Predictors of postoperative pain and analgesic requirements following abdominal hysterectomy: an observational study.

PURPOSE: A prospective observational study is conducted to identify independent predictors of pain and morphine consumption following abdominal hysterectomy. METHODS: Preoperative State Trait Anxiety Inventory (STAI), Numerical Rating Scales (NRS) for anxiety and pain expectations, thermal pain thresholds and pain scores at forearm and incision site, and pain scores generated from the insertion of an intravenous catheter were measured in female patients undergoing abdominal hysterectomy. Pearson correlations between the predictors and the two outcome measures postoperative pain scores and morphine consumption were studied and multiple regression analysis was conducted to identify independent predictors (primary outcome). Secondary outcomes included cut-off values of predictive tools for morphine consumption. RESULTS: Data from 60 patients were analyzed. STAI state anxiety, NRS pain expectations, and NRS anxiety scores were identified as independent predictors of postoperative morphine consumption. We identified a cut-off value of 4.5 (sensitivity 90 %, specificity of 60 %) for the NRS anxiety and a cut-off of 42.5 (sensitivity 70 %, specificity 70 %) for the state anxiety STAI score for increased postoperative morphine consumption. CONCLUSIONS: Preoperative STAI state anxiety scores and NRS pain expectations are independent predictors for increased morphine consumption following hysterectomy. The STAI state anxiety tool and NRS 0-10 anxiety tool can be used interchangeably. The NRS 0-10 anxiety is a much simpler tool than STAI state anxiety and is associated with a higher sensitivity for high morphine consumption. Thermal pain thresholds and IV pain scores were not predictive of postoperative morphine consumption.

Use of noninvasive positive pressure ventilation in emergency departments of public and private hospitals in Lebanon.

Noninvasive positive pressure ventilation is increasingly being used in emergency departments across Europe and North America. To our knowledge, no similar data are available from other countries. The aim of this study is to describe the current use of noninvasive positive pressure ventilation in the emergency departments of Lebanese hospitals. A structured and validated questionnaire was sent to all emergency departments in Lebanon. In Lebanon, 48.4% of emergency departments use noninvasive positive pressure ventilation. It is mostly used for patients with chronic obstructive pulmonary diseases and cardiogenic pulmonary edema. Bilevel and continuous positive airway pressures are the two most widely used modalities for noninvasive positive pressure ventilation. Face mask is the most used patient interface. The use of uniform protocols and training is lacking. Noninvasive positive pressure ventilation in Lebanese emergency departments is underused, with significant potential for improvements in its current practice.

A randomized controlled trial of variable rate phenylephrine infusion with rescue phenylephrine boluses versus rescue boluses alone on physician interventions during spinal anesthesia for elective cesarean delivery.

BACKGROUND: Phenylephrine infusion is used to reduce hypotension during spinal anesthesia for cesarean delivery. A prophylactic fixed rate infusion regimen may not improve hemodynamic control; a variable rate regimen adjusted in response to changes in arterial blood pressure and heart rate may allow more accurate maintenance of baseline blood pressure. We hypothesized that a combination of crystalloid solution coload with a variable rate phenylephrine infusion and phenylephrine rescue boluses may be associated with fewer physician interventions needed to maintain maternal systolic blood pressure within 20% of baseline and greater hemodynamic stability than crystalloid solution coload with phenylephrine rescue boluses alone. METHODS: In this prospective, double-blind study, 80 patients received a coload with 15 mL/kg lactated Ringer's solution immediately after the initiation of spinal anesthesia. Patients were randomized to receive a prophylactic variable rate phenylephrine infusion starting at 0.75 µg/kg/min (group P) or infusion of normal saline (group S). Maternal systolic blood pressure was maintained within 20% of baseline with rescue phenylephrine boluses using a preset algorithm. During the predelivery period, the number of physician interventions (primary outcome), hemodynamic performance, nausea/vomiting, and umbilical cord blood gas values were compared between the groups. RESULTS: One patient from group S was excluded due to protocol violation. Therefore, group P included 40 patients and group S 39 patients. The median (range) number of physician interventions needed to maintain maternal hemodynamics within the target range (0 [0-6] vs 3 [0-9], difference in median: 3, 95% confidence interval of difference: 2-4) and incidence of hypotension (8/40 [20%] vs 35/39 [90%]) were lower in group P compared with group S (P < 0.001). Group P had a higher incidence of hypertension compared with group S (6/40 [15%] vs 0/39 [0%], P = 0.026). The median performance error was closer to baseline (P < 0.001) with a smaller median absolute performance error (P = 0.001) in group P versus group S. In group P, 4/40 (10%) patients had nausea/vomiting compared with 17/39 (44%) in group S (P = 0.001). The number needed to treat was 1.4 women to prevent 1 case of hypotension, and 3 women to prevent 1 case of nausea/vomiting; the rate of hypertension was 1 case per 6.7 women treated. Neonatal outcomes were not different between the 2 groups. CONCLUSION: Prophylactic variable rate phenylephrine infusion and rescue phenylephrine bolus dosing is more effective than relying on rescue phenylephrine bolus dosing with respect to limiting clinician workload and maternal symptoms during spinal anesthesia for cesarean delivery.

Effect of vitamin C on morphine use after laparoscopic cholecystectomy: a randomized controlled trial.

PURPOSE: We designed a randomized double-blind placebo-controlled trial to assess the role of a single prophylactic dose of vitamin C (2 g) po in reducing the consumption of opioids postoperatively in patients undergoing laparoscopic cholecystectomy. METHODS: Eighty adult patients were allocated to receive 2 g vitamin C po or placebo approximately one hour prior to induction of anesthesia. Following laparoscopic cholecystectomy, patients received morphine patient-controlled analgesia for 24 hr. The following data were assessed postoperatively in the postanesthesia care unit at two, four, six, 12, and 24 hr: morphine consumption, verbal numerical rating scale scores for incisional pain and nausea/vomiting, and pruritus and sedation scores. The primary outcome measure was 24-hr morphine consumption. Patient satisfaction was assessed before hospital discharge. RESULTS: Morphine consumption was significantly lower in the vitamin C group vs the placebo group [16.2 (10.7) and 22.8 (13.8) mg, respectively; difference = 6.6 mg; 95% confidence interval, 1.1 to 12.1 mg; P = 0.02]. There was no difference in pain scores or side effects between the two groups. Satisfaction scores were similar in both groups. CONCLUSION: Our study showed that supplementation with vitamin C (2 g) po decreased morphine consumption in the postoperative period in patients undergoing laparoscopic cholecystectomy.

Subpleural block is less effective than thoracic epidural analgesia for post-thoracotomy pain: a randomised controlled study.

CONTEXT: Thoracic epidural and paravertebral blocks provide adequate analgesia for postoperative thoracotomy pain. Both procedures are usually performed percutaneously with considerable failure rates. A subpleural catheter placed in the space posterior to the parietal pleura and alongside the paravertebral area may provide superior postoperative pain relief. OBJECTIVE: To compare subpleural analgesia with thoracic epidural analgesia in patients undergoing thoracotomy. DESIGN: Randomised, double-blind study. SETTING: A tertiary care University Medical Centre between 26 June 2008 and 21 March 2011. PATIENTS: Forty-two patients scheduled for elective posterolateral thoracotomy. Patients with American Society of Anesthesiologists physical status ≥4, with a previous history of thoracotomy, on chronic pain medications or with a contraindication to receiving local anaesthetics or thoracic epidural block were excluded from the study. INTERVENTIONS: Patients were randomised to receive either subpleural analgesia or thoracic epidural analgesia for 24-h post-thoracotomy pain control. MAIN OUTCOME MEASURES: A visual analogue scale was used to assess pain at rest and on coughing during the first 24 h postoperatively and the incidence of hypotension was recorded. RESULTS: Patients who received subpleural analgesia had higher visual analogue scores at rest and on coughing than those who received thoracic epidural analgesia. Seven patients who started with subpleural analgesia were treated with thoracic epidural analgesia at a mean (SD) of 3.9 (4.8) h. The remaining 14 patients had a median (IQR [range]) visual analogue score of 5 cm (4-5 [3-6]) at rest and were maintained on subpleural analgesia until the end of the study. The visual analogue score at rest was <7 cm in all 21 patients who received thoracic epidural analgesia and none was switched to subpleural analgesia during the study. None of the patients in the subpleural analgesia group experienced hypotension compared with five of the 21 patients in the thoracic epidural analgesia group (P=0.047). CONCLUSION: Thoracic epidural analgesia is superior to subpleural analgesia in relieving post-thoracotomy pain.

Femoral vein cannulation performed by residents: a comparison between ultrasound-guided and landmark technique in infants and children undergoing cardiac surgery.

BACKGROUND: Percutaneous cannulation of the femoral vein, in the pediatric age group, can be technically challenging, especially when performed by residents in training. We examined whether the use of real-time ultrasound guidance is superior to a landmark technique for femoral vein catheterization in children undergoing heart surgery. METHODS: Patients were prospectively randomized into 2 groups. In group LM, the femoral vein was cannulated using the traditional method of palpation of arterial pulse. In group US, cannulation was guided by real-time scanning with an ultrasound probe. The time to complete cannulation (primary outcome), success rate, number of needle passes, number of successful cannulations on first needle pass, and incidence of complications were compared between the 2 groups. RESULTS: Forty-eight pediatric patients were studied. The time to complete cannulation was significantly shorter (155 [46-690] vs 370 [45-1620] seconds; P = 0.02) in group US versus group LM. The success rate was similar in both groups (95.8%). The number of needle passes was smaller (1 [1-8] vs 3 [1-21]; P = 0.001) and the number of successful cannulations on first needle pass higher (18 vs 6; P = 0.001) in group US compared with group LM. The incidence of femoral artery puncture was comparable between the 2 groups. CONCLUSIONS: Ultrasound-guided cannulation of the femoral vein, in pediatric patients, when performed by senior anesthesia residents, is superior to the landmark technique in terms of speed and number of needle passes, with remarkable improvement in first attempt success.

The analgesic efficacy of subarachnoid morphine in comparison with ultrasound-guided transversus abdominis plane block after cesarean delivery: a randomized controlled trial.

BACKGROUND: Ultrasound-guided transversus abdominis plane block is an effective method of providing pain relief after cesarean delivery. Neuraxial morphine is currently the "gold standard" treatment for pain after cesarean delivery. In this study we tested the hypothesis that subarachnoid morphine would provide more prolonged and superior analgesia than would transversus abdominis plane block in patients undergoing elective cesarean delivery. METHODS: In this prospective, double-blind study, 57 patients were randomly assigned to receive either subarachnoid morphine (group SAM; n = 28) or transversus abdominis plane block (group TAP; n = 29). Patients received bupivacaine spinal anesthesia combined with morphine 0.2 mg in group SAM and received saline in group TAP. At the end of surgery, bilateral transversus abdominis plane block was performed using saline in group SAM or using bupivacaine 0.375% plus epinephrine 5 microg/mL in group TAP with 20 mL on each side. Postoperative analgesia for the first 24 hours consisted of scheduled rectal diclofenac and IV paracetamol; breakthrough pain was treated with IV tramadol. For the next 24 hours, scheduled rectal diclofenac was given; oral paracetamol and IV tramadol were administered upon patient request. Patients were assessed postoperatively in the postanesthesia care unit (time 0 hours) and at 2, 4, 6, 12, 24, 36, and 48 hours. The primary outcome measure was the time to first analgesic request. RESULTS: Median (range) time to first analgesic request was longer in group SAM than in group TAP [8 (2-36) hours versus 4 (0.5 to 29) hours (P = 0.005)]. Median (range) number of tramadol doses received between 0 and 12 hours was 0 (0-1) in group SAM versus 0 (0-2) in group TAP (P = 0.03). Postoperative visceral pain scores at rest and on movement during first the 4 hours were lower in group SAM than in group TAP, but were not different at any other time points. The incidence of moderate to severe nausea was higher in group SAM than in group TAP [13/28 (46%) versus 5/29 (17%) (P = 0.02)]. More patients developed pruritus requiring treatment in group SAM than in group TAP [(11/28 (39%) versus none (0%) (P < 0.001)]. CONCLUSION: As part of a multimodal analgesic regimen, subarachnoid morphine provided superior analgesia when compared with ultrasound-guided transversus abdominis plane block after cesarean delivery, yet at the cost of increased side effects.

Excellent intubating conditions with remifentanil-propofol and either low-dose rocuronium or succinylcholine.

PURPOSE: The shortest time to tracheal intubation, the best intubating conditions, and the shortest duration of muscle paralysis are achieved with succinylcholine. During a lidocaine-remifentanil-propofol induction of anesthesia, we compared intubating conditions 90 s after administering low-dose rocuronium (0.3 mg . kg(-1)) with intubating conditions 60 s after administering succinylcholine 1.5 mg . kg(-1). METHODS: The randomized double-blind study included 184 healthy adult patients scheduled for elective surgery. Anesthesia was induced in all patients with lidocaine 1.5 mg . kg(-1), remifentanil 2 microg . kg(-1), and propofol 2 mg . kg(-1) administered over 30 s. In one group, rocuronium 0.3 mg . kg(-1) was administered before the induction sequence, and in the other group, succinylcholine 1.5 mg . kg(-1) was administered after the induction sequence. Laryngoscopy was attempted 90 s after rocuronium administration and 60 s after succinylcholine administration. Intubating conditions were assessed as excellent, good, or poor on the basis of ease of laryngoscopy, position of the vocal cords, and reaction to insertion of the tracheal tube and cuff inflation. RESULTS: There were 92 patients per group. In the rocuronium group, intubating conditions were excellent in 83 patients (90%), good in 8 (9%), and poor in 1 (1%), not significantly different from the intubating conditions in the succinylcholine group, which were excellent in 88 patients (96%), good in 3 (3%), and poor in 1 (1%) (P = 0.3). CONCLUSION: During a lidocaine-remifentanil-propofol induction of anesthesia, rocuronium 0.3 mg . kg(-1) administered before the induction sequence provides intubating conditions comparable to those achieved with succinylcholine 1.5 mg . kg(-1) administered after the induction sequence.

A comparison of a silicone wire-reinforced tube with the Parker and polyvinyl chloride tubes for tracheal intubation through an intubating laryngeal mask airway in patients with normal airways undergoing general anesthesia.

BACKGROUND: The intubating laryngeal mask airway (ILMA) is used in the management of difficult intubation. Usually, a silicone wire-reinforced tube is inserted for tracheal intubation. Because the silicone wire-reinforced tube is expensive, alternatives, such as polyvinyl chloride (PVC) and posterior beveled Parker tubes, are worth considering. We compared the blind intubation success rates among the silicone wire-reinforced tube, the Parker tube, and the PVC tube, and identified laryngeal structures preventing tracheal intubations through the ILMA. METHODS: Sixty-three adult patients were randomized into three groups: Group I (n = 20) silicone wire-reinforced tube, Group II (n = 21) Parker tube, and Group III (n = 22) PVC tube. Demographic and clinical continuous data were compared with the analysis of variance with the Scheffé test for post hoc analysis. Frequencies and percentages were compared with the chi(2) test. RESULTS: Tracheal intubation was successful from the first attempt in 18 of 20 patients in Group I (silicone wire-reinforced tube), which was significantly higher than the success rate in either Group II (12 of 22 patients) (Parker tube) or Group III (10 of 21 patients) (PVC tube). With clockwise or anticlockwise rotation of the tracheal tube, the number of successful intubations did not change in Group I, but it increased to 19 of 22 patients in Group II and to 12 of 21 patients in Group III. The rate of successful intubation between patients in Group I (90%) and Group II (86%) was not significantly different after manipulation of the tracheal tube (P = 0.72). However, the rate of successful tracheal intubations in patients of Group III (57%) was significantly lower in comparison to patients in both Group I (P = 0.02) and Group II (P = 0.03). In 3 of the 22 patients of Group II and in 9 of the 21 patients of Group III in whom blind intubation was not possible, the obstruction was due to the epiglottis tubercule. CONCLUSIONS: Manipulation improved the success rate of intubation with the Parker tube through the ILMA rendering it a possible alternative to the silicone wire-reinforced tube.

Recurrent postoperative aspiration following jugular foramen tumor resection.

We report a 38 year old male patient who underwent a craniotomy for jugular foramen tumor resection. In the postoperative care unit, the patient developed aspiration accompanied with oxyhemoglobin desaturation. Subsequently, he had several episodes of recurrent aspiration which were attributed to cranial nerves (IX, X) palsy as a complication of the surgery at the jugular foramen. It is suggested that aspiration prophylactic measures should be taken and early assessment of lower cranial nerves function should be done prior to tracheal extubation to decrease post-operative aspiration in patients undergoing base of skull surgery.

A single dose of propofol at the end of surgery for the prevention of emergence agitation in children undergoing strabismus surgery during sevoflurane anesthesia.

BACKGROUND: Emergence agitation in children after sevoflurane is common. Different drugs have been used to decrease its occurrence with variable efficacy. The authors compared the incidence and severity of emergence agitation in children who received a single dose of propofol at the end of strabismus surgery versus children who received saline. METHODS: In this prospective, randomized, double-blind study, the authors enrolled 80 healthy children aged 2-6 yr. The children were randomly allocated to the propofol group (n = 41), which received 1 mg/kg propofol at the end of surgery, or to the saline group (n = 39), which received saline. RESULTS: The mean scores on the Pediatric Anesthesia Emergence Delirium scale were significantly lower in the propofol group compared with the saline group (8.6 +/- 3.9 vs. 11.5 +/- 4.5; P = 0.004). Also, the incidence of agitation was significantly lower in the propofol group compared with the saline group (19.5% vs. 47.2%; P = 0.01). A threshold score greater than 10 on the Pediatric Anesthesia Emergence Delirium scale was the best discriminator between presence and absence of emergence agitation. Times to removal of the laryngeal mask airway (10.6 +/- 1.5 vs. 9.4 +/- 1.9 min; P = 0.004) and emergence times (23.4 +/- 5.7 vs. 19.7 +/- 5 min; P = 0.004) were significantly longer in the propofol group. However, discharge times were similar between the two groups (propofol: 34.1 +/- 8.4 min; saline: 34.9 +/- 8.6 min). More parents in the propofol group were satisfied. CONCLUSIONS: In children undergoing strabismus surgery, 1 mg/kg propofol at the end of surgery after discontinuation of sevoflurane decreases the incidence of agitation and improves parents' satisfaction without delaying discharge from the postanesthesia care unit.

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.

A randomized, placebo-controlled trial of bupropion sustained release in chronic low back pain.

UNLABELLED: Clinical trials of the efficacy of antidepressant drugs in patients with chronic low back pain have had mixed results, possibly because of the different mechanisms of action of the drugs that have been studied. Because bupropion has a mechanism of action that differs from other antidepressants and has shown efficacy in neuropathic pain, a randomized, placebo-controlled, 2-period crossover trial was conducted to evaluate its efficacy in subjects with chronic low back pain. The primary efficacy variable was mean daily diary pain intensity ratings, and secondary pain intensity and relief outcomes included weekly pain intensity ratings, the McGill Pain Questionnaire (MPQ) Present Pain Intensity scale, pain relief ratings, and satisfaction with pain relief ratings. Adverse events were also assessed throughout the trial. Analyses were performed of an intention-to-treat sample of 44 patients, only 3 of whom met criteria for neuropathic low back pain. Daily and weekly pain intensity ratings, the MPQ Present Pain Intensity scale, and pain relief ratings were not significantly different following treatment with bupropion sustained release (SR) vs. placebo. These results suggest that bupropion SR was not significantly better than placebo in the treatment of patients with non-neuropathic chronic low back pain. PERSPECTIVE: Antidepressant medications that have both noradrenergic and serotonergic effects appear to have greater efficacy in patients with chronic low back pain than those with only serotonergic activity. We studied bupropion because it inhibits the reuptake of both norepinephrine and dopamine, but found no evidence of efficacy in patients with non-neuropathic chronic low back pain.

Multimodal spinal anesthesia.

BACKGROUND AND OBJECTIVES: Cystoscopy and extracorporeal shock wave lithotripsy (ESWL) are common urologic procedures in the treatment of ureteral calculi. Spinal anesthesia with local anesthetics is the anesthetic technique of choice for these procedures. Sufentanil and/or clonidine have been combined with local anesthetics to provide effective and safe neuroaxial anesthesia. Our objectives were to review the efficacy and safety of combining both sufentanil and clonidine with reduced doses of intrathecal lidocaine in patients undergoing cystoscopy and ESWL. METHODS: We reviewed the medical records of 12 patients who underwent such urologic procedures using an intrathecal mixture consisting of 20 mg of lidocaine, 10 micrograms of sufentanil, and 50 micrograms clonidine from May 1st, 1998 to December 31st, 1998. Patients' demographics, intraoperative analgesia and adverse side effects as well as recovery times were reviewed. RESULTS: All 12 patients tolerated their urologic treatments using this combination of drugs without requiring conversion to another anesthetic technique or significant supplementation with intravenous analgesics. Motor power returned to normal by the end of the procedure. The systolic blood pressure dropped 26 +/- 8% intra-operatively and 25 +/- 9% postoperatively. The incidences of other adverse side effects were low. Time spent in recovery area was short, 45 +/- 15 minutes (mean +/- standard deviation). CONCLUSIONS: Intrathecal admixtures of sufentanil 10 micrograms, clonidine 50 micrograms, and lidocaine 20 mg can provided effective and prolonged analgesia in patients undergoing cystoscopy and ESWL. Patients had recovery of their motor power in their lower extremities by the end of the procedure. No urinary retention was noted. Mild hypotension was the most common adverse side effect and was the main confounding factor for the prolongation of the discharge time.