Persistent Pain After Cesarean Delivery and Vaginal Delivery: A Prospective Cohort Study.

BACKGROUND: Persistent pain after cesarean delivery and vaginal delivery has been the subject of only a few research articles. The primary outcome of our prospective study was the incidence of persistent pain and its association to mode of delivery. We also studied the nature and intensity of pain after delivery. METHODS: A questionnaire was distributed on postpartum day 2 to 1052 women who had given birth vaginally and to 502 who had undergone cesarean delivery in a tertiary maternity hospital in Helsinki, Finland, in 2010. A second questionnaire was mailed to the women 1 year later. We recorded the women's health history, obstetric history and previous pain history, details of cesarean delivery or vaginal delivery, and description of pain, if present. RESULTS: The incidence of persistent pain at 1 year after delivery was greater after cesarean delivery (85/379 [22%]) than after vaginal delivery (58/713 [8%]: P < .001, relative risk 2.8, 95% confidence interval 2.0-3.8). Because of initial differences in the groups, we performed logistic regression analysis with persistent pain as a dependent factor that confirmed the mode of delivery as a predictor of persistent pain. The incidence of persistent pain graded as moderate or more severe (25/379 [7%] vs 25/713 [4%]: P = .022, relative risk 1.9, 95% confidence interval 1.1-3.2) was also greater after cesarean delivery than vaginal delivery. The incidence of persistent pain was significantly more common in women with a history of previous pain and among primiparous women in logistic regression analysis. The women with persistent pain had experienced more pain the day after cesarean delivery (P = .023) and during vaginal delivery (P = .030) than those who did not report persistent pain. Complications such as perineal trauma, episiotomy, vacuum extraction, endometritis, wound infection, or ante- or postpartum depression did not predispose women to persistent pain. Dyspareunia was reported by 41% of women after vaginal delivery and by 2% after cesarean delivery among women with persistent pain at 1 year. CONCLUSIONS: The incidence of persistent pain at 1 year is greater after cesarean delivery than after vaginal delivery. Pain shortly after cesarean delivery and during vaginal delivery correlated with persistent pain.

The effective analgesic dose of dexamethasone after laparoscopic hysterectomy.

BACKGROUND: Apart from being antiemetic, glucocorticoids have an analgesic property. The optimal dose of dexamethasone in the management of pain after surgery has not been established. In this placebo-controlled, dose-finding study, we evaluated the analgesic effect of three doses of dexamethasone after laparoscopic hysterectomy. METHODS: We randomized 129 women scheduled for laparoscopic hysterectomy to receive placebo, dexamethasone 5 mg (D5), 10 mg (D10), or 15 mg (D15) IV before the induction of anesthesia. The patients were anesthetized with propofol and remifentanil in a standardized manner. Until the first postoperative morning, postoperative pain was managed with IV oxycodone using patient-controlled analgesia. The visual analog scale scores for pain and side effects, and the amounts of the analgesics were recorded for 3 days after surgery. RESULTS: The total dose of oxycodone (0-24 h after surgery) was smaller in the D15 (0.34 mg/kg [0.11-0.87]) group than in the placebo group (0.55 mg/kg [0.19-1.13]) (P = 0.003). The doses of oxycodone during Hours 0-2 after surgery were smaller in the D10 (0.17 mg/kg [0.03-0.36]) and D15 (0.17 mg/kg [0.03-0.35]) groups than in the placebo (0.26 mg/kg [0.10-0.48]) (P = 0.001, D10 versus placebo; P < 0.001, D15 versus placebo) group. During Hours 2-24 after surgery, however, the doses of oxycodone were equal in the placebo, D5, D10, and D15 groups (0.31 mg/kg [0.03-0.78], 0.22 mg/kg [0.03-0.92], 0.24 mg/kg [0.05-0.87], and 0.20 mg/kg [0-0.65], respectively). The visual analog scale scores for pain at rest, in motion, or at cough did not differ in the study groups. The incidence of dizziness was lower in the D15 group than in the placebo group (P = 0.001), the D5 group (P = 0.006), and the D10 group (P = 0.030) during the first 24 h after surgery. During the later course of recovery, the incidence of dizziness did not differ among the four study groups. CONCLUSIONS: IV dexamethasone 15 mg before induction of anesthesia decreases the oxycodone consumption during the first 24 h after laparoscopic hysterectomy. During first 2 h after surgery, dexamethasone 10 mg reduces the oxycodone consumption as effectively as the 15 mg dose.

Similar recovery from bispectral index-titrated isoflurane and sevoflurane anesthesia after outpatient gynecological surgery.

STUDY OBJECTIVE: To test the hypothesis that the recovery of gynecological day-case patients is equally fast after isoflurane and sevoflurane anesthesia, when administration of the inhaled agent is adjusted by monitoring the bispectral index (BIS). DESIGN: Prospective, randomized, controlled, single-blinded clinical study. SETTING: University-affiliated women's hospital. PATIENTS: 120 adult female patients, ASA physical status I or II, scheduled for ambulatory surgery under general anesthesia. INTERVENTIONS: Patients were randomized to receive either isoflurane or sevoflurane as the maintenance anesthetic. BIS values were titrated to remain between 50 and 60 during the maintenance of anesthesia by adjusting the inspired concentration of the inhaled agent. Administration of the inhaled agent was discontinued abruptly at the end of the procedure. MEASUREMENTS: The times to achieving several recovery end points were recorded. The main outcome parameter was the time to home-readiness. In the postoperative care unit, sedation was evaluated with the digit-symbol substitution test. The degree of pain and nausea was evaluated on the visual analog scale. MAIN RESULTS: There were no statistically significant differences in the times to home-readiness, or in any other parameters of early or intermediate recovery between the 2 groups. The degrees of sedation, pain, and nausea in the postoperative care unit were similar in the 2 groups. CONCLUSIONS: Isoflurane and sevoflurane are equally acceptable maintenance anesthetics in terms of the speed and quality of recovery in gynecological ambulatory surgery patients when the dose of the inhaled agent is adjusted to achieve a BIS between 50 and 60.

A rapid increase in the inspired concentration of desflurane is not associated with epileptiform encephalogram.

UNLABELLED: The large inspired concentration of sevoflurane (S) during mask induction of anesthesia can induce epileptiform electroencephalogram (EEG) associated with tachycardia. Tachycardia is also seen when the concentration of desflurane (D) is abruptly increased. It is not known whether this is associated with epileptiform EEG similar to S. We studied EEG and heart rate (HR) during rapidly increased concentrations of S or D in 31 females during the postintubation period of anesthesia. Anesthesia was induced with propofol and remifentanil, and the tracheas were intubated. Patients were randomized to receive either S or D in nitrous oxide-oxygen mixture after intubation, at a small dose first. After 10 min, S or D vaporizer was advanced to the highest reading of the vaporizer (7% for S, 18% for D) for 5 min. HR and EEG were recorded. Epileptiform EEG activity was recorded in eight of 15 patients in group S and in none in group D (P < 0.05). HR increased in both groups. In group S, HR increased gradually and the highest HR value was 84 bpm at 5 min after the increase in sevoflurane concentration. In group D, HR increased to 93 bpm 2 min after the increase in desflurane concentration (no significant difference, S versus D). A rapid increase in the concentration of S frequently induces epileptiform EEG during normoventilation. Tachycardia during increasing concentrations of D is not associated with epileptiform EEG. IMPLICATIONS: A rapid increase in the concentration of sevoflurane induces epileptiform encephalogram (EEG) with tachycardia. A rapid increase in the concentration of desflurane also induces tachycardia but is not associated with epileptiform EEG.

A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with desflurane for outpatient knee arthroscopy.

In this randomized and controlled trial, 64 adult ambulatory knee arthroscopy patients received either selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane. We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities, a shorter stay in the postanesthesia care unit, and earlier discharge home compared with GA with desflurane. Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group. No difference was seen in the fast-tracking possibilities or time in the postanesthesia care unit between the groups. Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS) in the SSA and GA groups, respectively. In the hospital, the pain scores were significantly (P < 0.001) lower in the SSA group compared with the GA group and the need for postoperative opioids was significantly (P = 0.008) larger after GA. The incidence of postoperative nausea and vomiting was 0% versus 19% in the SSA and GA groups (P = 0.024), respectively. We conclude that for outpatients undergoing knee arthroscopy, SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane.

Timing of administration of dolasetron affects dose necessary to prevent postoperative nausea and vomiting.

STUDY OBJECTIVE: To determine if the timing of administration affects the dose of dolasetron necessary to prevent postoperative nausea and vomiting (PONV). DESIGN: Pooled data from 8 randomized, multicenter, double-blind, placebo-controlled studies with common endpoints. SETTING: University hospital. PATIENTS: A total of 4,587 ASA physical status I, II, and III patients, including 4,124 females undergoing primarily gynecologic procedures and 463 males undergoing various procedures (i.e., thyroidectomy or orthopedic, ophthalmologic, urologic, ENT, or laparoscopic surgery). INTERVENTIONS: Balanced general anesthesia was used during all procedures. Patients received a dose of dolasetron either for prevention of PONV (25 or 50 mg IV at induction; 25, 50, 100, or 200 mg orally 1 to 2 hours pre-induction; or 12.5, 25, 50, or 100 mg IV at end of anesthesia) or for treatment of PONV (12.5, 25, 50, or 100 mg IV). One PONV prevention study had an ondansetron (comparator) group. MEASUREMENTS: Outcome measures over a 24-hour study period included complete response (defined as no vomiting/retching and no need for rescue medication), percentage of patients without nausea [defined as nausea visual analog scale (VAS) score < 5 mm], and maximum nausea according to VAS score. MAIN RESULTS: A 12.5-mg IV dose of dolasetron resulted in a complete response rate that was statistically significantly higher than placebo and comparable to higher dolasetron doses (25 mg to 100 mg IV) when administered either near the end of anesthesia for prevention of PONV or at the onset of symptoms for treatment of PONV. In contrast, when administered at induction of anesthesia, a statistically significant treatment response was observed with dolasetron 50 mg IV, but not at a lower dose. CONCLUSIONS: When dosed near the end of anesthesia, a 12.5 mg IV dose of dolasetron was comparable to higher doses administered at or before induction of anesthesia.