Experience of Immediate Ambulation and Early Discharge After Tumescent Anesthesia and Propofol Infusion in Cosmetic Breast Augmentation.

INTRODUCTION: Current cosmetic breast augmentation relies on general anesthesia that normally requires 40 min to total recovery. With experience, the surgical procedure can be completed expediently in 20 min under tumescent anesthesia and propofol full sedation to achieve immediate postoperative ambulation and home discharge readiness, and thus improve patient satisfaction and reduce cost. We retrospectively examined the outcomes of the protocol. MATERIALS AND METHODS: Per protocol, 1200 female patients underwent simple cosmetic breast augmentation accomplished with tumescent anesthesia, immediate mobilization, and early home discharge readiness after surgery. The following records were analyzed: vital sign stability during mobilization in the first 30 cases (primary goal), duration of surgery and anesthesia, frequency of intraoperative opioid use, frequency of ambulation needing assistance, Verbal Analog Scores and incidences of pain, orthostatic intolerance events, incidences of postoperative nausea and vomiting or anti-emetic use, and complications at follow-up visits (secondary goal). RESULTS: Hemodynamics during immediate postoperative mobilization demonstrated no statistically significant fluctuations and/or orthostatic intolerance requiring interventions. The mean duration of surgery was 20.4 ± 4.1 min. The mean duration of anesthesia was 25.2 ± 6.8 min. All patients tolerated immediate postoperative ambulation well. Adverse postoperative events were scarce. Only 9.1% reported postoperative pain, and 5.7% reported postoperative nausea and vomiting. One percent had transit post-ambulation dizziness needing supine positioning for less than 3 min. The average time to meet home-readiness criteria was 4.7 min, and there was no incidence of hematoma, infection, or complaints at follow-ups. CONCLUSIONS: For simple cosmetic breast augmentation, instead of general anesthesia and 40 min of recovery time, a tumescent anesthetic technique can be used for immediate postoperative ambulation and a 4.7-min home discharge readiness without a decrease in anesthesia quality and safety. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Metoclopramide improves the quality of tramadol PCA indistinguishable to morphine PCA: a prospective, randomized, double blind clinical comparison.

OBJECTIVE: Multimodal analgesia has been effectively used in postoperative pain control. Tramadol can be considered "multimodal" because it has two main mechanisms of action, an opioid agonist and a reuptake inhibitor of norepinephrine and serotonin. Tramadol is not as commonly used as morphine due to the increased incidence of postoperative nausea and vomiting (PONV). As metoclopramide is an antiemetic and an analgesic, it was hypothesized that when added to reduce PONV, metoclopromide may enhance the multimodal feature of tramadol by the analgesic property of metoclopramide. Therefore, the effectiveness of postoperative patient-controlled analgesia (PCA) with morphine was compared against PCA with combination of tramadol and metoclopramide. DESIGN: A prospective, randomized, double blind clinical trial. SETTING: Academic pain service of a university hospital. SUBJECTS: Sixty patients undergoing elective total knee arthroplasty with general anesthesia. METHODS: Sixty patients were randomly divided into Group M and Group T. In a double-blinded fashion, Group M received intraoperative 0.2 mg/kg morphine and postoperative PCA with 1 mg morphine per bolus, whereas Group T received intraoperative tramadol 2.5 mg/kg and postoperative PCA with 20 mg tramadol plus 1 mg metoclopramide per bolus. Lockout interval was 5 minutes in both groups. Pain scale, satisfaction rate, analgesic consumption, PCA demand, and side effects were recorded by a blind investigator. RESULTS: These two groups displayed no statistically significant difference between the items and variables evaluated. CONCLUSIONS: This combination provides analgesia equivalent to that of morphine and can be used as an alternative to morphine PCA.