Epidural Anesthesia for Neuromyelitis Optica in Obstetrics: A Case Report and Literature Review.

Neuromyelitis optica (NMO), also known as Devic disease, poses unique challenges in obstetrical anesthesia, with limited research available. This case report presents the anesthetic management of a 43-year-old gravida 2 para 1 (G2P1) woman with NMO undergoing labor induction at 39 weeks of gestation. Having received uneventful epidural labor analgesia in her first pregnancy, she faced the delicate decision of neuraxial anesthesia in light of her NMO diagnosis, which was made following her initial pregnancy. Collaborative discussions resulted in the choice of labor epidural analgesia, and an indwelling epidural catheter was placed successfully. An unplanned cesarean section with effective epidural supplementation followed. The case highlights the intricacies of balancing pain relief and neurological risks in NMO patients. Existing literature reflects varying perspectives on neuraxial anesthesia in NMO, with reports both supporting and cautioning against its use. The case aligns with the current view that epidural labor analgesia appears safe in NMO, but conclusive recommendations await larger studies. The decision for neuraxial anesthesia in NMO should be individualized, guided by comprehensive pre-anesthetic counseling and ongoing research developments.

The Greek Neuropathic Pain Registry: The structure and objectives of the sole NPR in Greece.

OBJECTIVES: Neuropathic pain (NP) is a complex condition that impairs the patients' quality of life. Registries are useful tools, increasingly used as they provide high-quality data. This article aims to describe the Greek Neuropathic Pain Registry (Gr.NP.R.) design, the patients' baseline data, and real-world treatment outcomes. METHODS: The Gr.NP.R. collects electronically, stores, and shares real-world clinical data from Pain and Palliative Care centers in Greece. It is a web-based application, which ensures security, simplicity, and transparency. VAS, DN4, and Pain Detect were used for pain and NP assessment. RESULTS: From 2016 to 2020, 5980 patients with chronic pain, of cancer or non-cancer origin, were examined and 2334 fulfilled the NP inclusion criteria (VAS > 5, DN4 > 4, and Pain Detect ≥ 19). At the first visit, the mean age was 64.8 years, 65.5% were female patients, and 97.9% were Greek. The mean (SD) time from pain initiation to visiting the pain clinics was 1.5 (3.8) years. Most patients were undertreated. Following the patients' registration, the national guidelines were implemented. The majority of the prescribed medications were gabapentinoids (70.2%), especially pregabalin (62.6%), and opioids (tramadol, 55.3%). At visits 1 and 6, mean VAS was 7.1 and 5, and mean DN4 score was 5.6 and 3.5, respectively. CONCLUSIONS: The Gr.NP.R. provides information on the demographics, clinical progress, treatment history, treatment responses, and the drugs of choice for patients with cancer and non-cancer NP. The collected data may help physicians plan the management of their patients.

Acute and Chronic Pain after Cesarean Delivery under Subarachnoid Anaesthesia. Is Postoperative Analgesia Adequate? A Cohort Observational Study.

Objectives: Uncontrolled pain after cesarean delivery is associated with women's dissatisfaction and limited ability to take care of the neonate. Materials and methods:This prospective observational study included 173 women scheduled for elective cesarean delivery under spinal anesthesia. Postoperative analgesia included subcutaneous morphine 0.1 mg/kg in the post-anesthesia care unit, followed by intravenous paracetamol 1000 mg every eight hours and intravenous diclofenac 75 mg every 12 hours in the ward. Subcutaneous morphine was repeated on demand. Pain intensity at rest, pain intensity after movement and cumulative morphine consumption were recorded at 2, 4, 8, and 24 hours postoperatively. Acute pain intensity was assessed on a 100 mm visual analogue scale (VAS, score 0-100 mm). Three and six months postoperatively, women were interviewed by phone for the presence of persisting pain, abnormal sensation in the wound area and analgesic consumption. Results:Our results showed that 24 hours postoperatively the mean dose of morphine was 16±7.1 mg and VAS scores at rest and after movement were 23±17.3 mm and 40±20.9 mm, respectively. The mean VAS scores at rest remained below 31 mm at all times, while after movement they were over 40 mm at both four and eight hours postoperatively (45±23.8 mm and 43±23.2 mm, respectively). Three months postoperatively, 15% of women reported the presence of continuous or intermittent pain, 72% loss of sensation or numbness at the site of surgery and 32% occasional analgesic consumption at home. Six months after surgery, 5% of women reported pain, 44% loss of sensation or numbness in the wound area and none of them (0%) consumed analgesics due to persistent post-cesarean delivery pain. Conclusion:Based on the above-mentioned findings, we concluded that the amount of morphine consumed in the ward was low and possibly inadequate to alleviate early post-cesarean delivery pain. The overall incidence of persisting pain was low and consistent with previous studies.

Postoperative abdominal free air: How much and when is enough? Report of two cases.

Postoperative intraperitoneal or ectopic free air may occur after abdominal surgery, gynecologic surgery, laparoscopic surgery, or endoscopic procedures and, in rare cases, represent gastrointestinal perforation, requiring emergency laparotomy. Evaluating patients with postoperative signs of bowel perforation may be difficult, especially when day-case laparoscopic or endoscopic surgery is performed, with the patient readily discharged from hospital. Delayed diagnosis of gastrointestinal perforation due to underestimation of postoperative free air is associated with a high morbidity and mortality rate. We report two cases of patients presenting with postoperative free air along with the clinical presentation and management.

Validation of the Patient Neurotoxicity Questionnaire for Patients Suffering From Chemotherapy-Induced Peripheral Neuropathy in Greek.

PURPOSE: The Patient Neurotoxicity Questionnaire (PNQ) represents a diagnostic tool concerning patients with chemotherapy-induced peripheral neuropathy (CIPN). The application of such a tool in the Greek clinical praxis requires validation. METHODS: Validation consists of three stages - translation, reverse translation, and patient application. Hundred oncologic patients were assessed by comparing the PNQ to the National Cancer Institute-Common Terminology Criteria for Adverse Events (NCI-CTCAE) at the chemotherapy onset and second, fourth, and sixth sessions. The diagnostic tool's specific requirements (compliance, validity, concordance, sensitivity, specificity, reliability) were statistically evaluated. RESULTS: Differences between translated texts and between the reverse translation and the original were considered negligible. At the second, fourth, and sixth session compliance was 98%, 95%, and 93% while Cronbach's α was 0,57 0,69, and 0,81, respectively. Cohen's weighted κ was 0,67 and 0,58, Spearman's ρ was 0,7 and 0,98, while the area under the curve (AUC) of the receiver operating characteristic (ROC) was 1 and 0,9 for the sensory and the motor part, respectively. The variance's linear regression analysis confirmed CIPN worsening over time (P<0.0001). DISCUSSION: The Greek version remains close to the original English version. Compliance rates reflect easy PNQ applications. Cohen's κ values highlight the physicians' tension to underestimate the patients' condition. Spearman's ρ, Cronbach's α, and AUC values reflect good validity, reliability, and specificity of the PNQ respectively. Finally, the linear analysis confirmed the PNQ sensitivity over time. CONCLUSIONS: The PNQ validation in Greek adds a crucial tool to the physicians' armamentarium. It can now delineate the necessary information to modify the chemotherapy and analgesic treatment regimens at both preventive and acute levels.

Free air after laparoscopic hysterectomy; from sigmoid perforation to upper airway compromise: a case report.

BACKGROUND: Free air after laparoscopic hysterectomy is a common finding; in rare cases, free air represents gastrointestinal perforation, requiring emergency laparotomy. Ectopic air localizations after pneumoperitoneum have been reported in various laparoscopic surgical techniques. Delayed diagnosis of visceral perforation is associated with high mortality rates. CASE PRESENTATION: We present a white Caucasian female in which dysphonia due to air entrapment in the cervical area, pneumomediastinum and pneumothorax, occured afterlaparoscopic hysterectomy. CONCLUSIONS: Upon mobilization of the patient, air from sigmoid perforation moved cephalad. Through the same path, pneumoperitoneum, causes subcutaneous emphysema in the neck and face, pneumomediastinum and pneumothorax.

Severe anaphylactic shock after anesthesia induction: An unusual initial manifestation of Churg-Strauss syndrome.

Churg-Strauss syndrome or eosinophilic granulomatosis with polyangiitits (EGPA) is a rare multisystem disorder. A case of anaphylactic shock after induction of anesthesia, as the initial clinical presentation of Churg-Strauss syndrome in a 15-year-old girl is reported. It is extremely rare to see pediatric patients with previous perioperative anaphylaxis receiving future anesthesia; a multidisciplinary approach including allergist, rheumatologist, anesthesiologist, and surgeon is necessary in order to provide a better future anesthetic plan.

Addition of 100 mg of Tramadol to 40 mL of 0.5% Ropivacaine for Interscalene Brachial Plexus Block Improves Postoperative Analgesia in Patients Undergoing Shoulder Surgeries as Compared to Ropivacaine Alone-A Randomized Controlled Study.

Background and objectives: Brachial plexus block is commonly used in shoulder surgery, as it provides satisfactory surgical conditions and adequate postoperative pain control. However, there are contradictory reports regarding the addition of tramadol to the injected regional anesthetic solution. We performed a prospective randomized study to evaluate the effectiveness of tramadol as an adjuvant to ropivacaine during interscalene brachial plexus block and assess its impact on the opioid consumption and the early postoperative pain in patients that underwent shoulder surgery. Materials and Methods: Eighty patients scheduled for elective shoulder surgery and anesthesia via interscalene brachial plexus block were randomly divided into two groups. In group A (n = 40), a solution of 40 mL of ropivacaine 0.5% and 2 mL (100 mg) of tramadol was administered during the brachial plexus block, while in group B (n = 40), a solution of 40 mL of ropivacaine 0.5% and 2 mL NaCl 0.9% (placebo) was administered. The effectiveness and duration of sensory and motor blocks were recorded in both groups. The sensory block was assessed recording the loss of sensation to pin prick test over the skin distribution of the axillary, radial, and musculocutaneous nerves. The motor block was assessed using the modified 3-point Bromage score (0-2 points). Cumulative morphine consumption and pain, using the Visual Analog Scale (VAS), were evaluated in both groups at 2, 4, 8, and 24 h after surgery. Results: Sensory block onset was achieved earlier in group A than in group B (5.21 ± 3.15 minutes (min) vs. 7.1 ± 4.51 min, p = 0.029). The motor block onset was similar between the two groups (13.08 ± 6.23 min vs. 13.28 ± 6.59 min; p = 0.932). The duration of the sensory block was longer in group A as compared to group B (13 ± 2.3 h vs. 12 ± 2.8 h; p = 0.013). The duration of the motor block did not present any difference between the groups (10 ± 2.2 h vs. 10 ± 2.8 h; p = 0.308). Differences in morphine administration were not significant at 2, 4, and 8 h, however, morphine consumption was found to be decreased in group A 24 h postoperatively A (p = 0.04). The values of VAS were similar at 2, 4, and 8 h, however, they were lower in group A at 24 h (p < 0.013). Conclusions: Combined regional administration of tramadol and ropivacaine during interscalene brachial plexus block improves the time of onset and the duration of the sensory block, while it is associated with reduced morphine consumption during the first 24 h after shoulder surgery.

Ischemic postconditioning decreases iNOS gene expression but ischemic preconditioning ameliorates histological injury in a swine model of extended liver resection.

BACKGROUND: Both pre- and postconditioning have been shown to protect the liver parenchyma from ischemia/reperfusion (I/R) injury during hepatectomy by altering the production of NO. However, to date there is no study to compare their effect on the inducible nitric oxide synthase (iNOS) and endothelial nitric oxide synthase (eNOS) gene expression, who are the main modulators in the pathway of NO during the acute phase of I/R injury. METHODS: We designed a prospective experimental cohort comprising of three groups (sham group-SG, preconditioning-PrG and postconditioning group-PoG) and consisting of 10 animals per group. All animals underwent extended hepatectomy (70%) under prolonged warm ischemia either after preconditioning or followed by postconditioning or without any protective maneuver (SG). Following reperfusion blood samples and liver biopsies were obtained at the start of reperfusion (0 hours), at 6 and 12 hours post reperfusion. iNOS and eNOS gene expression was assessed on liver tissue by polymerase chain reaction (PCR); in addition, the extent of hepatocellular injury was histologically assessed. RESULTS: At the beginning of reperfusion iNOS expression was significantly reduced in the PoG in comparison to the SG (Kruskal-Wallis test, P=0.012; Mann-Whitney U test, P<0.0005 Bonferroni correction) and continued to remain at low levels until 6 hours post reperfusion (Kruskal-Wallis test, P=0.01; Mann-Whitney U test, P<0.0005-Bonferroni correction) This difference was eliminated by 12 hours. No significant differences were found in the expression of eNOS between groups and within time measurements. Aspartate aminotransferase (AST) and Alkaline phosphatase (ALP) were found increased at the start of reperfusion; their levels continued to increase by 6 hours in all groups, however only in the PoG the increase attended statistical significance at 12 hours after reperfusion. ALT levels presented only minor alterations during the course of reperfusion. The PrG was found to have more intense hepatocellular injury at the start of reperfusion than the PoG however, that appeared to gradually settle by 12 hours in contrast to PoG where the hepatocellular injury continued to deteriorate. CONCLUSIONS: PoG appeared to decrease iNOS overexpression more effectively than PrG in comparison to animals who have undergone no protective maneuver (SG). However, PrG was more effective than PoG in ameliorating the hepatocellular injury observed at 12 hours after the ischemic insult.

The effect of transversus abdominis plane block on acute and chronic pain after inguinal hernia repair. A randomized controlled trial.

BACKGROUND: This prospective double-blind randomized study aimed at evaluating the short- and long-term postoperative analgesic efficacy of the ultrasound-guided tranversus abdominis plane (TAP) block in inguinal hernia repair under general anesthesia. METHODS: Sixty patients undergoing inguinal hernia repair were allocated to TAP block with either ropivacaine 0.75% 20 mL or placebo 20 mL. Postoperatively, they had access to a patient-controlled analgesia (PCA) device administering 1 mg doses of morphine as rescue analgesia. Pain was assessed at rest and during movement with the numeric rating scale (NRS) score 3,6 and 24 hs postoperatively. Other variables recorded were intraoperative dose of remifentanil required to maintain systolic arterial pressure within 20% of baseline, mg of morphine used in the Post Anesthesia Care Unit (PACU) and total dose of morphine administered via the PCA device. Six months after surgery, the occurrence of chronic pain was assessed with the NRS score at rest and during movement. Patients were also asked to fill in the DN4 questionnaire to estimate the development of neuropathic pain. RESULTS: Patients who were administered ropivacaine demonstrated significantly less pain at rest and on movement, as expressed by NRS scores in comparison to patients in the placebo group. The former group also required less remifentanil intraoperatively, less morphine during the PACU stay and had lower morphine consumption through the PCA device. Six months after surgery, pain scores at rest and during movement were comparable between the two groups. At the same time DN4 scores were low and comparable between the two groups. CONCLUSION: Ultrasound-guided TAP block provided better pain control than placebo in the acute setting after inguinal hernia repair. However, the incidence of chronic pain was low and not significantly affected by the performance of the block.

Pregnancy Complications in a-Thalassemia (Hemoglobinopathy H): A Case Study.

Thalassemia intermedia (TI) is a clinical definition which represents a wide spectrum of thalassemia genotypes but mainly includes patients who do not require or only occasionally require transfusion. An uncommon case of a 32-year-old Greek woman, para 1, at the 22nd week + day 3 of gestation with thalassemia intermedia (she was splenectomized), where her pregnancy was complicated with portal vein thrombosis, splenic thrombosis, and partial HELLP, is described. This is a generally uncommon event in thalassemia intermedia. She had no transfusion as her hematologist consulted and she took anticoagulation therapy. Thus, we present for the first time in the literature a case of HbH a-thalassemia pregnant woman whose pregnancy was complicated with portal vein thrombosis, splenic vein thrombosis, and partial HELLP; she was treated with anticoagulation therapy and she had a successful outcome.

Acupuncture and Acupressure Applied on the Extra-1 (Yintang) Acupoint in Healthy Volunteers Do Not Affect Regional Cerebral Blood Flow as Assessed by the Pulsatility Index: A Cohort Observational Study.

Objective: Acupressure applied on the Extra-1 (Yintang) point decreases bispectral index (BIS) values and stress in healthy volunteers. The current authors hypothesized that acupressure and/or acupuncture could alter regional cerebral oxygenation as expressed by middle cerebral-artery velocity. This study was conducted to test that hypothesis. Materials and Methods: After giving written informed consent, healthy volunteers received, randomly, (1) acupressure on the Extra-1 (Yintang) point, (2) acupressure on a sham point lying 2 cm over the lateral end of the right eyebrow, (3) no acupressure, or (4) modified manual acupuncture on the Extra-1 (Yintang) point. Each intervention lasted 10 minutes, except for acupuncture, which lasted for 20 minutes. The flow velocity of the left middle cerebral artery-as expressed by the Pulsatility Index (PI), heart rate (HR), and hemoglobin oxygen saturation (SpO2)-was recorded before each intervention, every 2 minutes during the intervention, and 10 and 70 minutes after the end of the intervention. A 2-MHz hand-held probe of a transcranial Doppler system (Companion II Micro TCD Nikolet Biomedical Inc., Madison, WI) was used to isolate the left middle cerebral artery via a transtemporal approach. Results: There was no difference among the four interventions at any timepoint in PI (P = 0.431; F = 0.929), HR (P = 0.948; F = 0.121), and SpO2 (P = 0.708; F = 0.465), as well as in systolic arterial pressure (P = 0.857; F = 0.255) or diastolic arterial pressure (P = 0.991; F = 0.036). Conclusions: There were no changes in PI measurements when acupuncture or acupressure was applied on the Extra-1 (Yintang) point once and for a limited time duration.

Measurements of oxygen saturation of brain, liver and heart areas in the supine and sitting position using near infrared spectrophotometry.

BACKGROUND AND AIMS: Regional oxygen saturation (rSO2) monitoring of the brain by near-infrared spectroscopy (NIRS) has been mainly used during carotid endarterectomy. The present study was conducted in volunteers and investigates the rSO2 values of the brain, heart and liver tissue as assessed by NIRS in the supine and the sitting position. METHODS: After obtaining written informed consent from forty-nine healthy volunteers, rSO2 values were recorded in the heart and liver areas in the supine and the sitting position, while simultaneously the rSO2 values of the brain. RESULTS: The rSO2 brain values in the supine and the sitting position were 69 ± 6.0 and 66 ± 6.1 respectively (p = 0.0001). The rSO2 values in the supine and the sitting position were 76 ± 10.5 and 79 ± 6.7 for the heart (p > 0.05) and 85 ± 6.8 and 82 ± 7.2 for the liver, (p = 0.007). Heart rSO2 values were higher than the brain rSO2 values in both the supine (76 ± 10.4 versus 69 ± 6.6; p = 0.0001) and the sitting position (79 ± 6.7 versus 66 ± 6.1; p = 0.0001). The liver rSO2 values were also higher than the brain rSO2 values in the supine (85 ± 6.8 versus 69 ± 6.0; p = 0.0001) and in the sitting position (82 ± 7.2 versus 66 ± 5.7; p = 0.0001). Arterial blood pressure and arterial oxygen saturation (SpO2) did not differ between the two positions but the heart rate was higher in the sitting position (p = 0.030). CONCLUSIONS: We conclude that brain and liver (but not heart) rSO2 values are higher in the supine than sitting position. Additionally, NIRS may be used to assess oxygenation of the heart and liver.

Cesarean delivery under spinal anesthesia is associated with decreases in cerebral oxygen saturation as assessed by NIRS: an observational study.

OBJECTIVES: To investigate the effect of spinal anesthesia on cerebral rSO2 during elective cesarean delivery (CD). METHODS: Thirty-four women scheduled for elective CD under spinal anesthesia were recruited. In the operating room rSO2 of the left and right frontal area and right thigh was recorded using three disposable sensors. A combination of 1.8-2.0 ml of 0.75% ropivacaine plus 10 µg of fentanyl were injected intrathecally. Systolic and diastolic blood pressure, heart rate, SpO2 as well as rSO2 of the left and right forehead areas and right thigh were recorded before, 5, 10, and 25 to 50 minutes after spinal injection, after uterine incision and placenta delivery, and analyzed with ANOVA repeated measures. The study was approved by the Aretaieio Hospital Institutional Review Board and registered with ClinicalTrials.gov (ID: NCT01669135). RESULTS: The rSO2 left and right frontal area values decreased significantly from baseline (p=0.0001 and p=0.0001 respectively), with most remarkable decreases 5 and 10 minutes after spinal injection, from 65 (SD 8.7)% to 56 (SD 9.3)% and 56 (SD 9.5)% (p=0.0001 and p=0.0001) for the left and from 63 (SD 7.7)% to 55 (SD 9.3)% and 56 (SD 8.9)% (p=0,0001 and p=0.0001) for the right frontal area respectively. The rSO2 right thigh values increased significantly during the study period (p=0.0001). KEY LIMITATIONS: Contribution of extracranial circulation to the rSO2, lack of PaCO2 and cardiac output measurements. CONCLUSIONS: Women undergoing CD under spinal anesthesia may present decreases in cerebral rSO2. The clinical impact of these results remains to be determined.

Intravenous lidocaine does not affect the anesthetic depth during rapid sequence induction and intubation as assessed by Bispectral Index monitoring: a randomized double blind study.

INTRODUCTION: We investigated the impact of intravenous lidocaine on anesthetic depth, as assessed by Bispectral Index score (BIS), and hemodynamic responses to rapid sequence induction/intubation. MATERIAL AND METHODS: Eighty-four surgical patients with risk factors for regurgitation/aspiration were randomized to receive either lidocaine 1.5 mg/kg or normal saline in a double-blind fashion. Propofol 2 mg/kg, lidocaine or normal saline, followed by rocuronium 1 mg/kg were administered intravenously and trachea was intubated under cricoid pressure application. The BIS scores were recorded before induction of anesthesia, immediately after, at 30 s and 1 min after rocuronium injection and every 30 s after intubation, for 10 min. Systolic/diastolic blood pressure and heart rate were measured before induction, immediately after and at 1 min following rocuronium administration, and every minute for 10 min after intubation. RESULTS: Data from 78 patients were analyzed. Demograpic characteristics did not differ between the study groups. A total of 24 BIS scores were recorded for each patient. No difference was found in BIS values between lidocaine and control groups at any time point (F = 2.936, p = 0.91). Also no difference was detected in heart rate, systolic and diastolic blood pressure at any time point of the study period between the two groups (F = 0.063, p = 0.80, F = 0.007, p = 0.93, F = 0.435, p = 0.51 respectively). No episodes of significant bradycardia occurred and none of the patients reported awareness/recall of the procedure. CONCLUSIONS: Lidocaine 1.5 mg/kg given intravenously during rapid sequence induction does not affect BIS values, or blunt the hemodymanic response to laryngoscopy and intubation.

Myocardial involvement during ischemia-induced acute liver failure in the pig.

OBJECTIVE: The objective of this experimental study was to investigate a possible myocardial involvement in acute liver failure. MATERIALS AND METHODS: A porcine model of acute liver failure induced by hepatic devascularization was used. Twenty animals were allocated to the Acute Liver Failure (ALF) or Control Group (CG). Serum cardiac troponin I (cTnI), MB isoenzyme of creatine kinase (CK-MB), and also hemodynamic variables were measured and compared before surgery (T1), at 4 hr (T2), and at 7 hr (T3) after the end of surgery. RESULTS: Data from 10 pigs in the ALF and 7 in the CG were analyzed. In the ALF group, cTnI increased from 0.3 ± 0.055 to 0.35 ± 0.696 and 0.39 ± 0.06 ng/ml at T1, T2, and T3 time points, respectively (p < .001). In the CG, cTnI was not significantly changed from 0.29 ± 0.07, to 0.31 ± 0.01, and 0.31 ± 0.11 ng/ml at T1, T2, and T3 time points, respectively (p = .895). A statistically significant difference was found in cTnI between the groups at T3 (z = -2.93, p = .002). CK-MB increased significantly in both groups: in ALF group, CK-MB changed from 3.43 ± 0.53 to 4.33 ± 0.73 and 7.14 ± 1.12 ng/ml at T1, T2, and T3 time points, respectively (p < .001). In the CG, CK-MB changed from 3.6 ± 0.597 to 4.6 ± 1.07 and 6.2 ± 1.17 ng/ml at T1, T2, and T3 time points, respectively, (p = .001). Mean arterial pressure (MAP) was significantly reduced in the ALF group. CONCLUSIONS: In a porcine model of acute liver failure, a significant increase of cTnI serum levels was found, indicating that a subclinical myocardial damage may occur as a result of heart involvement in the multiple organ dysfunction.

Perioperative pregabalin for acute and chronic pain after abdominal hysterectomy or myomectomy: a randomised controlled trial.

CONTEXT: The antiepileptics gabapentin and pregabalin are used as adjuvants to control postoperative pain. OBJECTIVE: The aim of the present study was to investigate the effect of perioperative administration of pregabalin on postoperative acute and chronic pain and analgesic requirements. SETTING: Department of Anaesthesiology, Aretaieio University Hospital, Athens, Greece. PATIENTS: Eighty patients scheduled for abdominal hysterectomy or myomectomy were randomly assigned to the pregabalin or to the control group. INTERVENTION: The pregabalin group received 150 mg of pregabalin 8-hourly, starting on the afternoon before surgery and continued until the fifth postoperative day. The control group was similarly treated, but received placebo capsules instead. MEASUREMENTS: Postoperative intravenous morphine and Lonalgal (30 mg codeine with 500 mg paracetamol) tablet consumption, visual analogue pain scores at rest and on coughing, sedation, anxiety, dizziness, ataxia, blurred vision and diplopia were recorded. One and 3 months postoperatively patients were interviewed for the presence of pain and analgesic needs due to surgery. RESULTS: The pregabalin-treated patients consumed less morphine during the first 48 h postoperatively (P = 0.0001). However, consumption of Lonalgal tablets and visual analogue scores for pain at rest and on coughing did not differ between the groups. No difference was found in sedation and anxiety scores between the patients who received placebo or pregabalin. Patients in the control group had lower incidences of dizziness (29 versus 58%, P = 0.015), ataxia (0 versus 18%, P = 0.011), blurred vision (6 versus 26%, P = 0.028) and diplopia (0 versus 16%, P = 0.023). Presence of pain, analgesic intake due to surgery and decreased or absent sensation around the wound did not differ between the groups 1 and 3 months postoperatively. CONCLUSION: Pregabalin in the doses given decreased morphine requirements for the first 48 h postoperatively, but neither altered the analgesic requirements beyond 48 h nor had any effect on acute, late or chronic pain.

Safety and effectiveness of outpatient laparoscopic cholecystectomy in a teaching hospital: a prospective study of 110 consecutive patients.

BACKGROUND: The aim of this study was to evaluate the safety and efficacy of outpatient laparoscopic cholecystectomy (OLC) in a day surgery unit in a teaching hospital. OLC was offered to patients with symptomatic cholelithiasis who met the following established inclusion criteria: ASA (American Society of Anesthesiology) physical status classification class I and II; age: 18 - 70 years; body mass index (BMI) < 30 kg/m2; patient acceptance and cooperation (informed consent); presence of a responsible adult to accompany the patient to his residency; patient residency in Athens. The primary study end-point was to evaluate success rates (patient discharge on the day of surgery), postoperative outcome (complications, re-admissions, morbidity and mortality) and patient satisfaction. A secondary endpoint was to evaluate its safe performance under appropriate supervision by higher surgical trainees (HSTs). FINDINGS: 110 consecutive patients, predominantly female (71%) and ASA I (89%) with a mean age 40.6 +/- 8.1 years underwent an OLC. Surgery was performed by a HST in 90 patients (81.8%). A mean postoperative pain score 3.3 (range 0-6) occurred in the majority of patients and no patient presented postoperative nausea or vomiting. Discharge on the day of surgery occurred in 95 cases (86%), while an overnight admission was required for 15 patients (14%). Re-admission following hospital discharge was necessary for 2 patients (1.8%) on day 2, due to persistent pain in the umbilical trocar site. The overall rate of major (trocar site bleeding) and minor morbidity was 15.5% (17 patients). At 1 week follow-up, 94 patients (85%) were satisfied with their experience undergoing OLC, with no difference between grades of operating surgeons. CONCLUSIONS: This study confirmed that OLC is clinical effective and can be performed safely in a teaching hospital by supervised HSTs.

Endoloop application as an alternative method for gastrotomy closure in experimental transgastric surgery.

BACKGROUND: Experimental studies investigating transgastric endoscopic surgery report closure of the gastric wall incision with clips. The author of this report describes endoloop placement as an alternative, equally efficient, faster method for gastrotomy closure. METHODS: Eight female pigs with a mean weight of 30 kg were used. Abdominal endoscopic exploration and transgastric operations including hepatic biopsies, bilateral tubal ligation, cholecystectomy, and closure of the gastrotomy were performed. The experiment was divided into two parts. The first part included five animals, which were killed immediately after the procedure. The second part included five animals, which were kept alive and killed 15 to 20 days later. RESULTS: The first part of the experiment, performed for technical skills acquisition, involved transgastric abdominal exploration, liver biopsies, and bilateral tubal ligation, which were successful for all five animals. The gastric wall incision was closed by applying clips in four animals and endoloops in one animal. During the autopsy at the end of the experiment, the sites of intervention were examined macroscopically. In the second part of the experiment, gastrotomy closure with endoloop application was performed in two animals and with clip application in one animal. All three animals survived, gained weight, and demonstrated no signs of infection. They were killed 15 to 20 days after the procedure, and no signs of intraabdominal infection were found. Cultures from the peritoneal cavity were negative. At necropsy, macroscopic and microscopic examination confirmed complete healing of the gastrotomy. CONCLUSIONS: Transgastric endoscopic surgery is technically feasible and effective. The application of endoloops for closure of the gastric opening is a fast, easy, and equally safe alternative to clip placement.