinded manner, to patient-controlled epidural analgesia with the same settings and without basal infusion, using 0.1% levobupivacaine or 0.1% ropivacaine. Both were combined with an epidural infusion of 0.1 mg/h morphine. Pain scores, side effects, motor block, and local anesthetic consumption were measured for 60 h. Pain scores measured on a 100-mm visual analog scale were approximately 20 mm at rest and 40 mm during mobilization in both groups. Bromage scores were 1 for all patients after the fourth postoperative hour. Consumption of levobupivacaine and ropivacaine were similar: 344 +/- 178 mg levobupivacaine versus 347 +/- 199 mg ropivacaine 48 h postoperatively. On postoperative day 2, 19 patients in the ropivacaine group versus 12 in the levobupivacaine group were able to ambulate (P < 0.05). No difference was noted concerning incidence of side effects. We conclude that when used as patient-controlled epidural analgesia and combined with small-dose epidural morphine, 0.1% levobupivacaine and 0.1% ropivacaine produce comparable postoperative analgesia with a similar incidence of side effects. IMPLICATIONS: Small concentrations (0.1%) of epidural levobupivacaine and ropivacaine combined with morphine (0.1 mg/h) produce comparable analgesia and have similar side effects for similar dose requirements.

Spinal mechanisms contribute to analgesia produced by epidural sufentanil combined with bupivacaine for postoperative analgesia.

UNLABELLED: When used alone, lipid-soluble epidural opioids are thought to produce analgesia supraspinally via systemic absorption. However, spinal opioids and local anesthetics have been shown to act synergistically at the spinal level in animal studies. We, therefore, tested the hypothesis that sufentanil requirements will be less when given epidurally than IV in patients simultaneously given epidural bupivacaine after major abdominal surgery. Forty patients were anesthetized with isoflurane and epidural bupivacaine for major abdominal surgery. After surgery, each was given a continuous epidural infusion of bupivacaine at a rate of 5 mg/h and sufentanil patient-controlled analgesia (PCA). In a randomized, double-blinded fashion, the sufentanil was given either epidurally or IV. PCA settings were the same in each group. For 60 hrs after surgery, the following variables were measured: pain scores at rest, during mobilization, and during coughing; extension of sensory block; side effects; and sufentanil consumption. Pain scores, extension of sensory block, and the incidence of side effects did not differ between the two groups. Consumption of sufentanil in the epidural group was half that of the IV group (48 h after surgery: 107 +/- 57 microg versus 207 +/- 100 microg for the epidural and IV groups, respectively; P < 0.05). We conclude that spinal mechanisms contribute to the analgesia produced by epidural sufentanil in combination with a local anesthetic. IMPLICATIONS: When combined with epidural bupivacaine, the sufentanil requirement was 50% less when given epidurally than IV. Epidural sufentanil thus appears to have a spinal mechanism of action.

A comparison of 0.1% and 0.2% ropivacaine and bupivacaine combined with morphine for postoperative patient-controlled epidural analgesia after major abdominal surgery.

UNLABELLED: Ropivacaine (ROPI), which is less toxic and produces less motor block than bupivacaine (BUPI), seems attractive for epidural analgesia. Few data are available concerning dose requirements of epidural ROPI when combined with morphine. In this study, we compared the dose requirements and side effects of ROPI and BUPI combined with small-dose morphine after major abdominal surgery. Postoperatively, 60 patients were randomly allocated (double-blinded manner) to four groups: patient-controlled epidural analgesia with the same settings using 0.1% or 0.2% solution of ROPI or BUPI combined with an epidural infusion of 0.1 mg/h of morphine. Pain scores, side effects, motor block, and local anesthetic consumption were measured for 60 h. Pain scores and the incidence of side effects did not differ among the groups. Consumption of ROPI and BUPI were similar in both 0.1% groups. Doubling the concentration significantly reduced the consumption (milliliters) of BUPI (P < 0.05) but not of ROPI. Consequently, using ROPI 0.2% significantly increased the dose administered as compared with ROPI 0.1% (ROPI 0.1% = 314 +/- 151 mg and ROPI 0.2% = 573 +/- 304 mg at Hour 48; P < 0.05). Patient-controlled epidural analgesia with the 0.1% or 0.2% solution of ROPI or BUPI combined with epidural morphine resulted in comparable analgesia. As compared with ROPI 0.1%, the use of ROPI 0.2% increased consumption of local anesthetic without improving analgesia. IMPLICATIONS: Small-dose (0.1%) ropivacaine and bupivacaine have similar potency and result in comparable analgesia and incidence of side effects.