Management program decreases postoperative nausea and vomiting in high-risk and in general surgical patients: a quality improvement cycle.

BACKGROUND: Preventing postoperative nausea and vomiting (PONV) is a major priority for postsurgical patient care. Our objective was to assess the efficacy of a multimodal postoperative nausea and vomiting (PONV) approach, which was associated with a continuous quality improvement program, in maintaining a low PONV incidence in the PACU. METHODS: Consecutive adult patients scheduled for surgery (ambulatory surgery or not) were prospectively included. PONV data were recorded in the PACU and over a 24-hour period. The management program was based on a multimodal approach with both changes in anesthetic techniques and anti-emetics, and on a three-stage protocol including: 1) phase I: institutional practice phase based on prospective observational study; 2) protocol implementation; 3) phase II: prospective observational study associated with feedback, scientific session and evaluation to guideline adherence. We used the Apfel risk scoring system to identify patients at high risk of PONV. Feedback with audit results and didactic sessions were scheduled quarterly in the Phase II. RESULTS: Thirty-seven/395 (9.4%) and 151/3864 (3.9%) patients experienced PONV in the PACU during Phase I and Phase II respectively (P<0.001). Among the patients with an Apfel risk score that included at least two risk factors, 16.6% and 4.2% experienced PONV in the PACU during Phase I and Phase II respectively (P<0.001). CONCLUSION: We highlight the association with a sharp decrease in PONV incidence over a one-year period and a multimodal PONV approach using feedback to clinicians associated with continuous quality improvement program.

Wound infiltration with magnesium sulphate and ropivacaine mixture reduces postoperative tramadol requirements after radical prostatectomy.

PURPOSE: This prospective, randomized, double-dummy study was undertaken to compare the effects of magnesium sulphate (MgSO(4)) administered by the intravenous vs. the infiltration route on postoperative pain and analgesic requirements. METHODS: Forty ASA I or II men scheduled for radical retropubic prostatectomy under general anaesthesia were randomized into two groups (n=20 each). Two medication sets A and B were prepared at the pharmacy. Each set contained a minibag of 50 ml solution for IV infusion and a syringe of 45 ml for wound infiltration. Group MgSO(4).IV patients received set A with 50 mg/kg MgSO(4) in the minibag and 190 mg of ropivacaine in the syringe. Group MgSO(4)/L received set B with isotonic saline in the minibag and 190 mg of ropivacaine +750 mg of MgSO(4) in the syringe. The IV infusion was performed over 30 min at induction of anaesthesia and the surgical wound infiltration was performed during closure. Pain was assessed every 4 h, using a 100-point visual analogue scale (VAS). Postoperative analgesia was standardized using IV paracetamol (1 g/6 h) and tramadol was administered via a patient-controlled analgesia system. The follow-up period was 24 h. RESULTS: The total cumulative tramadol consumption was 221 +/- 64.1 mg in group MgSO4.IV and 134 +/- 74.9 mg in group MgSO(4).L (P<0.01). VAS pain scores were equivalent in the two groups throughout the study. No side-effects, due to systemic or local MgSO(4) administration, were observed. CONCLUSION: Co-administration of MgSO(4) with ropivacaine for postoperative infiltration analgesia after radical retropubic prostatectomy produces a significant reduction in tramadol requirements.

Sublingual oxybutynin reduces postoperative pain related to indwelling bladder catheter after radical retropubic prostatectomy.

BACKGROUND: Bladder discomfort related to an indwelling catheter can exacerbate postoperative pain. It mimics overactive bladder syndrome that is resistant to conventional opioid therapy. Muscarinic receptor antagonists are effective for treatment of the overactive bladder. The aim of this study was to assess the efficacy of oxybutynin in the management of postoperative pain after radical prostatectomy. METHOD: Forty-six ASA I or II men undergoing radical retropubic prostatectomy under general anaesthesia were randomly assigned to two groups, in a double-blind fashion: Group O and Group P (n = 23 each). Group O and Group P received, respectively, sublingual oxybutynin 5 mg or placebo every 8 h during the 24 h after surgery. A 16F Foley catheter was placed during the vesico-urethral anastomosis and the balloon inflated with 10 ml of saline. Pain was assessed in the recovery room starting 10 min after extubation using a 100-point visual analogue scale (VAS). The patients were asked to specify whether pain was related to the surgical incision or bladder pain. Standardized postoperative analgesia included acetaminophen and tramadol administered via a patient-controlled analgesia system. RESULTS: The incidence of bladder catheter pain was 65% (15 of 23 patients) in Group P compared with 17% (4 of 23 patients) in Group O (P < 0.01). Overall VAS scores at rest were significantly lower in Group O. Cumulative tramadol consumption was 322.9(124.3) mg [mean(sd)] in Group P and 146(48) mg in Group O (P < 0.01). No oxybutynin-related side-effects were reported. CONCLUSIONS: Sublingual oxybutynin is an effective treatment for postoperative pain after radical retropubic prostatectomy and produces a significant reduction in tramadol requirements.

Intravenous magnesium sulphate decreases postoperative tramadol requirement after radical prostatectomy.

BACKGROUND: The purpose of this study was to assess whether the addition of intravenous magnesium sulphate (Mg) at the induction of anaesthesia to a balanced anaesthetic protocol including wound infiltration, paracetamol and tramadol resulted in improved analgesic efficiency after radical prostatectomy. METHODS: We conducted a randomized, double-blind, controlled study. Thirty ASA I or II males scheduled to undergo radical retropubic prostatectomy with general anaesthesia were prospectively assigned to one of the two groups (n = 15 each). The Mg group (Gr Mg) received 50 mg kg-1 of MgSO4 in 100 mL of isotonic saline over 20 min immediately after induction of anaesthesia and before skin incision. The patients in the control group (Gr C) received the same volume of saline over the same period. At the time of abdominal closure, wound infiltration with 190 mg (40 mL) of ropivacaine was performed in both groups. Pain was assessed by a 10-point visual analogue scale in the recovery room starting from the time of tracheal extubation. Standardized postoperative analgesia included paracetamol and tramadol administered via a patient-controlled analgesia device. RESULTS: In the postoperative period, both groups experienced an identical pain course evolution. Cumulative mean tramadol dose after 24 h was 226 mg in the magnesium group and 446 mg in the control group (P < 0.001). Postoperative nausea occurred in two patients in each group. Two vs. eight patients required analgesic rescue in magnesium and control groups, respectively (P = 0.053). CONCLUSIONS: This study shows that intravenous magnesium sulphate reduces tramadol consumption when used as a postoperative analgesic protocol in radical prostatectomy.

[Laparoscopic adrenalectomy for pheochromocytoma. Perioperative blockade with urapidil]. / Exérèse de phéochromocytomes par coeliochirurgie. Effet du blocage périopératoire par l'urapidil.

OBJECTIVE: To investigate the effects of coeliosurgery by catecholamine assays and the use of urapidil in the management of phaeochromocytoma. STUDY DESIGN: Prospective cohort study. PATIENTS: Nine consecutive patients from April 1997 to April 2001. METHODS: Urapidil (250 mg.j-1) was administered by continuous intravenous infusion three days before surgery and continued throughout anaesthesia. Plasma catecholamine concentrations were measured before surgery, after induction of anaesthesia, during insufflation, after adrenalectomy and in the recovery room. Haemodynamic disorders were treated by nicardipine +/- esmolol bolus doses. RESULTS: Creation of pneumoperitoneum and adrenal gland manipulations resulted in significant catecholamine releases associated with hypertension in five and eight patients respectively. Preventive urapidil use enabled easy control of blood pressure variations by additive antihypertensive drugs. CONCLUSION: Perioperative alpha 1 blockade by urapidil enables an effective and easy control of acute preoperative haemodynamic changes.

Effect of balanced analgesia with buprenorphine on pain response and general anaesthesia requirement during lithotripsy procedures.

The effectiveness of a balanced analgesia with buprenorphine ketoprofen-propacetamol for pain control during extracorporeal shock wave lithotripsy (ESWL) was evaluated in order to reduce the requirements for general anaesthesia. Two hundred and ninety-one consecutive patients were included in a randomized, placebo-controlled, double-blind study. Patients in each group received midazolam 5 mg pre-operatively as premedication. The subjects then received either placebo (group 1), buprenorphine 0.3 mg (group 2) or the combination buprenorphine 0.3 mg plus ketoprofen 100 mg and propacetamol 2 g (group 3) intravenously (i.v.) at a constant rate. The treatment was started 45 min prior to ESWL. Pain was assessed using a three-point verbal scale: (0)no pain; (1) moderate pain; and (2) intense pain needing general anaesthesia. The patients assessed their pain intensity on a 0-100 mm visual analogue scale. Only 69% of group 1 patients received ESWL with midazolam premedication. Buprenorphine provided good analgesia in 87% of group 2 patients, while the combination buprenorphine-ketoprofen-propacetamol was effective in 99% of group 3 patients (P < 0.05). The incidence of nausea and vomiting was similar in the buprenorphine groups. No respiratory depression was reported. In conclusion, the buprenorphine-ketoprofen-propacetamol combination provided effective analgesia, allowing ESWL to be performed without the need for general anaesthesia.

[Comparative study of buprenorphine and its combination to ketoprofen or propacetamol for postoperative analgesia in urologic surgery]. / Etude comparative de la buprénorphine et de son association au kétoprofène et au propacétamol pour l'analgésie postopératoire en chirurgie urologique.

OBJECTIVE: To compare the analgesic effect of subcutaneous buprenorphine alone and in combination with propacetamol and ketoprofen following urologic surgery. STUDY DESIGN: Open randomized clinical trial. PATIENTS: Sixty ASA II/III patients undergoing urologic surgery. METHODS: The patients were randomized into three groups to receive either buprenorphine (0.3 mg subcutaneous) on demand (group 1, n = 20), or a combination of buprenorphine (0.3 mg)-propacetamol (2 g)-ketoprofen (100 mg) by intravenous route over 2 hours followed by an infusion of propacetamol (2 g) and ketoprofen (100 mg) at a constant rate over. The remaining 22 hours (group 2, n = 20), or the same loading dose as in group 2 prolonged by a continuous infusion of buprenorphine (0.3 mg), propacetamol (2 g) and ketoprofen (100 mg) over the same period (group 3, n = 20). Visual analogue scale pain scores (0-10) were assessed every hour during the 24 hours of the study. When the VAS score exceeded 5, an additional dose of 0.3 mg of buprenorphine was administered. RESULTS: Groups were similar for age, surgery, anaesthesia and initial pain levels. Compared to group 1, the onset of analgesia was earlier in groups 2 and 3 at the 1st hour (P < 0.05); the level of analgesia was lower at the 3rd hour (P < 0.05). The maintenance of this analgesia level required constant buprenorphine administration. Buprenorphine requirements were decreased to 56% and 37% in groups 2 and 3 respectively, compared to group 1 (P < 0.05). Incidence of nausea and vomiting was lowered to 15% in group 3 (P < 0.05). CONCLUSION: A combination of buprenorphine, propacetamol and ketoprofen provides effective postoperative analgesia with a low incidence of nausea and vomiting and decreased requirements of buprenorphine.

[Comparative study of sufentanil and fentanyl in urologic surgery in adults]. / Etude comparative du sufentanil et du fentanyl en chirurgie urologique de l'adulte.

Sufentanil is compared with fentanyl as a supplement to N2O isoflurane anaesthesia in a double blind study of 30 elderly patients undergoing major urological surgery. Comparison is made with respect to 1) haemodynamic (heart rate, blood pressure) responses during surgery and recovery; 2) time to extubation after the end of surgery; 3) Postoperative analgesia. No difference is observed between the two groups with respect to demographic data, duration of surgery, and total doses of muscle relaxants. Total doses of opioids used are 195 micrograms of sufentanil and 1,215 micrograms of fentanyl. Arterial pressure and heart rate are different during intubation and major events of surgery. Times between end of surgery and extubation are different: 77 +/- 13 min the sufentanil group versus 57 +/- 22 min the fentanyl group (p < 0.05). Use of analgesia is significantly delayed in the sufentanil group. It is suggested that sufentanil, in elderly patients, provides a better haemodynamic stability and a greater residual analgesia than fentanyl in the immediate postoperative period.

[Glycine poisoning after percutaneous kidney surgery]. / Intoxication par la glycine après chirurgie rénale par voie percutanée.

We describe two cases of altered consciousness associated with nausea and vomiting after renal surgery. These events occurred respectively one and two hours after surgery. They are believed to be caused by the transfer of large amounts of irrigating solution containing glycine 1.5%. The effects of hyponatraemia (132 and 129 mmol.L-1) and glycinaemia (3518 and 8589 mmol.L-1) are discussed. We conclude on the importance of an early clinical diagnosis completed by biological investigation to allow an adequate symptomatic management.